Mouth sealed completely--AHIs go through roof

StillAnotherGuest · Post by **StillAnotherGuest** » Sun Jan 11, 2009 6:40 am

Paul22 wrote:Those are interesting points there SAG, but I have one question. WTF are you talking about?

OK, let me be a little more specific.

mindy wrote:On this forum we sometimes seem to be, imho, very focused on leaks.

I think "obsessed" would be a better description. But humor me here, just for laughs, let's say the Respironics tech isn't a LSOS, and is, in fact, correct about the leaks, that your leak pattern isn't so bad that it's giving you false information.

Go to bed and hook yourself up to your machine NOW. Lie there awake for about an hour, breathe like you normally do when you go to bed, including any "controlled breathing" stuff, such as like when you mentioned about how 3 seconds isn't time enough to get a breath. Do a download. Post it.

Here's all your previously posted downloads. Put an "X" on the ones that you think you were awake all or most of the night.

Click here to go to downloads

Here's a sleep log form, start filling it out, put in times where possible. If you want to track position, put in those times as well, as best you can.

Click here to go to sleep log

Get the complete reports of your sleep studies. Your first study supports horrible sleep efficiency. Your titration supports central apneas (your sleep disordered breathing gets worse if the settings aren't right, especially when there's too much pressure). Based on this information you have at least 2 problems which can/will be made worse by arbitrarily wingin' the dials around (insomnia and complex breathing disorder). And if you've got some horrendous GI problems, maybe it wouldn't be a real good idea to start cranking up the pressure with that, either.

Here's the SAGpothesis. Your sleep disordered breathing is fine, well-controlled with your present settings and somewhat leaky set-up, and that "AHI through the roof" is simply you tossing and turning during wake. In other words, your issue is no longer with sleep apnea, but sleep itself. And until you find out specifically what it is you're trying to fix, you have no chance of fixing it.

SAG

Paul22 · Post by **Paul22** » Sun Jan 11, 2009 1:19 pm

SAG

I will do as directed in your last post, but, in the meantime, here is the Daily Report from last night--did sleep well and the report looks pretty good to me. The only changes I made for last night, as compared to previous nights, were:

1. No slow breathing.
2. Slept on side instead of back.
3. Used a ramp time of 20 m, initial pressure of 6 cm, instead of remp off. Think that I read someplace that the
mahine did not record during the ramp time and would miss some of the crap that might be present at the first.

Thank you for everything. I do not intend to shoot at a target when I don't even know what the specific target is. I do not know the specifics of how this machine registers an apnea. It seems possible to me--used to be a measuremnts and instrumentation engineer in the chemical industry--that other disturbances could be recorded as apneas.

Paul22

[img]SAGhttp://i721.photobucket.com/albums/ww216/2Paul2/Jan11-09.jpg[[/img]

Paul22 · Post by **Paul22** » Sun Jan 11, 2009 1:25 pm

Whoops! Screwed up picture of previous post.

Paul

mindy · Post by **mindy** » Sun Jan 11, 2009 1:39 pm

Paul,

That report looks much better And I agree completely with your comments about a target to shoot at. I'd leave things alone for a week or two before contemplating anything else. I found my own patterns were more complex than I had originally realized and feel I don't know enough to say exactly what my settings should be. I don't have BIPAP so it's a little less complicated.

Good luck!
Mindy

roster · Post by **roster** » Mon Jan 12, 2009 7:34 pm

Paul22 wrote:.........

2. Slept on side instead of back.
............

This makes a big difference for many of us. In my case a pressure of 19 cm is needed for back sleeping while 8.5 cm is fine for side sleeping. I have a special backpack that forces me to sidesleep.

Thanks for your service to our country.

Paul22 · Post by **Paul22** » Tue Jan 13, 2009 5:21 pm

SAG

Go to bed and hook yourself up to your machine NOW. Lie there awake for about an hour, breathe like you normally do when you go to bed, including any "controlled breathing" stuff, such as like when you mentioned about how 3 seconds isn't time enough to get a breath. Do a download. Post it.

Wasn't able to do it then but did this morning--the results are below. The first part of the report is my doing the slow breathing, trying to keep my lips closed (no tape), the second is done with no slow breathing. Subjectively, I did not have "uptight feeling" that occurred with the bad nights.

