BPAP Titration Sleep Study

[HalfAsleep]

Saints preserve us...The months, weeks, days are going by, hours ticking away. I'm still trying to get this sleep doc to explain a simple thing, and she dug in! And she's being extremely manipulative. Can you believe how she's purposely misrepresenting my words?

-----Here was a recent note to her from me regarding my BiPAP titration study:

I still haven't got an answer for my main question, and the answer is foundational for treatment. It's not complicated. It's one data point. And it jumps off the page. This is my third attempt.


I did two sleep tests overnight at Dartmouth's Sleep Center. One was diagnostic, no machine (August), one was BPAP titration (December). Both registered an AHI of 18. THEY BOTH HAD THE SAME RESULT. But one is considered "untreated" the other "treated [with BiPAP]."

How could that be? NOTHING HAPPENED.

The other data points on the two studies are pretty much the same as well.

Thanks in advance for answering this very basic question.


A BPAP may indeed be helpful to me, as you recommend, and I've come to you for your experienced perspective, but the titration study showed 0 efficacy.



-----Here's most of the Doc's response to that note:


I'm very sorry that I am not making my messages clear in my explanation. As you have pointed out - the sleep apnea was not fully treated at the highest pressure seen on the BIPAP study. That is why there is a residual AHI.

-----My newest response: 

It doesn't look like you're responding to my basic question. The "sleep apnea was not fully treated" [on the BiPAP study] misrepresents my point and is just plain wrong on the facts. The sleep apnea was not treated AT ALL.

Per my fourth grade science teacher, that's a null experiment. Either the process was botched or the hypothesis was incorrect or both.

I have an appointment with my PCP regarding a second opinion on the validity and protocols of the titration sleep study, its relevance, and the analysis of the data. I will proceed from there and get back to you.

[SarcasticDave94]

Sorry about the Duck you got assigned for this failed process, to put it all nicely. Time to shop for a replacement would likely be best, and it seems you're headed that direction via a second opinion. Hope that goes better than the current roadblock. I had some similar dealings for a while with the original Duck character, but as he approached retirement, he actually got pretty reasonable for the final visit.

Relax with hot tea or coffee, then work on getting a replacement.

Oh, yeah, probably wouldn't be a great idea to visit any Duck's office with anything resembling weapons.

[Sleeprider]

You have been through a particularly bad experience in this saga, and in the process educated yourself in the technical aspects of your sleep apnea problem and the methodologies to diagnose, analyze and titrate an appropriate solution. You are well equipped to discuss this with another doctor. The original one is a lost cause, and you need to write it off. Your primary criteria in selecting a physician for a second opinion is their experience in dealing with central apnea. Your first doctor refuses to acknowledge it. Once you have overcome that mental block on the part of any doctor, and found one open-minded and knowledgeable in its treatment, this process should be very easy.

[HalfAsleep]

You’re right, SleepRider, and actually I’m quite pleased with how well I’m armed going forwards. The forum has been a big help in that.

But time has also let me get situated in the more academic aspects of my sleep info, much as I’m impatient.

It’s not been all bad that I’ve had to wait this long; it’s been all bad that I’m dealing with incompetence and manipulation. But I also now know enough, and precisely enough to evaluate the process and the “experts”.

Onwards...

[Spy Car]

You will prevail. This physician does seem like a lost cause. Find another.

Hoops.

Bill

[HalfAsleep]

I am awaiting a second opinion so I can get a new sleep doc. I have for the moment declined a BPAP. This is gonna take a while.

In the meantime, I'm still on the APAP, which is better than nothing. I can actually tolerate substantially higher pressures than I used to.

But I do have a question.

I have a sudden increase in obstructive events. I noticed it especially when I switched the top pressure to 16 from 15. I rarely max out the pressure. But the APAP didn't respond to the max.I can't figure out why the increase in obstructives. Perhaps they're centrals in disguise?


Here are some examples....








My AHI has been higher, most days, but I no longer use the machine for naps (15-30 minutes), because the Sleep Center was using that nap-included AHI to tell me I was pretty much " treated" (around AHI 6). I don't usually have events while napping. (I don't like sleeping without the APAP, however; but I have a ridiculous Sleep Center). I have also removed the blank space (why is it there?) at the beginning of the flow rate.

I try not to linger when I wake up, so I don't generate sleep-junk centrals.

Ideas about why this would happen? I'm going to have to stick with the APAP for the next little while, so I'm indulging my curiosity.

----------

Update on the sleep studies. I have a brand new PCP. He seemed to agree right off the bat that my titration study was a null experiment and noticed my diagnostic study involved two different beds. He said he has to look at the sleep reports in depth (translation: he probably had to ask his supervisor how to read them), before deciding how to proceed.

[Sleeprider]

Pretty amazing progress on leaks. Congrats, I know you worked very hard on this. Going way back, I recall taking you all the way back to 8 cm fixed pressure and no EPR and in time, we decided that low pressure was not a good idea, and that EPR or lack of it doesn't make much difference. You have intractable flow limitation, and frankly I can think of a number of reasons BPAP might have been interesting to see if the flow limit could be addressed without causing a lot of centrals. Even if you got centrals but beath the FL we would at least know that what you need is pressure support with a backup rate. I don't know how to advise on this other than to suggest that if increasing pressure caused more events, don't do that.

[Fixit50]

I noticed the mode is "auto for her." Is standard mode available. If so, would the more aggressive response help or ???

[HalfAsleep]

IIRC "for Her" algorithm only goes up to 12 cm2, and then the black machine algorithm takes over at higher pressures.

[HalfAsleep]

SleepRider.....I didn't want to accept a BPAP, since I didn't feel I could go along with the doc's analysis of the study, the conclusions, or recommendations at all. By accepting the BPAP, I was going to give the appearance of agreeing with her, when she was entirely wrong.

I am open to the idea that the Sleep Center has to reimburse my insurance company (Medicare) for the cost of the study. I didn't want to nuke that possibility, either.

The doc's numbers on the BPAP titration (AHI 18) were actually worse than mine on any pressure with the APAP. Gosh, what a dimwit that she never looked at the data.

--------------

Thanks for noticing my leak management! I am very pleased with the experiment I did (titrating up from a low pressure every few nights until I reached prescription level) to make that happen. I still get those long apneas, though, with the minimal leaks. My record is 88 seconds.