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CobaltSky
Unread post  Post subject: I need help with this titration report - Maybe from Jason?  |  Posted: Thu Nov 16, 2017 2:15 pm

Joined: Thu Nov 16, 2017 1:32 pm
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Location: Peyton, CO
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I am 45 and have had sleep apnea since I was in my late teens. I have had maybe 6 sleep studies over the years and 5 or 6 different CPAP/APAP machines in that time. 2 years ago I had lost weight and was told I didn't really need it anymore, but I couln't sleep without it, so I kept using it with low pressure. Then I moved from near sea level to 7400ft, and my AHIs have gone up (I don't see detailed data from my S8), and I have gained about 60 lbs back. So I went to get a study in Colorado Springs about 6300ft elevation (1000 ft less than where I sleep every night). I do take a couple of trips per year into the higher mountains to ski (sleeping about 9k ft) and my AHI goes way up. So I decided I needed another study, STAT. I have never had Central Apneas before and now it is all centrals... The tech could not find a bilevel pressure that worked for me. Most of my apneas occurred on that bilevel experiment. I also didnt't tolerate the "clipping" of my breaths on the bilevel treatment, and subsequently didn't sleep well during that portion.

I thought it curious that I was only recommended APAP 11-20 based on this study and so I tried setting my S8 to 9-12 last night and set my EPR off to see what happened. My AHI was 18 and pressure was 11.7
Problem is I had HORRIBLE mouth leaking all night, and problems with the pressure, and lots of aerophasia. I got maybe 3-4 hours out of 8 attempted. It sucked. I am feeling that 11-20 will destroy me because everytime the machine "sees" an event the pressure goes up and I get more and more uncomfortable. 11 seems to be my upper limit of tolerance, not my lower limit!

Also, I am wondering if I should ask for an O2 concentrator to help with the CSA, which my tech said is probably due to altitude. Basedon my Bilevel experience during the study, I think ASV would not be tolerated well. I'm used to CPAP after all these years.
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TheLankyLefty
Unread post  Post subject: Re: I need help with this titration report - Maybe from Jaso  |  Posted: Thu Nov 16, 2017 8:37 pm
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I'm thinking that 11cmH20 is an upper limit of therapeutic settings too. First you need to control for that mouth leak or you're going to be spinning your wheels all night.

It's kind of an ugly study from what little I see. I really question the long segment of the report where you are allegedly asleep, but your SPO2 looks like a caterpillar from back to back desaturations. I don't believe you were awake during this. Things like this bring in to question the validity of all of it.

ASV is a completely different animal than Bilevel. There really isn't a comparison between the two even though they are both basically "bilevel." A Ferrari and a Pinto are both basically "cars" too. ;)

Oxygen may be needed because of elevation. Looks like you were pretty steadily in the mid to low 80's, so that may not be a bad idea. I would suspect that many of the "hypopneas" scored during the sleep study were really mouth leaks. They manifest in the same way and look the same to the scorer if the night tech isn't documenting well or paying attention.

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CobaltSky
Unread post  Post subject: Re: I need help with this titration report - Maybe from Jaso  |  Posted: Thu Nov 16, 2017 9:01 pm

Joined: Thu Nov 16, 2017 1:32 pm
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Location: Peyton, CO
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Pressure Setting: 7

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Thanks! Yes, I felt this study was very ugly compared to past ones (except a split night they made me do about 20 years ago), and a real pain to be the subject of. It doesn't really scream good night's sleep, does it? I don't think I have ever had so many events during a straight titration study. Stupid altitude giving me centrals and treatment keeping me from sleeping. (The wake times and sleep percentages look like what I remember from the night. I was awake more than any other study I have ever had.)

I just saw my doctor (primary care) and pretty easily talked him down to an 8-12 range (which I will of adjust as needed after I start getting data). I asked him to write for an Airsense 10 Autoset vs. just APAP, and had him specify I wanted a Dreamwear (based on your video, because I want to try it over my normal P10, and also an Airfit F20 for when I have nasal congestion (which seems chronic with me...) I am hoping insurance will at least cover the full face mask.

So are you saying that I had ASV in the titration or Bilevel? What ever it was, I hated it, even at low pressure. It upset me that it had such a sharp cutoff of air before I was ready, like trying to force me into a pattern while I was awake. The tech turned it down to the slowest setting and I still just hated it.