Here's all your previously posted downloads. Put an "X" on the ones that you think you were awake all or most of the night.

Never have figured out how to do that--and have been unable to find any instructions, Until I can do better, all that I can do is tell you the dates of the reports of the nights that I felt that I was awake most of the night: Jan 3,4,10.

Get the complete reports of your sleep studies. Your first study supports horrible sleep efficiency. Your titration supports central apneas (your sleep disordered breathing gets worse if the settings aren't right, especially when there's too much pressure). Based on this information you have at least 2 problems which can/will be made worse by arbitrarily wingin' the dials around (insomnia and complex breathing disorder). And if you've got some horrendous GI problems, maybe it wouldn't be a real good idea to start cranking up the pressure with that, either.

Still trying to get those.

Thanks.

Paul22 (Don't know how to make the quote sections shaded)

StillAnotherGuest · Post by **StillAnotherGuest** » Wed Jan 14, 2009 5:54 am

Paul22 wrote:Don't know how to make the quote sections shaded

Put the stuff you want to have in "shaded quotes" using brackets and the following format:

*quote="Paul22"]Don't know how to make the quote sections shaded[/quote*

except the first and the last "[]"s were changed to "*"s cause otherwise it would just appear as

Paul22 wrote:Don't know how to make the quote sections shaded

again.

Paul22 wrote:SAG

Go to bed and hook yourself up to your machine NOW.

OK, the first quote clears things up. Since I don't have a PAP machine (at least at home, anyway), ya had me goin' there for a minute. And I won't say what "machine" I was going to try to hook myself up to. Suffice to say that it was going to be pretty disgusting.

Paul22 wrote:Never have figured out how to do that--and have been unable to find any instructions, Until I can do better, all that I can do is tell you the dates of the reports of the nights that I felt that I was awake most of the night: Jan 3,4,10.

No prob, just get a Magic Marker and

The high concentrations of respiratory events consistently coincide with perception of prolonged wake. Perception of sustained sleep coincide with successfully addressed respiratory events.

Paul22 wrote:The first part of the report is my doing the slow breathing, trying to keep my lips closed (no tape), the second is done with no slow breathing. Subjectively, I did not have "uptight feeling" that occurred with the bad nights.

This is a great puzzle! OK, what are all the factors, forces, and variables that have to be accounted for:

Code: Select all

Wake/sleep
Position
Set-up to control leaks
Leak pattern recorded on Encore
Events recorded on Encore
Voluntary breathing during wake
Patient anxiety
Nasal patency
CO2 washout
Loop gain
Mode of pressure support

If it's really a slow day, and there's no good guests on "The View", repeat the test with the tape, dental creme and some anxiety.

Better yet, is it the set-up that creates the anxiety?

I hope Sam doesn't bolt for the NFL.

SAG

rested gal · Post by **rested gal** » Wed Jan 14, 2009 8:45 am

Paul22 wrote:Wasn't able to do it then but did this morning--the results are below. The first part of the report is my doing the slow breathing, trying to keep my lips closed (no tape), the second is done with no slow breathing. Subjectively, I did not have "uptight feeling" that occurred with the bad nights.

Wow. If you were fully awake and were not mouthbreathing during that entire hour shown on the Encore Pro report you posted for your experiment from 7:33 a.m - 8:38 Jan. 13, I wonder why the leak rate became so jagged and shot up so badly before you switched to "normal" breathing during the second half hour.

Do you think you may have drifted off to sleep during the first half hour of your experiment?

That kind of extremely jagged leak line during so much of the first half hour of your experiment sure looks wild, if you were awake the whole time. If awake, you'd surely have been aware of that much "leak" going on, I'd think. But if you drifted off to sleep in the first half hour of "slow breathing", the jagged leak line stuff was probably massive mouth air leaks.

Guest RPSGT/Sleep Lab Manager · Post by **Guest RPSGT/Sleep Lab Manager** » Wed Jan 14, 2009 11:12 am

There is alot of false/confusing information being spewed around in this post, so let me clear some things up from the perspective of a RPSGT/Sleep Lab Manager, who has treated thousands of patients, as well as someone who attends nearly every sleep conference each year and speaks to the engineers of sleep producs.

