Post-Surgery Blues: Scoring Question

[mollete]

I score 95% + consistently in the AASM inner scorer reliability monthly testing.

Well that's impressive!

Certainly looking forward to your analysis.

In the meanwhile, here's an example from your website. Could you comment on it please? Thanks!

[mollete]

I guess ol' Lefty suddenly realized that this Epoch just dropped his "Inner" Scorer Reliability down to 50%.

Oh well. We'll give him another day to work on Damage Control.

[BrianinTN]

Sorry for the delay on posting this. It was a good (albeit exhausting) weekend in Tahoe. Below is everything from the sleep study. As for my food and sleep log, I started it upon my return, although I'm afraid it may not be representative of my normal patterns. Specifically, I'm trying to use CPAP at home (again), and because it's wearing me out, I'm exhausted and thus not following what would otherwise be my normal routine. For example, I took a nap yesterday for the first time in ages, I dozed off over the weekend, and I went to bed at 8 p.m. on Saturday night. Anyway, when I have some stuff cobbled together, I'll post that. Thanks in advance so much for taking a look. I very much appreciate it.

[mollete]

Sounds like a case of Post-Surgical CompSAS:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3365092/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2670335/

[BrianinTN]

Interesting. I do sound similar to the types of subjects they mention (i.e., being younger, not obese). However, my surgery was considerably less complex than those described (no maxillofacial surgery, tracheostomy, or MMA). In Table 1 of the first study, the patient didn't show onset of centrals after the UPPP, but rather only after the MMA (which appeared to address his OSA). In my case, I'm sitting on a roughly equal number of CAs and OAs after a conservative UPPP, tonsillectomy, lingual tonsillectomy, and base of tongue reduction.

I only have a few days of data, but putting aside issues associated with imprecision in measurement in home xPAP devices, my CPAP appears to be getting me to levels roughly equivalent to those from pre-surgery. Specifically: nightly AHI averages have been around 5 (almost all of which have been attributed to hypopneas; the CA index is less than 1). The pressure remains pretty steady around 4-5cm. The max has been 7.5, and in general the 95% level is between 6-7cm.

I don't know where this leaves me. Dr. G is booked months out, although I'm on a standby list for cancellations. After that appointment happens, the letter says they'll want me to do yet another titration (yay, a 6th sleep study in 3 years! Woohoo!). I question how useful that will be, given that (a) as before, low pressures appear to get the job done, but (b) the whole reason I got the surgery in the first place was that I felt worse on xPAP than without it, and that does not appear to have changed.

[mollete]

Interesting. I do sound similar to the types of subjects they mention (i.e., being younger, not obese). However, my surgery was considerably less complex than those described (no maxillofacial surgery, tracheostomy, or MMA).

Well, the Goldstein-Kuzniar patient only had some nasal stuff done.

PSCompSAS appears to be somewhat rare, so chances are we're not going to find another patient with AHI results like yours who had a conservative UPPP, tonsillectomy, lingual tonsillectomy, and base of tongue reduction named Brian.

Further, I would propose that it is not the type of surgery that determines PSCompSAS, but rather

• The net result of removal of airway obstruction; and
• Most important, the pre-existence of ventilatory instability.

In many/most (all?) cases of CompSAS, time alone can be a healing factor (although that never seems to come up in the Respironics or ResMed ASV presentations).

That NPSG architecture is a little shaky with all those awakenings.

Looking forward to sleep log, it is still suggested that sleep hygiene stinks.

I wonder where Lefty went? Probably dropped dead of embarassment.

[mollete]

I score 95% + consistently in the AASM inner scorer reliability monthly testing. Resume to follow! J/K.

Hey, not necessary! We'll just do an ISR on your previously submitted Epoch!

ISR looks at 4 categories: Sleep Staging, Respiratory Events, Arousals and PLMs. Let's see how LL fares in his scoring:



Staging

Wake is correct based on eye movements, EMG and EEG.

Arousals

The scored arousal in incorrect. There is no sleep whatsoever so you can't have an arousal. The little bit of alpha or alpha/beta comes as a result of the patient closing his eyes.

