Was my OSA misdiagnosed?

Was my OSA misdiagnosed or does the auto setting on my DeVilbiss APAP not work for my condition? I have done 3 professional sleep studies and more of my own (see below for Details of sleep study). Two of them at home and one of them in the lab. I was diagnosed with Moderate OSA and they gave me a prescription of 8 for a CPAP. I purchased a DeVilbiss APAP And tried it on the settings prescribed (min 8 and max 8 ). The sleep was horrible even with the smartflex on so I decided to try some settings on Auto with the following results (as you can see the pressure will go to 4.5 and stay there if allowed):

Min 5 Max 10 – AHI 2.5 90% 5 95% 5 (See pulse Oximeter #1 readings below)
Min 7 Max 11 – AHI 5 NRI 0.75 EPI 1 90% 7.5 95% 7.5
Min 4 Max 8 – AHI 1.5 90% 4.5 95% 4.5
Min 3 Max 8 – AHI 1.5 90% 4.5 95% 4.5 (See pulse Oximeter #2 readings below)
Min 4.5 Max 10 – AHI 2 90% 4.5 95% 4.5
Min 4 Max 10 – AHI 3.5 90% 4.5 95% 4.5

Oximeter #1
Event Data SpO2 Pulse
Total Events 13 177
Time In Events(min) 15.4 93.2
Avg. Event Dur.(sec) 71.0 31.6
Index (1/hr) 1.8 25.0
% Artifact 0.1 0.1
Adjusted Index (1/hr) 1.8 25.0
%SpO2 Data
Basal SpO2(%) 93.4
Time(min) < 88% 0.0
Events < 88% 0
Minimum SpO2(%) 89
Avg. Low SpO2(%) 92.2
Avg. Low SpO2 < 88% ----
Pulse Data
Avg Pulse Rate(bpm) 66.0
Low Pulse Rate(bpm) 49

Oximeter #2
Event Data SpO2 Pulse
Total Events 13 99
Time In Events(min) 17.5 64.8
Avg. Event Dur.(sec) 80.7 39.3
Index (1/hr) 2.2 16.7
% Artifact 0.2 0.2
Adjusted Index (1/hr) 2.2 16.8
%SpO2 Data
Basal SpO2(%) 94.1
Time(min) < 88% 0.0
Events < 88% 0
Minimum SpO2(%) 88
Avg. Low SpO2(%) 92.6
Avg. Low SpO2 < 88% ----
Pulse Data
Avg Pulse Rate(bpm) 61.8
Low Pulse Rate(bpm) 50

Here is the details of one of my at home sleep studies:
505 Minutes of sleep time

AHI of 16.6
8 Obstructive Apneas
0 Mixed Apneas
9 Central Apneas
145 Obstructive Hypoapneas
0 Central Hypoapneas

O2
Average 91%
51 desaturations of 4% or greater
Lowest SaO2 84%

EKG normal

Diagnosis:
Moderate Obstructive Sleep Apnea
Moderate Hypoxia with OSA events
Normal sinus rhythm without arrhythmia

Are you doubting the diagnosis and need for the machine or the Devilbiss as being the best choice of machines?

How long have you been using the Devilbiss? Have you ever used any of the other brands of machines?

Are you doubting the 95% pressure numbers in the 4.5 category as an indication that maybe you don't need cpap since the AHI is not super exciting no matter what pressure range you are using?
Or the fact that you still aren't sleeping well no matter what settings you use?

I have never used a Devilbiss machine but we have forum members here who have used it with great success and love it.
It's just like each of the other brands. Devilbiss has its own criteria for the event detection and response. You aren't the first person to have a Devilbiss report where the 95% pressure in APAP mode doesn't vary much from the minimum. Why does this happen? I don't know except that the triggers for pressure increase in the Devilbiss appear a bit different from what I have read especially when it comes to snores. Snores are used as an important trigger and if you aren't snoring much then it may not respond as much.
Also the sensitivity settings for event detection and criteria for the Devilbiss is a bit different than the other machines. I don't know how much this may impact the machines responsiveness when compared to other machines.

I am doubting the diagnosis based on that I can set it to the lowest setting and my O2 levels stay above 88% and I sleep fine at the low pressure.
At the higher pressures my sleep is disturbed and it seems the AHI number increases from Central Apneas. Now I have only had the machine for around 2 weeks but I am just wondering if it is really necessary since I don't feel like I am suffocating at low or no pressure or seeing any benefit from the prescribed pressure. I was sent to a Pulmonary Doctor from my endocrinologist based on low testosterone and high red blood cell counts. So far this experiment has cost me upwards of $2500 with no real results so far.

Comment....Any time you make changes in your pressure range, you need at least a week at that setting to get any meaningful data. ! or 2 days means nothing. You don't say how long between pressure changes, but since you have only had your machine for 2 weeks, I assume it's a daily change.

LSAT wrote:Comment....Any time you make changes in your pressure range, you need at least a week at that setting to get any meaningful data. ! or 2 days means nothing. You don't say how long between pressure changes, but since you have only had your machine for 2 weeks, I assume it's a daily change.

You are correct. What would be the suggestion to keep the pressure at the prescribed (min 8 max 8 ) or set it on auto say between 6-10 for at least a week?

There is therapy value at 4 cm pressure and for some people that are lucky...all they need as long as they can sleep okay because for some people the low pressures feel stifling..not enough air movement.
Just because someone doesn't need much pressure to prevent the collapse of the airway doesn't mean that there is no need for pressure.