First of all, it scares me how many people on this site are adjusting their own machines. Too much pressure can cause cause central Apneas by eliminating the hypoxic drive, this can do alot more problems than just increasing your AHI, just read through respiratory journals for "elimination of hypoxic drive" to see, I don't want to scare you here.

second, the AHI derived from the PAP machines is only an estimate, and should not be used to titrate with. There are variables in the mix that are not accounted for. The only thing that AHI is there for is to trigger the DME/patient to go back to the sleep lab/physician for a follow-up study and re-titration.

Auto titrating machines can easily be fooled by such things as leaks, patient holding his breath while awake, central apneas and the like. In fact when bored during the night techs used to play a game to see how high they could fool the machines into titrating ourselves. My friend holds the record for my lab at the time at 23 sonometers before he had to take it off as he was getting light headed. They are also a re-active system, not a pro-active approach think of it as getting punched in the face then stepping back vs stepping back before you get punched. So many patients come to me wanting an auto titrating device because they think they are the second coming, yet they are a distant second to a correctly set up pap device with a good titration

Some machines can maintain pressures even at high leaks. The new M series from Respironics can do this up to about 50cm, however I would not like my patients to be on a true leak of more than say 40 at 10-15 cm.

Different manufacturers display their leaks in different ways. Respironics displays true leak, Res-Med displays leak above an "acceptable" leak... how they calculate "acceptable" is beyond me. So a leak of 20 on a Res Med machine is a greater leak than a 30 on a Respironics machine. Other manufactures I've dealt with at the trade shows have salesmen at the booths not engineers, so I do not trust the information they give me enough to repeat it here.

The final resolution I have for the origional poster is that he needs to find a better sollution. Tape and paste are not a good thing to have on your lips if for some reason you wake up and vomit, this could cause you to aspirate that and die.

What you need to do is to see a ABSM approved sleep specialist, and to get a proper titration at an AASM accreditied sleep lab. Ensure that your aquiring tech and scoring tech are both Registered by the BRPT. Spend some time with the techs doing a proper mask fitting. I only use full face masks as a last resort, I believe that a nasal mask with a delux chin strap to support your chin and lower lip are a good sollution to train someone to become a nasal breather only.

Hope I helped out some.

Wulfman · Post by **Wulfman** » Wed Jan 14, 2009 1:25 pm

Guest RPSGT/Sleep Lab Manager wrote:There is alot of false/confusing information being spewed around in this post, so let me clear some things up from the perspective of a RPSGT/Sleep Lab Manager, who has treated thousands of patients, as well as someone who attends nearly every sleep conference each year and speaks to the engineers of sleep producs.

First of all, it scares me how many people on this site are adjusting their own machines. Too much pressure can cause cause central Apneas by eliminating the hypoxic drive, this can do alot more problems than just increasing your AHI, just read through respiratory journals for "elimination of hypoxic drive" to see, I don't want to scare you here.

second, the AHI derived from the PAP machines is only an estimate, and should not be used to titrate with. There are variables in the mix that are not accounted for. The only thing that AHI is there for is to trigger the DME/patient to go back to the sleep lab/physician for a follow-up study and re-titration.

Auto titrating machines can easily be fooled by such things as leaks, patient holding his breath while awake, central apneas and the like. In fact when bored during the night techs used to play a game to see how high they could fool the machines into titrating ourselves. My friend holds the record for my lab at the time at 23 sonometers before he had to take it off as he was getting light headed. They are also a re-active system, not a pro-active approach think of it as getting punched in the face then stepping back vs stepping back before you get punched. So many patients come to me wanting an auto titrating device because they think they are the second coming, yet they are a distant second to a correctly set up pap device with a good titration

Some machines can maintain pressures even at high leaks. The new M series from Respironics can do this up to about 50cm, however I would not like my patients to be on a true leak of more than say 40 at 10-15 cm.

Different manufacturers display their leaks in different ways. Respironics displays true leak, Res-Med displays leak above an "acceptable" leak... how they calculate "acceptable" is beyond me. So a leak of 20 on a Res Med machine is a greater leak than a 30 on a Respironics machine. Other manufactures I've dealt with at the trade shows have salesmen at the booths not engineers, so I do not trust the information they give me enough to repeat it here.

The final resolution I have for the origional poster is that he needs to find a better sollution. Tape and paste are not a good thing to have on your lips if for some reason you wake up and vomit, this could cause you to aspirate that and die.

