BPAP Titration Sleep Study

[SarcasticDave94]

I'm being quite serious here, sounds very much like what I had to deal with for a while. And you're not wrong on the assessment IMO.

I'm not on Medicare, but I asked my primary care physician to assist in a second opinion. My disabled but not yet on Disability status has me on United Healthcare community plan with Medicaid backup. As simple as I mentioned, "PCP refer me to a second opinion for the need of treating sleep apnea."

The rest of my story is that the initial doc got me to the ASV sooner, although it required me to get an urgent visit and get other people involved in seeing the ASV need.

Best wishes again this works out before all your hair is gone. Need pointers etc.? Just ask.

[HalfAsleep]

That's just sooooo zen. Walla Walla!

My sleep center owns every sleep center for about 2 hundred miles....

[Sleeprider]

I'm impressed with the case you made, that untreated AHI is not improved by any clinical titration attempted. The doctor is apparently cherry-picking the facts she wants to see that support a diagnosis of obstructive sleep apnea and the need for more pressure, in spite of the predominately central event rate interpreted in the study. Whether these are transitional and insignificant is still buried in the detailed data.

As far as I know, you can go to another doctor for a second opinion without a referral, but you better do your homework. https://www.mymedicarematters.org/2016/0...-opinions/ There are many contradictions in your sleep studies, but you really need to find a doctor that is interested, engaged, and independent minded, with experience in complex apnea, UARS and willing to look at your event types, duration and impact with an open mind.

If auto bilevel is paid for, you should get it and use it. There is a lot more we can do with bilevel that can't be done with CPAP. If it solves the problem, all the better; if it makes central events worse, then you are on a logical path to a different solution. I think I'm repeating myself, and you'll have to clarify for me, your financial liability in this approach.

[SarcasticDave94]

Monopoly xPap edition. Instead of Water Works it's a DME. Airlines are Ducks offices.

[ajack]

If it were me, I'd get the bpap and get a cms50f off of ebay for $50 and self titrate the hell out of it. get your o2 and AHI as good as you can. We have all commented about the quality of the sleep tech and how the study was done.

You are going to have to get use to pressure, that really isn't an option. When in the future you are going to have another sleep study with another doctor. Medicare may come to the party for a sleep review in 3, 6, or 12 months. I don't know what the rules are. It would be better if you see another doctor before you accept the new machine, that will out a hold on it.

I can see their position, although I don't agree with it. You wouldn't be the first distressed, complicated patient they have treated.
" a lady comes for a sleep study, can't handle the pressure and wants it turned down. They turn it down and give up on the night and make no attempt to titrate further and make a guess at the data the next morning. Doctor gets report and follows it, there are no medical grounds to do otherwise. prescibes said machine and settings, The flippant, well some people just get high apnea, was just a parting gift."

[Sleeprider]

One other "proof" of cherry-picking, compare the number of events and duration between OA and CA in this page you posted earlier. When 80% of events are central or mixed, and the duration is comparable to the OA, why are they "incidental or transitional"?

[HalfAsleep]

I decided to:

1. Accept the prescription, if she'll prescribe a Resmed BPAP VAuto. If not, skip this.

2. Get an appointment with my [new] PCP. He's already assigned to me, but I've never met him.

     I'm going in the PCP direction, because I can get him (I expect) to coordinate care across specialties that might have relevance to sleep. As it was, I was referred for sleep analysis in the first place by several specialties (e.g. neurology), as well as the PCP. I can keep these links going via the new doc under my supervision.
     The PCP is at a hospital, and all my specialists are at the same hospital.

[HalfAsleep]

Thanks for pointing that out, SleepRider. Yep, she rated all those as "mild" events, with the centrals belonging to "sleep wake junk" "transitional arousals", whatever. I never woke up during the whole study. No "sleep wake" there. And I was awoken in the am (short about 3 hours of my normal sleep): no sleep/wake there, either. Nope, no "snooze button centrals" that morning.

She didn't answer any of my questions as far as I can see.

And that titration study (supposedly with treatment) reads almost identically to the diagnostic study.

My AHI during the titration study was 2-3x higher than my SleepyHead AHI. Go figure.

[Walla Walla]

Zen, Who's he?  

[HalfAsleep]

This Sleep Doctor is so into writing a prescription for a BiPAP without answering my questions and without any evidentiary basis that it would work.

So much for science-based, evidence-based medical practice. Considering how data-oriented sleep treatment is, and how they actually experiment on you (e.g. via titration) presumably to make customized, science-based treatment decisions, I find this bizarre, not to mention, patronizing.

This is what I got last night:
I will go ahead and order the BIPAP from Keene Medical. The BPAP machines we order can be placed in an auto-adjusting mode or a fixed pressure mode. I believe it is best to order a fixed pressure, as this generally provides better control of sleep apnea events, although if it's bothersome it can be changed to auto-adjusting. The sleep apnea on the BIPAP study was not fully controlled (there were some mild, subtle events persisting). My plan was to prescribe a slightly higher pressure which will likely lead to a lower residual AHI.

Sleep quality is complex and can be impacted by many factors. Some of those factors we may be able to treat -- sleep apnea may play a role, so it is a reasonable goal to treat the sleep apnea and see if this leads to an improvement and then reassess.

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My exasperated note today read:

Thank you.


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.


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Heck, look at another conclusion I just read in my sleep study...

Sleep efficiency: mildly reduced at 73%; prolonged sleep onset latency and awakenings after sleep onset.

Is a 73% sleep efficiency really mild? It seems unlikely that anything 73% could be called "mildly reduced." Not my candy stash, not commuter traffic, not the amount of grey hair on my head, not the dollars in my checking account.

And, dah dah dah dah, she mentions the awakenings through the night, even though I never woke up (even for the restroom); I'm assuming she means frequent arousals, which she poo-poo-ed me for mentioning.


Can anyone make a guess as to what machine she is describing?


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I'm seeing my PCP in a couple of weeks about a referral for a second opinion. I have to drive 150 miles to a very rural sleep clinic to get a sleep specialist that is not tied into the Sleep Center where I currently go.  Dartmouth has a 2-state area monopolized for medical stuff.

Onwards...