Pick a pressure that let's you sleep well and feel good....if higher pressures disturb your sleep quality then use a lower range...since the O2 is good no matter what you use.
GIve yourself at least a week at whatever you choose and evaluate how you feel.

How you feel and how you sleep that's more important than what pressure you use or need or minor changes in AHI.

If your AHI is more than 5 on a diagnositic sleep study then that buys you the diagnosis...doesn't matter what the pressure is that does the job. Based on what you have said...looks like you have mild sleep apnea so I wouldn't doubt the diagnosis.
Now just find the pressure that lets you sleep the best and feel the best and it doesn't really matter what it is.
Count your blessings that you don't need pressures in the teens or 20s.

Thanks for the help! I kind of felt like I was being taken for a ride when the auto pressure just sat that the lowest setting after all these "sleep studies". I will try it 2 above and below my diagnosed titration (6-10) for a week and see what comes about. The thing that gets me is the lowest AHI is coming from the absolute lowest pressure measured of 4.5. Does anyone know if the DeVilbiss SmartCode AHI goes below 4.5 or is that the lowest it will ever display?

laserjobs wrote:Thanks for the help! I kind of felt like I was being taken for a ride when the auto pressure just sat that the lowest setting after all these "sleep studies". I will try it 2 above and below my diagnosed titration (6-10) for a week and see what comes about. The thing that gets me is the lowest AHI is coming from the absolute lowest pressure measured of 4.5. Does anyone know if the DeVilbiss SmartCode AHI goes below 4.5 or is that the lowest it will ever display?

Hi,

When I used it before getting the module for the datacard, mine would frequently go below 4.5.

49er

49er wrote:

laserjobs wrote:Thanks for the help! I kind of felt like I was being taken for a ride when the auto pressure just sat that the lowest setting after all these "sleep studies". I will try it 2 above and below my diagnosed titration (6-10) for a week and see what comes about. The thing that gets me is the lowest AHI is coming from the absolute lowest pressure measured of 4.5. Does anyone know if the DeVilbiss SmartCode AHI goes below 4.5 or is that the lowest it will ever display?

Hi,

When I used it before getting the module for the datacard, mine would frequently go below 4.5.

49er

Great information! So it looks as of the APAP is titrating me to 4.5

If your titration is really that low, I would look hard at 'positional apnea' (search forum or Google) because at such a low point you may not need Cpap at all. What position do you sleep in?

Julie wrote:If your titration is really that low, I would look hard at 'positional apnea' (search forum or Google) because at such a low point you may not need Cpap at all. What position do you sleep in?

It very well could be, here are the charts with positional data

Might also be partly related to REM stage sleep...do you have something that shows sleep stages in correlation with the event clusters?
My OSA is much worse in REM and not so exciting in the other stages of sleep....
It's very common to have OSA worse in REM stage sleep or while sleeping on one's back or maybe even both. I got lucky...only REM...supine sleeping doesn't help or make it worse but REM sure does.

That last cluster...you weren't supine all the time for it and it is in a time frame where REM is likely to have happened to cycle through.

Pugsy wrote:Might also be partly related to REM stage sleep...do you have something that shows sleep stages in correlation with the event clusters?
My OSA is much worse in REM and not so exciting in the other stages of sleep....
It's very common to have OSA worse in REM stage sleep or while sleeping on one's back or maybe even both. I got lucky...only REM...supine sleeping doesn't help or make it worse but REM sure does.

That last cluster...you weren't supine all the time for it and it is in a time frame where REM is likely to have happened to cycle through.

Yes, all of those circles are during REM stage sleep. I hope to have the details from my overnight sleep study in the lab soon.

I kinda figured the clusters might be in REM but the first cluster threw me ...according to the time line sleep recording began pretty much immediately prior to the onset of the first cluster and normally REM doesn't occur for an hour or 2 for that first cycle.

Normally REM is around 90 minutes after sleep onset but there are instances where REM can start pretty much immediately.

Here's the deal when someone has more events in REM than in non REM sleep....sometimes that overall AHI doesn't reflect the actual severity of the OSA because the overall AHI encompasses the hours of sleep not in REM where not a whole lot of exciting stuff happens.

Now that I see your sleep study report and the truckload of events in REM and supine...I would be going ahead with the titration study unless you can figure out some way to sleep without ever going into REM. We can control our sleeping position to some extent but we can't control REM and that last cluster of events circled...you weren't on your back the whole time.

I bet if they could give you an AHI for your period of time just in REM sleep that it would be a lot more exciting and grab your attention more. I would be having the titration study as planned if it were me and start educating myself on the ins and outs of dealing with DMEs, insurance and all that good stuff.

Might as well start here if you haven't see it.
Learn about full data machines
http://maskarrayed.wordpress.com/
I would suggest narrowing the brands to Phillips Respironics and ResMed...they are the 2 main players it seems like.
Software for either is easily obtained, comprehensive data is collected and the software is easier to use than some of the other brands (if you can find them and figure out how to use it).

And this for what to expect from your DME or insurance and what to do to prepare yourself.
http://maskarrayed.wordpress.com/what-y ... me-part-i/

I already did have a titration study and they prescribed me a CPAP at 8. I bought a DeVilbiss DV54 Intellipap. As for insurance, I have a HSA so it doesn't pay for anything and just has me paying negotiated rates. I have spent around $2500 so far as sleep studies, mask fittings and equipment and I am not done yet as I have a follow up this week. Do you have any suggestions on set-up based on the data I provided in my first post? I am thinking of keeping the settings at 4-10 for a week since that setting has given me the lowest AHI and then see what my oximetry reports show.