What you need to do is to see a ABSM approved sleep specialist, and to get a proper titration at an AASM accreditied sleep lab. Ensure that your aquiring tech and scoring tech are both Registered by the BRPT. Spend some time with the techs doing a proper mask fitting. I only use full face masks as a last resort, I believe that a nasal mask with a delux chin strap to support your chin and lower lip are a good sollution to train someone to become a nasal breather only.

Hope I helped out some.

Yep......you helped ME out......you just told me you don't know SHIT! Do you realize how far from reality all of that BS is?
Sleep medicine has become a money grab. Run 'em through and hope they make it. If the don't, order yet another sleep study and grab some more loot. There ARE a few good ones and some of them even hang out on this forum to lend some of their expertise when necessary. (don't worry, I won't mention names)

We hear this spiel every so often when someone like you finds this site on the Internet. You need to be talking to the people in your own industry and tell them to get their act together. If they WERE "properly" doing their jobs, there wouldn't be a need for these forums. What about the sleep doctors who prescribe the WRONG pressures? What about the patients who just can't get their therapy going because they were run through that "money mill" and sent on their way to give up therapy out of frustration?

Spread the word to others in your (money-grubbing) profession to come here and see how people actually get HELP with their therapy.

Den

Sleep4aHealthyLife · Post by **Sleep4aHealthyLife** » Wed Jan 14, 2009 2:29 pm

Paul,

I agree with GoofProof, your leaks are out of sight. And based on how the machine works, if the air "circuit" between your lungs and the machine is broken (i.e. high leak), then any results that the machine would try to give are inaccurate. I'd get a FFM and go from there.

Recommend:
HYbrid FFM
ResMed Liberty - though it has some issues with wear and tear

Hope this helps.

Guest RPSGT/Sleep Lab Manager · Post by **Guest RPSGT/Sleep Lab Manager** » Wed Jan 14, 2009 3:38 pm

Wulfman wrote:
Guest RPSGT/Sleep Lab Manager wrote: What you need to do is to see a ABSM approved sleep specialist, and to get a proper titration at an AASM accreditied sleep lab. Ensure that your aquiring tech and scoring tech are both Registered by the BRPT. Spend some time with the techs doing a proper mask fitting. I only use full face masks as a last resort, I believe that a nasal mask with a delux chin strap to support your chin and lower lip are a good sollution to train someone to become a nasal breather only.

Hope I helped out some.

Yep......you helped ME out......you just told me you don't know SHIT! Do you realize how far from reality all of that BS is?

Please... In detail, please tell me how what I said is "BS" or that I don't know what I am talking about? What I said is spot on.

Wulfman wrote:Sleep Medicine has become a money grab. Run 'em through and hope they make it. If the don't, order yet another sleep study and grab some more loot.

I agree with you 100% and it disgusts me. I have left 2 sleep labs for their unethical practices. I finally moved across the country to work with a center that was not-for-profit

Wulfman wrote:There ARE a few good ones and some of them even hang out on this forum to lend some of their expertise when necessary. (don't worry, I won't mention names)

fine... but what exactly does this statement have to do with the current situation, or your arguement with my suggestion?

Wulfman wrote:We hear this spiel every so often when someone like you finds this site on the Internet. You need to be talking to the people in your own industry and tell them to get their act together. If they WERE "properly" doing their jobs, there wouldn't be a need for these forums. What about the sleep doctors who prescribe the WRONG pressures?

Medicine is like any other profession. There are good doctors and facilities and bad doctors and facilities. Unfortunately the boom of sleep medicine was driven by facilities that are owned by greedy doctors and venture capitalists. However, that is an arguement that is neither here nor there... I am just trying to help out this patient, and to spread some facts. As for "sleep doctors who..." This is why I recomended an AASM accredited lab, and an ABSM boarded sleep physician.

Wulfman wrote:What about the patients who just can't get their therapy going because they were run through that "money mill" and sent on their way to give up therapy out of frustration?

For those patients, I suggest that they educate themselves and find a sleep lab that is not driven by the "money mill" as you so call it. Find a lab that is associated with a not-for-profit hospital, one that is AASM accredited. the AASM accreditation is not a profitable accreditation to have. It requires far more steps and a far higher standard than a typical laboratory. One that is profit based will not waste their time getting and following that AASM accreditation.