Respiratory Events

The scored RERA is incorrect. You can't score RERAs in Wake, and besides, there's no arousal anyway.

PLMs

No PLMs is correct (although those 2 events look tempting).

Passing Score: 85%

Your Score: 50%

Remedial Action Required.

[mollete]

Resume to follow!

BTW, you left the patient name on one of your hypopnea examples, so IIWY I'd crop that off (lest you be sending your resume out of Leavenworth)(OK, so it'll probably only be a fine (albeit a BIG one) but I need a line here).

[BrianinTN]

Sleep logs thus far:
Lights-out times: 11:45, 12:00, 11:30, 12:30
Wake-up times: 4:15/8:30 (woke up in middle of night and couldn't get back to sleep); 6:45, 7:30, 7:45

All food has been consumed at least 90 minutes before going to sleep. The one 90 minute food was just a small snack; 2 hrs 15 mins is the next incremental time.

Alcohol consumption on 2 of four days; 2 beers on each day, always at least 5 hours before bedtime

[BrianinTN]

Unrelated to my log: the last few nights have witnessed an ever-increasing boost in AHI. Check out last night (below). Zooming in to the latter part of the night looks like I'm getting into the vicious cycle of a pressure increased, followed by more events, followed by more pressure to "treat" those events. I assume this is the familiar pattern of treatment-emergent centrals? In my pre-surgery diagnostic, there were very few CAs (who knows what the hypnopneas were?), but once they put me on CPAP and BiPAP S/T, it was a symphony of centrals.

Anyway, I've turned my max pressure back down to 9 cm in the meantime but will await further dial-win...err...instructions.

[mollete]

Zooming in to the latter part of the night looks like I'm getting into the vicious cycle of a pressure increased, followed by more events, followed by more pressure to "treat" those events. I assume this is the familiar pattern of treatment-emergent centrals?

Well, "IMHO", it doesn't have quite the rhythmicity of PICs, and, together with hypnography above, it's a little more suggestive of SWJ. Can you upload the file someplace (for breath-by-breath review)?

...but will await further dial-win...err...instructions.

Keep in mind that mollete cannot participate in DWing.

[BrianinTN]

Well, "IMHO", it doesn't have quite the rhythmicity of PICs, and, together with hypnography above, it's a little more suggestive of SWJ. Can you upload the file someplace (for breath-by-breath review)?

I do start waking up a lot during the night toward the end, so I can see the SWJ explanation, but it's interesting that it happens when the pressure jacks up. I hadn't noticed this pattern before, as you can see from the first few nights when the pressure stayed low. Obviously, that could be a spurious correlation. I had more of them last night, despite turning my max pressure down to 9 cm.

What are PICs? A forum search for SWJ was easy; PICs gets a lot of lolcats.

Keep in mind that mollete cannot participate in DWing.

I was joking. I'll leave the diagnostic observations to you and the DWing to me. (And in all seriousness, I don't see much room for DWing anyway. I feel like crud, even using it at these low pressures, so I'm more interested in getting a handle on an explanation, since I don't think any amount of machine tweaking will fix it. Cue your poor sleep hygiene/architecture theme song.)

Data is here: https://dl.dropbox.com/u/15497133/waveforms.zip

[TheLankyLefty]

Mollete, you are a funny one.

Yes, that is sleep. I have a much clearer image than the Pixelated jpg. posted to my website. It does look scrunched there so I can see the clear reason for your targeted hatred and mistrust. Put the cap back on that red pen that's not what this thread is about. This wouldn't be anything in the ISR other than a spontaneous arousal. They don't score RERAS there.

I don't know that the "patient" name on there is a problem since it was a test subject and I received their written permission to use screenshots as examples on my website....as I do for all my educational materials. Plus I have a feeling my uncle isn't going to sue me. Just a hunch though.

[mollete]

Yes, that is sleep.

Ambiguity in those Epochs could have been avoided had you simply queried the patient:

"Are you still awake?"

[mollete]

Yes, that is sleep.

Ambiguity in those Epochs could have been avoided had you simply queried the patient:

"Are you still awake?"

BTW, either reply would necessitate a scoring of W.