Home titration test expectations

Hi guys & gals,

I hope you don't mind a few questions from another newbie

For the record, 43 years old, 275 pounds, mild hypertension, cholesterol, gout, gerd, esophageal spasms, poor sinuses (surgery ~10 years ago) / enlarged tonsil, and now apnea. Fun times By the way, I have a feeling I'm a very shallow breather which most likely adds to my problems..

I actually have good insurance but they refused to pay for a lab study so I had to settle for an in-home monitor from NovaSom. Here are my initial 3 night results:

Night 1: 4 hours, AHI 92.7
Night 2: 8 hours, AHI 65.0
Night 3: 8 hours, AHI 79.8

Total number of events @ 4%: 1494
Total number of apneas: 1229
Total number of hypopneas @ 4% criteria: 265
Apnea Hypopnea Index/Respiratory Disturbance Index @ 4% criteria: 76.7

Oxygen saturation < 90%: 497 minutes (42%)
Oxygen saturation > 90%: 688 minutes

Night 3 Oxygen saturation:

100-95%: 0 drops, 00:24
94-90%: 10 drops, 03:22
89-85%: 190 drops, 2:45
84-80%: 206 drops, 00:54
79-70%: 78 drops, 00:21
<70%: 8 drops, 00:01

Now they sent me an S8 APAP for a home titration test. Nothing groundbreaking yet unfortunately -- still have trouble sleeping, still tired..

I poked around in the results menu and found that my average AHI is now 14.8 at a pressure of 10. After four initial nights are those promising results? Would I be able to fine tune things and get that number down lower or is there more at play here than just OSA (such as CSA)?

I don't have a way to get the detailed reports off the S8 - I'm just going to have to send the machine back and wait a few weeks for the results..

Are home studies a reliable method to diagnose OSA / CSA and prescribing an APAP/BiPAP/VPAP? Would I be better off attending a sleep lab?

When I figure out what I have and which type of machine I need I'm just going to purchase a top machine online.. I just hate the waiting game. This testing has been going on for weeks now..

Any insight appreciated!

Thanks,
Joe

I wish they had given you a S9 Autoset for the home titration because that S8 Autoset (APAP) doesn't gather or flag centrals and the S9 does.

What are your pressure settings? You mention 10 cm and not a range so that leads me to believe you are using the machine in straight cpap mode. Are you sure it is an APAP machine? It would say Autoset on it.

If you are using straight cpap mode at 10 cm pressure and assuming that AHI that you see on the machine is all obstructive, then the pressure is not adequate to prevent those events and you likely need more pressure.

If they have the machine set in APAP mode with starting pressure of 10 cm...that starting pressure is too low to prevent the apnea events optimally (again assuming no centrals) and you need a little more starting pressure.

Centrals...which your machine doesn't flag in a separate category, but will sense, are not treated with an increase in pressure.
If it senses a "central" occurring at 10 cm or more pressure and there is no other obstructive type of event going on to trigger a pressure increase the S8 simply won't increase the pressure.
We don't treat centrals (if they are occurring) with an increase in pressure with the regular cpap/apap machines.
At pressures of 10 cm and above the S8 machine requires there to be signs of an actual collapse of the airway (obstructive) before it will respond with more pressure.

Whatever you do...don't accept the S8 machine as your final machine...push for the S9 model and avoid anything with Escape in the name. Escape models have severely limited to no data depending on which Escape.

Pugsy wrote:What are your pressure settings? You mention 10 cm and not a range so that leads me to believe you are using the machine in straight cpap mode. Are you sure it is an APAP machine? It would say Autoset on it.

Correct, it is on auto mode from 5-20. Although I wish it started higher as I feel like I can't get enough air at 5. Around 8-9 feels much better..

The 10 was in the results display so I assume it's the average pressure? No idea though.

Pugsy wrote:I wish they had given you a S9 Autoset for the home titration because that S8 Autoset (APAP) doesn't gather or flag centrals and the S9 does.

HI,

This sounds like a job for Craig's List. If this were my case, knowing what I know today, I'd be tempted to buy a data capable auto machine off of Craig's List and see what the data looks like. With an AHI near the moon and an O2 level that is close to strangulation, running your own machine wide open for a few days to see your data certainly couldn't be any more dangerous than sleeping with no machine at all.

-john-

jdr999 wrote:Correct, it is on auto mode from 5-20. Although I wish it started higher as I feel like I can't get enough air at 5. Around 8-9 feels much better..

The 10 was in the results display so I assume it's the average pressure? No idea though.

