Help! Questioning treatment recommendations

Hi,
My husband went for his first sleep study 2 weeks ago, and they ended up doing a split night study. (I guess he met the parameters). The sleep center called him last week to come in for a mask fitting, and I asked him to get a copy of his study results and a copy of his script. When he came home with the copy of the sleep study I was not surprised to find out he had osa, but that he had severe osa (mostly hypotonias) with severe plm issues also. I am waiting for a return call from the sleep center, but I question the treatment suggestion.

During his titration they started his cpap at 5 cm h2o, and went up to 12 cm h20. When it got to 10, 11 & 12 he had a huge increase in central apnea's. The recommendation is to use an apap for 8 weeks set at 4-20, and then have a full nights titration when he becomes accustomed to the cpap. Shouldn't he be re-titrated soon with a bi-level? Our insurance works with Apria, and their co-pays are outrageous. I have always found it to be more economical to purchase my equipment outright than rent it. I am concerned that because of the centrals he may end up needing a bi-pap.

What is the cause and treatment of PLM's? I have no experience with this, do we speak with the sleep Dr. or with our PCP?

Any help is greatly appreciated
Caroline

I'm not a doctor, and this is not medical advice!

I'm not sure I understand your concern about his needing a bi-level titration. Your machine, the M series auto, and other modern apap machines have features that recognize non-responsive apneas and reduce the pressure. Some take other actions, but all take care not to just ratchet up the pressure. If you get a data-capable machine and your own software, you can see for yourself how the therapy is working. Apparently the doctor who evaluated the study didn't think the centrals were a big problem. If his centrals do not respond well to apap, the data you collect will provide a much better (and much cheaper) case than another night or two in a sleep lab.

I'm not saying he doesn't need bi-level, just that the modern machines go to some lengths not to administer inappropriate therapy in the presence of non-responsive apneas.

As for periodic limb movement, I always start with Wikipedia and go from there:
Periodic Limb Movement Disorder

Good luck.

PS - I just found this story of using a data capable machine to get the docs to understand the need for a bilevel system. See point #7 in the 3rd response from the bottom of the page:

Oximeters Compared - Wrist-worn styles.

7. I purchased my own REMstar Auto-M A-Flex unit in July and recently presented all of that 92% successful-therapy data to the doctor(s) and RT. They immediately, without hesitation or another sleep study prescribed an Auto BIPAP w/BIFLEX for me, delivered just several days after my most recent appointment. They had forced me to endure grossly unsuccessful therapy with a straight CPAP for almost 6-years, and a CPAP with C-Flex for almost a year before I acted on my behalf and bought my own auto-titrating machine.

Not a doc either and hope you are going to the 'local' hospital.

I think part of the reason for a re-titration is to determine if the use of cpap has 'reduced the PLM's' before starting unneeded meds. There is a chance cpap may solve the PLM's completely. You won't find that out at home.

Insurance is often the deciding factor of when they will cover a bi-level.

Thanks for the input.

I just spoke with an RT from the sleep lab, because the Dr. is on vacation. They want to do the home titraton because the split night didn't give them enough info on the centrals, and if they were caused by the cpap or not. They said that often times they find that centrals can show up with on pressure, but if a higher pressure is needed they can disappear. Or that this home titration can give them enough data to justify a bi-pap.

Gumby Ct, I am going to the 'local' hospital, and as you know I do trust that Dr. The second titration would determine if the cpap did help to relieve the plm's or not, and at that time with the info from the apap they can do a bi-pap titration if it is needed.

Thanks,
Caroline

My PLM was 12.5/hour during my overnight sleep study and was 15/hour during my overnight titration study three months later. My wife said that I kept her awake with all my leg movement. Now, after 3 months of CPAP, my PLMs/hour are nearly 0 per my observant wife. I wake up in the morning feeling refreshed, my avg weekly AHI < 1, and, most nights, my leak rate is low (< or = 32 LPM) and my leak line is flat or with just a few pressure change steps. My observation, from reviewing my nightly charts for 3 months, is that my flat leak line may be indicative of my not moving much during my sleeping time (I sleep on my left or right side, never my back). During my first few weeks on CPAP, my leak line looked like a roller coaster. Now my leak line looks like a level sidewalk or my front steps. Before I would do another study (with the associated $$$$ cost) just to look at PLM, I would ask my spouse to observe me sleeping, take good notes, and give me a detailed debriefing in the morning.

Caroline,

I am not very knowlegeable regarding centrals, but did have some show up during some of my studies, just not a significant number. It seems there needs to be more info to know if your husband is one who will adjust to cpap use and the centrals will resolve, or if he will always have to consider if a higher pressure therapeutic for his OSA will cause centrals. If that were to be the case, all the discussion about machines could change, as it may be found that he needs a machine that provides support for CSA. Going that route now would likely be premature, but I'd be hesitant to make a big investment in a machine that may still be not the best option. I'm always impressed at the brilliance of some on here in regards to this topic, so maybe as this progresses and more specific info is available the discussion can be more targeted.

As far as the PLMs, again, it seems there's not enough info to know what they mean. When one has apnea events, the body often moves as part of its struggle to resume breathing. These movements can "usually" be correlated on a sleep study with the events. Once therapeutically treating the apnea, any residual movements can be evaluated. Having limb movements periodically (as in occasional or random) is not the same as Periodic Limb Movement Disorder, which presents with rythmic stereotypical movements. As was previously mentioned, observation is a useful tool, as is video. I agree that it is too soon to start medication without knowing there is truely a need. My PLMD was diagnosed before my OSA, but it was only after treating my OSA that the full extent of my PLMD was manifested.

It's not likely you'll have instant answers on all of what's going on with your hubby. It may be more of a methodical process. In my nonprofessional view, being sure about the OSA treatment and centrals would be priority, as these are most integral to immediate (and long term) health. If he does have persistent limb movements, they can impact health mainly due to disruption of sleep and maybe joint and muscle pain, which in the long run is important, but not immediately as with the apnea. Sure hope his answers come as soon as possible.

Kathy