Newbie sleep study - Machine and Doctor advice?

I think I will be able to get an autopap using my insurance and DME. The top choices for me are the APAP S8, M-series, and GoodNight 420E. I just got the sleep study results today and I wonder what advice people might have given the sleep study I've posted at the end of this message. First, do you see anything that suggests a particular machine that would be good or to avoid?

I meet with my doctor next week (I did my titration study last week but no results yet except the tech said unofficially my pressure will probably be around 5). I want to give him reasons to justify the autopap for the insurance since he knows little about sleep studies but is a good listener (bless him!). Any observations about why this might be good in my case would be helpful. The only thing I can think of is that I have a very different picture sleeping on my back than on my sides. I also have allergies which might make a difference, but I'm not sure.

I'm posting the whole long thing, because I'm not sure what might or might not be important. Here's the summary, as I understand it (not very well, so I may be wrong) I have an AHI=20.3 with OA=8.6 and HYP=11.7, Most of the OAs and HYPs are when I sleep on my back. O2 saturation is generally above 90. I have a number of spontaneous arousals.

I'm very appreciative of this forum and the great info here, but just started learning and don't yet get the fine points, so would greatly appreciate any help.


Procedure

Polysomnography was conducted on the night of___. The following were monitored: central and occipital EEG, electrooculogram (EOG), submentalis EMG, nasal and oral airflow, thoracic wall motion, anterior tibialis EMG, and electrocardiogram. Arterial oxygen saturation was monitored with a pulse
oximeter. The tracing was scored using 30 second epochs. Sleep latency was defined as the first 3 consecutive epochs of sleep or the first epoch of Stage 2 sleep.

Sleep Staging Data

Lights Out 9:22:02 PM Sleep Onset 10:32:02 PM
Lights ON: 5:10:02 AM Sleep Efficiency 65.7%
Time In Bed (TIB) 468.0 min % inter Sleep/wake: 21.7%
Total Sleep Time (TST) 307.5 min REM Onset (from Sleep Onset) 57.0min
Sleep Staging % Total Sleep Time
Stage 1- 0.7
Stage 2 - 51.9
Stage 3 - 2.1
Stage 4 - 28.0
Stage REM - 17.4

Wake During Sleep 85.0
Total Wake Time 146.0
%wake 31.2
#of REM periods = 9

Arousals
REM – total=8 w/resp event=0 w/resp event/desat=3 Spontaneous arousal =5
NREM – total=147 w/resp event=23 w/resp event/desat=18 Spontaneous arousal=106
MVT (all were 0)
WK – total=15 w/resp event=0 w/resp event/desat=3 Spontaneous arousal=12
Total arousals tot=170 w/resp evt=23 w/resp evt/desat=24 Spontan. arousal=123


AHI = 20.3
CA=0 OA=8.6 MA=0 HYP=11.7 Events = 20.3

Supine – Total min=169 Tot Apn=44 Tot Hyp=51 AI=15.61 HI=18.10 RDI=33.71
Left – Total min=46.51 Tot Apn=0.0 Tot Hyp=9 AI=0.00 HI=5.87 RDI=5.87
Right – Total min=92.00 Tot Apn=0.0 Tot Hyp=0.0 AI=0.00 HI=0.00 RDI=0.00

Mean Heart Rate – Awake=86.7 REM=72.8 NREM=70.0



Impressions:
There were arousals and some respiratory events noted throughout the recording. There was a significant decrease in sleep efficiency down to 65.7% of the night. There were prolongations to stage 1, stage 2, and stage 3-4 slow wave sleep noted with a slightly prolonged REM latency of 127 minutes. There was a slight decrease in REM sleep noted with an increased amount of stage 3-4 slow wave sleep seen. There were 170 arousals noted throughout the recording and an apnea/hypopnea index that is moderately abnormal and elevated at 20.3 principally in the form of obstructive hypopneas. Respiratory events were seen in all sleep stages and predominantly occurring in the supine position. Oxygen desaturation reached a minimum of 90%. There were no significant cardiac arrhythmias noted and no abnormal leg movements that led to any arousals seen.

