Medical Evidence of High Res Data...a physician perspective

[Loggerhead]

I'm a board certified primary care physician, but not a board certified sleep physician. I review high res data multiple times each day in ResScan for my patients (man, that software sucks compared to OSCAR, but IT guys doesn't like OSCAR). I manage a LOT of PAP therapy, well over 500 patients in my own personal practice.  This comes as a result of an enormous shortage of sleep specialists...we are the de facto "specialists".  The issue I run into is that, as a primary care physician who isn't board certified in sleep medicine, I feel an obligation to refer my patients that have significant CSR or CSA to Pulm/Sleep Medicine.  My consultant physicians aren't very supportive of reviewing high res data.  My patients with CSR/CSA are coming back to me to take over management, because the consultant won't review high res data, saying it isn't accurate or it is flawed.  Today I got a phone call encouraging me not to review high res data and just rely upon an in-lab titration study if patients aren't doing well.

So, my question is, are there physicians on here that have links to clinical guidelines or peer reviewed articles discussing office based review of high res data?  

It makes a ton of sense to me to use high res data; I don't admit my patients to the hospital every night I feel like I need to change their blood pressure medication...I review flawed blood pressure logs and use that data.  Same thing here with PAP therapy.


In medicine we don't rely upon anecdotes, we rely upon good quality studies to change practice.  I performed a cursory lit review on pubmed and didn't find a study evaluating outcomes of office based titrations (via data download) vs in lab titrations.  Maybe I'm not searching the right terms or methodology.

[akarifur]

TLDR; Maybe reach out to Jason at [DME Link Removed] Supplier #41 he'd probably have any data etc you are looking for considering basically your arguement is his entire business XD.

Hi there. First of all I am NOT a physician or medical expert at all. But I wanted to respond and say thank you for caring about your patients to the degree of looking at the high res data. There are alot of physicians who won't even try or go that far. To be honest with you, from my experience with the sleep center I was referred to, you are probably more qualified than my sleep "doctor" was. First of all my sleep "doctor" misrepresented herself as a doctor, or even as a board certified sleep specialist (she was not at all). Her only actual accreditation was paying 100 bucks a month for a sleep medicine journal. However, there literally is no better option in my area. For me I had to take ownership over my own data and learning to look at it. Though I did pay Jason at ([DME Link Removed] Supplier #41 ) for a consultation. He is a registered sleep technician so maybe reaching out to him would be helpful for you? Anyway one thing to be aware of is to try and give support to your patients even when the sleep doctors play cagey. For me Jason and this community was able to identify i needed to switch from CPAP to Bilevel. However my sleep "doctor" refused to prescribe it or even consider it unless i went through a battery of her tests inlab, despite me having weeks of hires data i could show her and (she could view herself). When I refused to do the in lab study she basically threatened to cancel my referral to her, to which i found a way to find someone else (legitimate don't worry) to do my prescription so she ended up having no power over me.

Point is the sleep medicine space is a trash fire, and IMO you just by being willing to look at the data have magically become more qualified then probably most of the sleep medicine doctors. (Especially in my area.)

Disclaimer: This was in no way meant to be an insult to sleep technicians and sleep doctors who actually take an ownership and interest in patients, the sad reality is that you are few and far between and i think most people on this forum if we knew were one of them would line up at your practice so be careful

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[Loggerhead]

He's a smart guy. Maybe a good idea to email him, I'll do that. 

For years I just gave my patients a 5-15 APAP and if they had any problems, I sent them to sleep medicine. Then I became a patient...what a change.

[Crimson Nape]

FYI: Experience has shown that a starting IPAP pressure of at least 7cm-H₂O is better for an adult to prevent a suffocation feeling. The lower pressures seem to be for small individuals and adolescents.
- Red

[Loggerhead]

So funny you say that. I just started a patient on PAP about 10 min ago and I walked her through it today and I started her on 7 right in clinic and she threw off the mask saying she couldn't exhale. I ended up decreasing the pressure to 5 and she still couldn't exhale, so I turned on epr, and then she did just fine. I'm gonna bump her back up to 7 tomorrow and turn off EPR and I think she will be golden. She bought an aircurve and I don't have a titration study, so I have to use her high res data to do a manual titration myself over the next week.