A starting pressure of 5 cm would indeed make a lot of people feel rather stifled or suffocated..simply not enough air movement for some people.

The 10 you see off the LCD display for pressure isn't an average in the typical sense of what you think averages are.
Instead it is what we call a 95% number and all that means is that for 95% of the time you were at OR BELOW that 10 cm of pressure. It's not a true average in what we typically think of as average. There is an average pressure available but you need the software to see it. It's going to be below 10 though.

Change the minimum pressure if you feel comfortable changing it or tell whomever supplied the machine to you that you want it changed.
Are you using EPR? That's ResMed's exhale relief and if you are that reduces the pressure on exhale by 1 cm per EPR setting.
It won't ever go below 4 cm though.
Are you using the ramp feature? If so it starts out at 4 cm..so even lower.

If you do change your minimum pressure say up to 7 or so and that AHI doesn't budge from what you are seeing...you need to for sure get a S9 model (if you stay with ResMed brand) because we would want to make sure that the AHI you are seeing isn't made up primarily of centrals and with the S8 you have zero way to know.

jweeks wrote:With an AHI near the moon and an O2 level that is close to strangulation, running your own machine wide open for a few days to see your data certainly couldn't be any more dangerous than sleeping with no machine at all.

-john-

Are my results are that bad? Anything dangerous? I just thought I was a light sleeper as I would wake up at the slightest noise and have a hard time sleeping deeply.

Are there any risks to not using a machine for the few weeks it takes to get my mail-order results? I did have a nuclear stress test and was told the results were fine..

I'd love to buy a machine today, but how do I know if I need an APAP/BiPAP/or VPAP? If I can get my numbers down with some tweaking on an APAP I'd love to give it a try. I just don't know, is it that simple?

jdr999 wrote:I'd love to buy a machine today, but how do I know if I need an APAP/BiPAP/or VPAP? If I can get my numbers down with some tweaking on an APAP I'd love to give it a try. I just don't know, is it that simple?

Yes, it could be as simple as a few tweaks with the pressures on the APAP. Can I guarantee it? Of course not but you gotta start somewhere don't you?
Start with more minimum pressure and if you get up to 8 cm minimum pressure and the AHI doesn't budge...then we talk about more complicated things like centrals and such along with the pesky S8 tending to score hyponeas high (that's part of the AHI).
The majority of the people with sleep apnea have the plain old garden variety obstructive sleep apnea caused solely by the collapse or partial collapse of the airway and respond well to just the right amount of pressure needed to hold the airway open better.
Start by assuming that is what you have and go from there.
I really, really wish that they had given you a S9 Autoset......

jdr999 wrote:

jweeks wrote:With an AHI near the moon and an O2 level that is close to strangulation, running your own machine wide open for a few days to see your data certainly couldn't be any more dangerous than sleeping with no machine at all.

-john-

Are my results are that bad? Anything dangerous? I just thought I was a light sleeper as I would wake up at the slightest noise and have a hard time sleeping deeply.

Are there any risks to not using a machine for the few weeks it takes to get my mail-order results? I did have a nuclear stress test and was told the results were fine..

I'd love to buy a machine today, but how do I know if I need an APAP/BiPAP/or VPAP? If I can get my numbers down with some tweaking on an APAP I'd love to give it a try. I just don't know, is it that simple?

I can't speak for the danger... short of the danger of falling asleep while driving and the like... not sure of it's feasible that you could die in your sleep (this was a concern I had pre machine, not sure if it was a rational one.) Your results as far as Ahi goes are pretty severe. Its not in the 116 range like I was, but 30 is considered severe.

There is alot of good information already posted by pugsy and others and I feel no need to regurgitate what they already wrote. Hope you can figure out something... once you can get on therapy and get your Ahi down I'm sire you will feel alot better.

Another thing to add... if your in straight cpap, higher pressures can cause you to have centrals. Id be interested in knowing if this was an issue your having. Hopefully someone more knowledgeable can weigh in in better detail on this.

Please go to a sleep lab that kind of AHI needs to be tackled. The benefit of a sleep study is that us techs know what's happening and can intervene. Leak, AHI, mask changes etc can all be tackled.

sleepstar wrote:Please go to a sleep lab that kind of AHI needs to be tackled. The benefit of a sleep study is that us techs know what's happening and can intervene. Leak, AHI, mask changes etc can all be tackled.

Agreed. I wanted to do the home sleep study to not pay the out of pocket costs associated with not meeting my deductible. My insurance is weird and would not cover it (despite them listing them on their site). But what I paid for the study did go to my deductible (study 2 out of 3 ensured I met this for the year). In your case, not being sure if you are having centrals or not due to the s8... a lab setting sleep study seems a good idea.