Treatment Recommendations:
1. Weight loss.
2. Nasal CPAP titration.
3. Avoid driving if daytime sleepiness is present.

Final Diagnosis:
1. Moderate Obstructive Sleep Apnea with an apnea/hypopnea index of 20.3 with both
obstructive apneas and obstructive hypopneas seen in all sleep stages. Principally
respiratory events were seen in the supine position and more severe in the supine
position.
2. Oxygen desaturation down to 90% which is borderline normal and is secondary to
number 1 above.
3. No significant cardiac arrhythmias were noted.
4. No evidence for Periodic Limb Movement Disorder of sleep.

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): 420E, Titration, Arousal, CPAP, DME, AHI, RDI, APAP

A titrated pressure of 5?????
I would think it would be pretty hard to justify getting an Auto with a low titrated pressure, unless your titration was totally "hosed".....and I'm sure they won't want to admit that.

My advice would be to at least get a machine that will record nightly details and get the software to go with it.....THEN you will know whether an Auto may be warranted.
If your pressure is truly going to be 5, you wouldn't even need C-Flex or EPR.

Den

Rosemary,

I'm with Den on you getting a machine that records data (not just compliance), though my reasons are personal experience.

I'm sure there are folks out there that a pressure of 5 is truly all they need. It just makes me want to say, "But are you SURE?" Without a data recording machine you have to wait for weeks or months to see if feeling bad is ever going to go away. I wasted my first months getting worse instead of better, so I'm really a big proponent of data capable machines. I feel so very strongly about it, and wonder how a doctor can not want all possible available information to help a patient. Okay, off the soapbox.

Best wishes in working everything out and getting good sleep on a regular basis.

Kathy

Rosemary,

I would try to use the low titrated pressure as a REASON to get the APAP. In other words, on that one night, in those certain positions, with no other complications (like a cold), you had a very low titrated pressure. But an APAP would compensate for any variables that might raise the pressure needed to open your airway, on any given night.

Good luck to you!

Thanks for the input, Den, Kathy, and tangents. This is very helpful. A machine with full data capability is a must as far as I'm concerned, too.

I suspect that the tech who did this is not very good. She's not certified and made a lot of mistakes in the reports, like my age, typos, said I tried several types of masks when I only tried one type (nasal) but different brands, and I couldn't even figure out one of the words she wrote in context.

Also, after the first study, she said that she didn't think I had sleep apnea, but it turned out that I had moderate sleep apnea. I had the same tech for the titration study, and I couldn't help but wonder how she could titrate if she couldn't figure out that I had moderate apnea in the first study. What would be the basis for her titration? I may be able to see more about the accuracy of her work when I see the full titration study, at least I hope so.

I'm hoping I do have a low pressure like 5, but I'd like a good way to make sure easily without running back and forth to the DME and the doctor and trying to convince people. I have to find a more diplomatic way of saying I don't think the tech was good when I talk to my GP, though. I have an appt with the GP on Tuesday, if the titration report is done by then.

Can you tell I'm anxious about all this?

Rose

Anonymous wrote:I couldn't help but wonder how she could titrate if she couldn't figure out that I had moderate apnea in the first study. What would be the basis for her titration?

Sounds like you didn't have a very good experience for sure. Sleep techs have different levels of accreditation, experience, and yes, skill. To answer your question, it looks like this tech isn't qualified to score a sleep study, or when she was scoring it on the fly wasn't very attentive, or maybe even had 3 patients going simultaneously. Your AHI is made up primarily of hypopneas, and to an unexperienced/inattentive eye, that's just loud snoring.

My guess is that she doesn't score, watched you sleep, and noted that you weren't having all out apneas all over the place, and then (unprofessionally) gave you a non-diagnosis before the study had actually been scored. So, the basis for the titration is someone proving she's wrong. Lovely. I'd be leery of the titration as well, as there could be psychological motivators for the low pressure. A data capable machine would be a great way to trust and then verify.

[quote="blarg"][quote="Anonymous"]Your AHI is made up primarily of hypopneas, and to an unexperienced/inattentive eye, that's just loud snoring.