[Crimson Nape]

She got the pick of the litter. On an AirCurve, setting the pressures to match the same values on an AirSense is a little. If you were going to set an AirSense for her, you would probably use a pressure range of 7 to 15 and an EPR of 3, to manage any flow limitations. On the AirCurve the comparable setting in the VAuto mode would be Min 4, Max 15, and a PS=3. In case you are unaware, the EPR on an AirSense is subtracted from the IPAP pressure setting, whereas the AirCurve adds the PS to the EPAP pressure to determine the IPAP pressure. The Max setting will not allow the IPAP to exceed this value.

I realize that you probably know this, but I thought I'd mention it anyway.
- Red

[Sleeprider]

Loggerhead, one of the sources I use in supporting titration online and helping patients self-advocate is the Resmed Clinical Titration Guide. https://www.resmed.com/us/dam/documents/...er_eng.pdf It's easy enough for patients to understand and a pretty good general resource. I don't have much respect for board certified sleep specialists due to their fixed mindset that titration is the only valid data, and unfathomable tendency to prescribe the wrong devices to patients with complex and central sleep apnea and even patients with a history of pulmonary diseases. Neither LankyLefty, nor myself have that credential, and apparently you freely acknowledge the same, yet experience counts. You probably have a better instinct on how to treat patient and how to judge the efficacy of your recommended treatment and modifications to therapy settings than the average certified sleep physician. I would actually bet on it.

In the nearly 30k posts I have logged here on Apnea Board, I have coached all manner of individual with diverse respiratory issues, health concerns and of course our favorite idiopathic results. That experience has shown that while we can fall back on certain rules and generalities in therapy, individual response to therapy options is not necessarily predictable. Sleep medicine remains a scientific process of trial and error that is critical to success, and seems to be missing in many board certified sleep specialists. It also helps to have an open mind, observe the results and understand fully the suite of options that exist to address problems. WTF happens to good physicians after they become certified, that they think machine data or patient input is not a significant resource in their decisionmaking? Anyway, I'd enjoy spit-balling some ideas concerning common problems the sleep specialists ignore like inspiratory flow limitation (aka UARS) which doesn't even factor into diagnoses, and the use of EPR and pressure support in resolving that significant source of fatigue and non-compliance.

A question I have for you is, why would you hesitate to provide the best care you know will help a patient with complex apnea, and instead defer to a specialist? The specialists are quite frankly seen here as an impediment to good results at reasonable costs. Sleep apnea is frankly dead simple, low-risk and specialists seem to be in the pocket of insurance companies and suppliers. We have encountered a number of practices with a direct conflict of interest offering diagnostic physician services and dispensing equipment under the same roof. That's not the norm, but it can be a problem. Personally, I use my primary physician (internist) to prescribe equipment and supplies I need. My needs are fairly simple, but my opinion is that a patient's physician is often the best qualified to respond to their sleep disordered breathing needs. That is particularly true if the physician has the awareness and expertise you apparently have.

[Sleeprider]

Back in line with your original question:
Reliability of respiratory event detection with continuous positive airway pressure in moderate to severe obstructive sleep apnea — comparison of polysomnography with a device-based analysis

Portable Monitoring and Autotitration versus Polysomnography for the Diagnosis and Treatment of Sleep Apnea

Accuracy of an intelligent CPAP machine with in-built diagnostic abilities in detecting apnoeas: a comparison with polysomnography 

Apnoea–hypopnoea indices determined via continuous positive airway pressure (AHI-CPAPflow) versus those determined by polysomnography (AHI-PSGgold): a protocol for a systematic review and meta-analysis

Detection of Upper Airway Status and Respiratory Events by a Current Generation Positive Airway Pressure Device

Interpreting CPAP device respiratory indices in children

Real-world data on polysomnography- and patient-reported outcomes in hypoglossal nerve stimulation and auto-titrating positive airway pressure therapy for obstructive sleep apnea

Respiratory Event Detection by a Positive Airway Pressure Device

Accuracy of Residual Respiratory Event Detection by CPAPs. a meta-analysis

Central sleep apnea during CPAP therapy: first insights from a big data analysis

Lots more out there, but in addition to the articles, you can compare events with detailed "zoomed" visualization of the flow rate data with Oscar.  If you question the CPAP data, just look at the 25 Hz data that is the respiratory flow rate. It is higher resolution than most PSG. It gets a lot harder to dismiss CPAP data as inaccurate when you can review the therapy on a breath by breath basis, visualizing tidal volume, minute rate, I:E timing, flow limitation and many other details. In fact, those that dismiss the data are either uninformed, or have such a huge ego or insecurity that they won't do their own work with the abundance of data at hand. Show me a certified sleep specialist that even knows about the Trigger sensitivity on a Resmed VPAP, and how it can significantly improve therapy to remove mild or moderate CA events and periodic breathing.