He also wrote me for 2LPM of O2 based on this study I showed him: http://jcsm.aasm.org/viewabstract.aspx?pid=28368
He doubts the insurance will pay for it but I'll likely foot the bill for it myself early next year if I can get it to count in my deductible for the (very) HDHP I am being forced into.

Tonight I am going to put my EPR back on the old S8 and try 8-11 and check my morning numbers on the green screen if I can get those accursed soft touch buttons to work the way they used to. An AHI of 17 is the lowest number I have seen in Colorado, with my tinkering. I think it was just over 100 when I spent a week in Breckenridge, sleeping at about 10k ft. Oye the headache!


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CobaltSky
Unread post  Post subject: Re: I need help with this titration report - Maybe from Jaso  |  Posted: Tue Nov 21, 2017 9:51 am

Joined: Thu Nov 16, 2017 1:32 pm
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Can anyone explain why with 0 OSA events, and 69 CSA events, the recommendation from the study was just APAP, not BiPAP or ASV or O2>APAP? My only thought is that they are trying to treat for the hypopneas only and hoping the centrals clear up on their own. My problem is that Jason seems to doubt the hypopneas, and I don't necessarily disagree.

In my home pressure experiments since the study (with just whatever data is on the screen, my leak rate is up and my AHIs are mostly awful.
For example, last night I tried a 7-10 range, it reported 10 in the morning with a .44 leak (my yearly leak rate is like .02) and a 45 AHI. I had dry mouth whenever I woke up. I had EPR on 3, which kind of blew away my working theory from previous nights that EPR was helping with mouth leaks. (at 6-9 with EPR my AHI was 18, but at 5-8 without EPR, I was at 28 AHI).

So tonight I guess I may try a narrow 8-9 range with EPR and see what happens. Still waiting on the DME to contact me about updated machine after doc wrote the order, and really not feeling good.


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TheLankyLefty
Unread post  Post subject: Re: I need help with this titration report - Maybe from Jaso  |  Posted: Wed Nov 22, 2017 5:05 pm
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CobaltSky wrote:
Can anyone explain why with 0 OSA events, and 69 CSA events, the recommendation from the study was just APAP, not BiPAP or ASV or O2>APAP? My only thought is that they are trying to treat for the hypopneas only and hoping the centrals clear up on their own.
That is a very common practice. If after a month the CSA is still present you will likely have a bilevel trial.

CobaltSky wrote:
My problem is that Jason seems to doubt the hypopneas, and I don't necessarily disagree.
For the same reason you could doubt the Central Apneas. Mouth leaking causes all sorts of problems.

CobaltSky wrote:
I had dry mouth whenever I woke up.
Focus on controlling the mouth leak and the rest is easy. Try a double sided boil and bite mouth guard or a soft cervical style piece of equipment to go under your chin and encourage it to stay closed.

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CobaltSky
Unread post  Post subject: Re: I need help with this titration report - Maybe from Jaso  |  Posted: Sat Nov 25, 2017 9:22 am

Joined: Thu Nov 16, 2017 1:32 pm
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Location: Peyton, CO
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PAP Machine: ResMed s8 Autoset II
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Pressure Setting: 7

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Well I went straight for the tape to see what effect the mouth leak was having. Pressure of 8-11 showed a 10.8 in the morning with leak 0.02 and AHI of 23. Better but still bad.

I am going to step up to a 9-12 and keep taping and see what I can get. Still no word from DME on my new prescription. It has been a week an a half since the order... Not sure what is a typical wait but this seems long.


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CobaltSky
Unread post  Post subject: Re: I need help with this titration report - Maybe from Jaso  |  Posted: Fri Dec 01, 2017 7:30 pm

Joined: Thu Nov 16, 2017 1:32 pm
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With the tape, when it doesn't gap and open up a leak, I can get my leak # down to 0 or very close to 0 lps on the old S8. Most nights I seem to be able to get my AHI to about 10 now (never under 9), with nights where the tape fails or I find myself awake a lot with insomnia it is 30+.

Apria has my order for the new machine and concentrator and FFM but hasn't acted on it yet :( I leave for a week at 10000ft on the 10th so I am hoping to see results from them by then.

Once I get the sleepyhead compatible machine, I might be able to see where that 10 minimum AHI is coming from and tune it down further. That is my hope anyway. I bet the O2, if I can get it, will be a difference maker with centrals at my altitude.


