A question for my patient

Illinois RRT here,
I have a question about a patient of mine. He had a sleep study done in November and was diagnosed with moderate to severe OSA. The sleep study found a pressure of 11 to benefit him the most and he was set up with a CPAP. Over the course of time since then, he has been fighting with his CPAP. First we changed the mask and solved that problem. He has an Ultra Mirage FF and loves it. He wanted to have it D/Cd but the doctor said to titrate to patient comfort. Patient thought he wanted to have MORE pressure than 11, so I tried to find a pressure to suit him. The doctor is reluctant to repeat a sleep study (don't get me started). I set him at 14, which he tolerates fine, his oximetry was good, but the patient just does not feel that it helps him. He wears it through the night and doesn't think it helps him one bit. I increased it again per doctor's request to 16. I'm beginning to think that something else is wrong with the guy. He is trying to be compliant with it, but is just confused because he feels that he should be feeling better. He's still snoring, still not feeling rested, etc. Am I wrong to not want to keep turning his pressure up? Especially when the sleep study found him to benefit most from 11? I don't know if AutoCPAP would help at this point- I really wish the doctor would do some more investigating, I'm just a lowly RT. Anyone else have a similar experience? Ideas?

In my ever so humble opinion, if you atleast put him on a trial with an autopap you can find out what his AHI is averaging at night and if it's low then you know he either needs more time to adjust or that it might be something else. If his AHI is still to high then you can see where he should be. Hope you figure it out.

He is trying to be compliant with it, but is just confused because he feels that he should be feeling better. He's still snoring, still not feeling rested, etc. Am I wrong to not want to keep turning his pressure up? Especially when the sleep study found him to benefit most from 11?

First of all, it feels especially wrong for me to be suggesting anything to you, an excellent RT (lowly though you may be... ). That being said, I'll now of course offer my suggestion....

If I wasn't aware of my nightly stats and only based efficacy of treatment on how I felt, I'd have thought I needed more pressure too; reasoning (falsely) more would be better. It takes some people months to notice they're benefitting, and I am one of them. If I didn't know better, heck, I'd have been begging to have that thing cranked up to 20 if someone would do it! What's surprising to me is that a doctor shares that misguided philosophy and isn't getting some empirical data to find out what is going on. If he won't order another PSG, he could at least get the poor guy an auto and the software to see what's happening. Hard to believe he just keeps indiscriminately raising the pressure without looking at any data, even though this man was titrated at 11. (Hey, do you suppose this doc does the same thing with prescription medicine? --Oxycotin, valium, etc.? "So you say with 200mg. you're not feeling any better? Okay, lets try 500mg..." Must be a very popular fellow with his patients... the conscious ones, anyway...)

Then again, just because he's a doctor doesn't mean he's smart. Here we have a doc who just ups the pressure without examining data, and on another thread we have a cardiologist who says OSA has no effect on the heart. When I was a little girl I assumed all docs knew what they were doing. Now I know they're just like the general population. Some smart, some not so smart, some buffoons.

Good luck with your patient, and good luck with the doctor!

Christine,

Do you know if this guy has RLS or some other sleep disrupting condition? If he is still "waking up" many times per night the cpap will only minimize the SDB arrousals. Also if he is using a FF the mask leaks may be causing him to have disturbed sleep without him realizing it. Is he using a FF because of mouth leaks? Do you have any leak data on him? These sorts of problems seem to suggest that a trial on an auto for everyone may make you life much easier. You would be able to collect data and make adjustments until all the problems are worked out.

Good Luck! ...you're one of the good ones.

Trial on autopap, absolutely. (imho, of course! )

As Wader said, there might be other sleep disruption things going on. The patient is lucky to have you, Christine, as his RT...you're taking more than a passing interest in what happens to him.

You'll need the software to really see what's going on with the man and machine if he gets an autopap trial. Christine, please check your private messages. I just now sent you one.

Autopap sound slike it would work great - to find out what is going on anyway - without the additional sleep study. Jen

here's a link to ask someone who knows a lot about this type of thing.

http://www.cpap-forum.com/forum/viewtopic.php?t=84

It may well be worth a try.

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