Rosemary,

I'm not even going to try to comment on the technical aspects of your questions, but I just wanted you to be aware that some on this forum (including me) feel suffocated at a pressure of 4-5. Another reason for an APAP, so you can set a comfortable setting for yourself. Higher pressures can sometimes trigger central apnea events, but your data should help you figure out the best setting for you.

Rosemary:

I am very surprised that you had an AHI of 20, yet they Rx'd pressure at 5!

They started me out at 5 also. Guess what? I'm on an Auto (I purchased), and my settings are 9-12 !! I usually read at a steady 11 for most of the time. My AHI went down drastically to between 0 and 1.

YES, you need a machine that allows your breathing to fluctuate during the night, because you do fluctuate NATURALLY! I bought my APAP out of pocket (cpap.com) because I felt I needed it .

You're on the right track, getting 'ammo' for your doctor. If he's looking out for you, I'd think he would go along with what you can justify. If they don't know as much as you, they may just do that.

In addition, some of us have had more than one sleep study, each with DIFFERENT RESULTS! I doubt there was a Respiratory Therapist at your sleep lab! So, that's why we buy software, card readers, study the reports, ask questions here when needed, then make adjustments in small increments, and continue from there. I doubt that you'll get a RT (if you can find one) to work with you on doing that...further reason for getting an AUTO - it will show you what levels you're at during the night. If they are at the highest setting, then set the higher number up one, etc. OR, the numbers may be lower, and you can set the parameters accordingly.

One problem may arise...your DME will get a copy of the sleep study, along with the Rx from the doctor. They may just tell you (as they did me) that you "don't need and Auto, and they'll rent you something cheaper for them.

My recommendations are purely from experience.

Thanks for the heads up on the low pressure, tangents. The tech started me off at 4 and I did feel suffocated. I asked her to turn off the heated humidifier after a while due to this, but I'm sure I'll need this because my mouth, nose, and eyes are already quite dry.

Offerocker, my titration study was only 3 hours long, but in the original study, I had the vast majority of the apnes after that time, between hours 3-5. I will point this out to my doc, but I haven't seen the complete titrations study yet, so I'm not sure what it will show. I was surprised at the low pressure, too, which the tech did during the last part of the study.

Some good points here that I will bring up with my doc. I'm determined to get the machine I want. I already called the DME telling them I was shopping for a place to buy my xPAP. They said that what I needed to have was a script for a specific machine and they'd give me that one. If they try to rent me a different one, I have the name of the person I spoke to. I won't hesitate to go elsewhere if I need, but hope I've laid the groundwork enough to make it smooth and pleasant. This is a small regional DME with a decent reputation from what I hear.

I'm keeping my fingers crossed.

My experience has been that the small regional DMEs provide much better, friendlier service and do try to provide the machine you want. My 3 state-wide DME is a PITA to describe them nicely.

You seem to be on the right track, RosemaryB. Don't sign for any machine that isn't what you want to be stuck with! Good luck!

I personally think it's a good idea to have at least a trial on autopap (I'd want an autopap, period) rather than rely on a titration night that found either a very low pressure or a very high one for me. It's very possible that 5 is all you need, but the autopap trial at home could confirm that, or show that there are times that more is needed.

I'd want to use a Respironics REMstar Auto for the trial.

Am I right in thinking that her best reason for an AutoPAP is the line in the report that says: "Principally respiratory events were seen in the supine position and more severe in the supine position."

Isn't that (one of) the best arguments for getting an AutoPAP -- that it will reduce/increase the pressure as it's needed -- so if she's sleeping on her side, it will cut back the pressure since she doesn't need it. (Thus, more comfort, better compliance, etc).

Just another newbie's thoughts...

John

johntee wrote:Am I right in thinking that her best reason for an AutoPAP is the line in the report that says: "Principally respiratory events were seen in the supine position and more severe in the supine position."

Isn't that (one of) the best arguments for getting an AutoPAP -- that it will reduce/increase the pressure as it's needed -- so if she's sleeping on her side, it will cut back the pressure since she doesn't need it. (Thus, more comfort, better compliance, etc).

Just another newbie's thoughts...

John

Very good thoughts. I agree.