Wulfman wrote:Spread the word to others in your (money-grubbing) profession to come here and see how people actually get HELP with their therapy.

Den

Den, first, I would rather spread the word to the consumers what to look for in a good lab, because if patients only go to labs that are good, this way the bad labs that you are reffering to will go out of business.

I am sorry that your experiences are so poor. However I really am here to help. I am not getting paid for this, nor am I making any future profits by offering this advice. As you can tell I didn't mention my lab, or even my state. By recomending to this patient that they need a proper titration I am only motivated to get this patient the best treatment alone, not by greed or job security.

I also mentioned ways for him to find a sleep lab and physician that are not based on greed, because they disgust me as well.

As for the whole grouping me in with the other poorer quality, profit based laboratories

My Center offers free evaluations of sleep disorders and Free 1-on-1 consultations with patients with possible sleep disorders
My Center gives follow up calls to patients to assist them with their therapy (No Reimbursement)
My Center offers free mask fittings and trial masks (No Reimbursement)
My Center does NOT sell CPAP equipment or any other medical supplies
My Center sponsors an AWAKE support group for CPAP wearers (No Reimbursement)
My Center only hires RPSGT for technical positions (cost nearly 2x the rate of a normal sleep tech)
The list goes on and on and on why I and my center are not "money grabbing" as you so elegantly put it. I am here to help and to lend my vast expertise.

Just let me know how I can help.

jules · Post by **jules** » Wed Jan 14, 2009 4:05 pm

hmm - tend to be with Den on this although I agree that Paul needs more titration work as what he had several years ago isn't cutting it and the mask issue is there.

Last I knew pressure for xpap was measured in cm H2O and leaks were measured in liters/min or liters/sec. Some of us can actually covert the liters/sec into liters/min on a good day.

However, for the life of me, I can't convert cm into l/min.

I guess my math sucks AGAIN.

I need to go back and find a good math prof and see if they can take me on for some intensive tutoring. Anyone got any good ideas on who I can find here on the forum?

jnk · Post by **jnk** » Wed Jan 14, 2009 4:10 pm

Guest RPSGT/Sleep Lab Manager wrote: There is alot of false/confusing information being spewed around in this post, so let me clear some things up from the perspective of a RPSGT/Sleep Lab Manager, who has treated thousands of patients, as well as someone who attends nearly every sleep conference each year and speaks to the engineers of sleep producs.

First of all, it scares me how many people on this site are adjusting their own machines. Too much pressure can cause cause central Apneas by eliminating the hypoxic drive, this can do alot more problems than just increasing your AHI, just read through respiratory journals for "elimination of hypoxic drive" to see, I don't want to scare you here.

Good point. That is why this forum unfailingly stresses the importance of having a data-capable machine that will let the patient know he/she may be temporarily triggering a central or two if, as he/she raises pressure by 1 cm, apneas increase.

Guest RPSGT/Sleep Lab Manager wrote: second, the AHI derived from the PAP machines is only an estimate, and should not be used to titrate with. There are variables in the mix that are not accounted for. The only thing that AHI is there for is to trigger the DME/patient to go back to the sleep lab/physician for a follow-up study and re-titration.

Please do not fear for your job. Although auto-titrating machines are the future, sleep labs will still be needed. Especially SLEEP CENTERS [nod to SAG].

Guest RPSGT/Sleep Lab Manager wrote: Auto titrating machines can easily be fooled by such things as leaks, patient holding his breath while awake, central apneas and the like. In fact when bored during the night techs used to play a game to see how high they could fool the machines into titrating ourselves. My friend holds the record for my lab at the time at 23 sonometers before he had to take it off as he was getting light headed. They are also a re-active system, not a pro-active approach think of it as getting punched in the face then stepping back vs stepping back before you get punched. So many patients come to me wanting an auto titrating device because they think they are the second coming, yet they are a distant second to a correctly set up pap device with a good titration

Your buddies must be a real barrel of laughs at all the office alcohol-titrating contests!

Guest RPSGT/Sleep Lab Manager wrote: Some machines can maintain pressures even at high leaks. The new M series from Respironics can do this up to about 50cm, however I would not like my patients to be on a true leak of more than say 40 at 10-15 cm.