[Loggerhead]

Thanks a bunch for both replies, truly, super helpful. I'm very appreciative of your detailed response. 

A couple of responses. I'm very open to engaging in educational dialogue about management. With flow limitations, this is what drives me nuts. My patients have been told "AHI is 0.5, you are awesome". Then they come to me and ask why they are so tired. I look at the data and the whole night is flow limitation that isn't being reflected on the compliance report. 5 second glance at flows and I know the problem. 

A little insight into sleep medicine that I've encountered with my colleagues. Pulmonologists spend the vast majority of fellowship and their career in the ICU manging mechanically vented patients that are dying. Sleep medicine is an afterthought. Someone is responsible to read the reports this week, and so they have to do it. The real money is in critical care CPT codes, not PSG reports. It just isn't a priority. When I started deep diving into learning about how to actually manage these patients, I'd get their advice and after a while, they offered to pay me to join their clinic.They didn't want to manage sleep. 

Next up are the board certified sleep docs. Most are FM trained or IM trained that did a 1 year fellowship, that many say can be packed into 2 or 3 months. They don't have vent management skills. Similar to how I feel at times, I think they regularly have imposter syndrome and feel threatened when asked about the deeper details of pap therapy by patients (I don't feel threatened anymore). They probably rely upon the titration studies because the RTs actually know a hell of a lot more than patients think and they value that team member to guide them in the clinical decisions. 

Now, follow the money. Regular follow up visits bring in revenue for these docs that don't have ICU privileges, because they are FM doctors. You gotta move quick. So, reviewing high rest data for every patients will slow them down, if money is the primary goal. "oh, you are tied? Go see your PCP, your AHI is below 5 and not your pap therapy. Maybe you have depression." That sucks. 

That's why I think we end up with a bunch of gaslit patients in sleep medicine clinics. 

Now,for the reason I refer...I don't feel comfortable managing ASV using my medical license. It is one thing to give some recommendations online, it is entirely different to use your medical license. I don't want to hurt patients. So, I refer. I need to take some courses, and I'm trying to find the right ones. I'd love to pay for a CME course in interpreting PSGs and also ASV management for complex CSA. I just need to find the right one. 

Also, there is a hospital M&M committee and if a sleep doc that has more letters after their name than me disagrees with management, then my career could be over. That's why I want studies to prevent issues before they happen. 

The new guy in town told me to stop reviewing high rest data. A potential call to admin might require me to teach a suitcoat what a RERA or hypopnea is and show a bunch of flow data where the machine didn't label them, or how the reported AHI of 0.5 actually sucks because of the flow limitations. I don't want to do that.

I'm actually slated to teach a group of 500 FM physicians the basics of pap therapy at grand rounds. Maybe that will help.

[Sleeprider]

Fascinating response, and close to what I expected. I think in spite of your comfort level managing ASV patients, they are likely to be better off in your care than with the certified specialist. A surprising number of the specialists have limited to no experience with ASV, and I commonly see people here that have received ST because the specialists are so hesitant to really learn. In the case of ASV, experience is the teacher, and I'll also suggest that Resmed has great resources available only to physicians that can really up your game. I shared your hesitancy with ASV as a lay-person, but soon learned that if we don't step up and help, there won't be any useful help. I accept that each individual may have an individual response to settings we trial. A common problem with ASV are individuals that experience complex apnea and aerophagia. It's okay to compromise a certain amount of efficacy for comfort, and accommodate both issues at the same time. SV like all PAP is an exercise in trial and error, and it's important to remember that in an otherwise healthy patient, the device is unlikely to do harm, and we can affirmatively help these individuals by listening to their feedback and observing the detailed data. The Resmed ASV requires that IPAP be set at least 5-cm above EPAP, and it's amazing how many people we help can tolerate EPAP min 4 or 5 to resolve obstruction, and that get sufficient inspiratory stimulation with IPAP at +5 cm with ASV. Similarly, we have found many cases of milder CA are resolved with the Vauto using 3 to 5 cm of PS with very-high trigger sensitivity. I would live to see the researchers pick up on some of the permutations outside of normal therapeutic practice because my anecdotal experience is so persuasive.

I hope you'll stick around and talk more about your perspectives.