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LSAT
Unread post  Post subject: Re: I need help with this titration report - Maybe from Jaso  |  Posted: Fri Dec 01, 2017 8:00 pm

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I used the S8 for several years and it is known to overstate Hypopnias. I always had an AHI of 4-5 with the S8 and as soon as I switched to the S9 my AHI dropped in half and it has stayed there.


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CobaltSky
Unread post  Post subject: Re: I need help with this titration report - Maybe from Jaso  |  Posted: Sat Dec 02, 2017 10:13 am

Joined: Thu Nov 16, 2017 1:32 pm
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LSAT wrote:
I used the S8 for several years and it is known to overstate Hypopnias. I always had an AHI of 4-5 with the S8 and as soon as I switched to the S9 my AHI dropped in half and it has stayed there.

Awesome to hear, I was hoping for that.
I seem to throw off my results a ton while awake on the machine. This morning I woke up too early (Saturday) :) and immediately checked AHI and it was 10.7 I never took the mask off and tried to go back to sleep for about an hour before giving up. I thought I was breathing regularly during that hour trying to get back to sleep. When I gave up and checked AHI it was over 20. So an hour of awake breathing doubled my average AHI from the entire night. I don't remember this behavior from when I lived near sea level, so I don't know if it is something I am doing or something with the machine or some effect of my 7400ft elevation, but it means I can't trust the aggregate numbers on this S8 Autoset, so I wait for new equipment, not so patiently...


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cindyY
Unread post  Post subject: Re: I need help with this titration report - Maybe from Jaso  |  Posted: Sat Dec 02, 2017 9:24 pm

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CobaltSky wrote:
LSAT wrote:
I used the S8 for several years and it is known to overstate Hypopnias. I always had an AHI of 4-5 with the S8 and as soon as I switched to the S9 my AHI dropped in half and it has stayed there.

Awesome to hear, I was hoping for that.
I seem to throw off my results a ton while awake on the machine. This morning I woke up too early (Saturday) :) and immediately checked AHI and it was 10.7 I never took the mask off and tried to go back to sleep for about an hour before giving up. I thought I was breathing regularly during that hour trying to get back to sleep. When I gave up and checked AHI it was over 20. So an hour of awake breathing doubled my average AHI from the entire night. I don't remember this behavior from when I lived near sea level, so I don't know if it is something I am doing or something with the machine or some effect of my 7400ft elevation, but it means I can't trust the aggregate numbers on this S8 Autoset, so I wait for new equipment, not so patiently...


It's possible that you had some sleep onset centrals flagged while you were trying to get back to sleep. This happens to me sometimes, I'll think that I don't drift off, but when I check SleepyHead I have a cluster of centrals in that time frame that throw off my numbers. I have decided if I have slept over 6 hours and don't fall back to sleep within 10 minutes of waking that I just take off the mask and get up. Hopefully you will get your new machine soon and can figure out what's going on.


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CobaltSky
Unread post  Post subject: Re: I need help with this titration report - Maybe from Jaso  |  Posted: Fri Dec 08, 2017 10:38 am

Joined: Thu Nov 16, 2017 1:32 pm
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Location: Peyton, CO
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PAP Machine: ResMed s8 Autoset II
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So I did get the O2 concentrator yesterday, and still waiting on the data capable APAP. '

I have settled on a mouth taping regimen which has my leaks at 0.00 L/s and a APAP range of 9-12, and my 95% pressure reading in the morning has been between 11-11.8 lately. My EPR setting is a fulltime 3 at the moment,

These are my Spo2 numbers from the night before O2 arrived:

Without O2:
Average SpO2 % 91.12
Min SpO2 % 85.00

After 1 night on 2LPM bleed in.
With O2:
Average SpO2 % 96.74
Min SpO2 % 93.00

My AHI last night was 2.3 with a 0.0 AI and pressure read 10.6 in the morning.
I am at a loss to explain how my hypopneas and autoset pressure decreased in response to added O2, but that seems to be the case. (Expecially since I am coming down with a cold and was fighting congestion last night.) I wonder if there is such an animal as "central hypopnea". I just assumed that all hypopneas were obstructive in nature.

Anyway I woke up without a headache today, but I think my body misses the O2 from overnight, because as I sit here on the computer at 7400ft elevation my Spo2 is running back down at my 92% baseline noted in my sleep study and a headache is starting...


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