Hey, I think you HAVE been to some seminars!

Guest RPSGT/Sleep Lab Manager wrote: Different manufacturers display their leaks in different ways. Respironics displays true leak, Res-Med displays leak above an "acceptable" leak... how they calculate "acceptable" is beyond me. So a leak of 20 on a Res Med machine is a greater leak than a 30 on a Respironics machine. Other manufactures I've dealt with at the trade shows have salesmen at the booths not engineers, so I do not trust the information they give me enough to repeat it here.

I could explain the acceptable leak thing with the ResMeds, but the clinician's manuals explain it pretty well.

Guest RPSGT/Sleep Lab Manager wrote: The final resolution I have for the origional poster is that he needs to find a better sollution. Tape and paste are not a good thing to have on your lips if for some reason you wake up and vomit, this could cause you to aspirate that and die.

Funny you should mention that. Sometimes my buddies will all tape their mouths shut and see who can vomit the most to . . . Oh, nevermind.

Guest RPSGT/Sleep Lab Manager wrote: What you need to do is to see a ABSM approved sleep specialist, and to get a proper titration at an AASM accreditied sleep lab. Ensure that your aquiring tech and scoring tech are both Registered by the BRPT. Spend some time with the techs doing a proper mask fitting. I only use full face masks as a last resort, I believe that a nasal mask with a delux chin strap to support your chin and lower lip are a good sollution to train someone to become a nasal breather only.

Hope I helped out some.

Some good stuff. I think you can fit in around here, if you don't mind people giving you a hard time. I know it is hard to understand what some users do here at first. But if you keep reading and keep posting, some things will fall into place for you.

Feel free to sign up and sign in. But you may want to do that a little more anonymously without posting your credentials. Nothing wrong with that, of course--we have some well-credentialed posters here who are absolutely invaluable to this forum. But you can do good work here without wearing it like a badge. And it might help take the edge off the preachy tone.

Anyway, pull up a chair, grab an autotitrating machine, or a beer, whichever you prefer, and let's talk. Your observations for the original poster have their place like anyone else's. And you may have some particularly interesting things to say.

We'll see.

jeff

GumbyCT · Post by **GumbyCT** » Wed Jan 14, 2009 4:47 pm

Guest RPSGT/Sleep Lab Manager wrote:
As for the whole grouping me in with the other poorer quality, profit based laboratories

My Center offers free evaluations of sleep disorders and Free 1-on-1 consultations with patients with possible sleep disorders
My Center gives follow up calls to patients to assist them with their therapy (No Reimbursement)
My Center offers free mask fittings and trial masks (No Reimbursement)
My Center does NOT sell CPAP equipment or any other medical supplies
My Center sponsors an AWAKE support group for CPAP wearers (No Reimbursement)
My Center only hires RPSGT for technical positions (cost nearly 2x the rate of a normal sleep tech)
The list goes on and on and on why I and my center are not "money grabbing" as you so elegantly put it. I am here to help and to lend my vast expertise.

Just let me know how I can help.

1st let me say That I have taped and glued my mouth so I would know what I was talking about. I found I was able to open my mouth much easier and faster than with straps holding it shut. Give it a try just so you know.

2nd if you truly want to help I would suggest you offer Paul a FREE eval AND titration.

I think it's only because he was unable to find a solution he came here. in fact I am sure.

So you're ON - your time to shine. Time to come out of the closet, my friend.

Mouth sealed completely--AHIs go through roof

There's More To Sleep Than Just AHI...

Re: Mouth sealed completely--AHIs go through roof

Re: Mouth sealed completely--AHIs go through roof

Re: Mouth sealed completely--AHIs go through roof

Re: Mouth sealed completely--AHIs go through roof

Re: There's More To Sleep Than Just AHI...

Great, But Who's Sam, Anyway?

Re: There's More To Sleep Than Just AHI...

Re: Mouth sealed completely--AHIs go through roof

Re: Mouth sealed completely--AHIs go through roof

Re: Mouth sealed completely--AHIs go through roof

Re: Mouth sealed completely--AHIs go through roof

Re: Mouth sealed completely--AHIs go through roof

Re: Mouth sealed completely--AHIs go through roof

Re: Mouth sealed completely--AHIs go through roof