Are home studies a reliable method to diagnose OSA / CSA and prescribing an APAP/BiPAP/VPAP? Would I be better off attending a sleep lab?

By the way, I have a feeling I'm a very shallow breather which most likely adds to my problems..Yes it does.

A sleep lab is your best bet, and in your situation it's a question of being alive or being sick for the rest of your life. Borrow the money!

Thanks everyone for the thoughts..

I found my way into the clinical menu and up'd the minimum to 7. We'll see how that goes tonight.

Where do you think I'm headed with NovaSom and the S8? From what I've heard the S8 already assumes that I'm suffering from OSA, not CSA - correct? So do you expect that I'll be put on a run of the mill APAP for a period of time until they decide it is or isn't working for me? Is that how this normally works without a lab study?

My AHI definitely showed improvement with the APAP. Am I trying to get that number below 5?
Does it take the body a while to adjust to the machine and better breathing in general or should the AHI drop drastically low the first night?

Thanks again!
Joe

Your not considered to be treated until you are below 5. It can get better over time with some machines (the type I'm on in particular). Not sure if this applies to Cpap, but I believe it does apply to any of these devices.

jdr999 wrote:Where do you think I'm headed with NovaSom and the S8? From what I've heard the S8 already assumes that I'm suffering from OSA, not CSA - correct?

Correct. But sometimes centrals pop up after the beginning of cpap therapy...or if there were a few of them they get worse on therapy. Small percentage though if playing the odds.
Have no idea who NovaSom is or what they do or how they go about things...is the S8 just a trial machine?
Is it just to find a suitable pressure and they give you something else or do you have to go buy something else?
Where are you located? US? Other country?

Typically home titrations on APAP are for a predetermined amount of time then they look at the data the machine collects and prescribe a suitable machine and pressure...might be cpap ....might be apap...they might even dispense a machine that gathers zero data. They might expect this to be a permanent machine...I would put a stop to that if it were me.
I would make sure I know all the models that offer full data. Read this.
http://maskarrayed.wordpress.com/
You for sure want to be able to monitor the effectiveness of your therapy.

jdr999 wrote:My AHI definitely showed improvement with the APAP. Am I trying to get that number below 5?

Yes, that's the goal. Below 5 is considered "acceptable" but a lot of people like for it to be as low as they can get it.
Some do notice a difference in how they feel with AHI of 4.9 vs 1.5.

jdr999 wrote:Does it take the body a while to adjust to the machine and better breathing in general or should the AHI drop drastically low the first night?

While it may take a period of time for you to maybe generally feel better...with optimal pressures (and minimal leaks) the AHI should have a pretty significant drop.
My RX initially was for 8 cm pressure...I felt like total crap and when I looked at my reports I saw AHI of 10 to 12 when using 8 cm. I increased my pressure to 9.....the AHI dropped to around 6 to 8...then I increased pressure to 9.5 and the AHI dropped to 4 to 5 ish (but still had some clusters with times with zero events and times with a truckload within 30 minutes)...so one more increase to 10.0 and the AHI dropped to around 2.0 and I noticed significant change in how I felt...Morning killer headaches gone and peeing every hour all night long stopped.

You will find that everything associated with OSA than cpap therapy comes with a YMMV sticker.

If you had an in lab titration study the tech has access to all sorts of information that makes it so much easier to see what is going on. Like leaks...have you seen the leak number on your machine somewhere? It will be a L/sec number and a 95% number which means the leaks were at OR below that number for 95% of the night. Your large leak number to avoid with the S8...0.4 L/sec and that equals 24.0 L/min (multiply sec X 60 to get minutes).
Also an in lab study would have shown if centrals were likely going to be an issue or not.
A few centrals no big deal but a lot of them and we may have a problem. That's why I wish you had a S9 machine...we would know if your high AHI now was either central or obstructive in nature and have a better idea what might be happening.

Of course that's all a bunch of what iffing....looking for problems or issues before we know for sure what is going on.
If the increase in pressure doesn't reduce the AHI (and BTW don't expect one night to show the change..you might just have a crappy night tonight...but I hope not)...then we do more detective work. You might be better off having an in lab titration study. But let's do what we can for right now with what we have...might as well huh?

You may want to consider purchasing a recording pulse oximeter. With low O2 sats like that, AHI should not be the only concern. You want to make sure your O2 is improving with it. Search this forum for some recommendations on pulse oximeters.