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+--- Thread: BPAP Titration Sleep Study (/Thread-BPAP-Titration-Sleep-Study)
RE: BPAP Titration Sleep Study - ajack - 12-31-2017
I missed the doctor paragraph. when you are asleep you can tolerate pressure, it was when you were going to sleep you have an issue and not use to it. When you were asleep, they could have tritrated you. They didn't try. To suggest a higher pressure without testing it, when CA is in question, is a pointless sleep study.
When there is no o2 drop below 90%, to get them to do anything will be a big ask. They are going to be rightly able to say the events don't desaturate you below 90%. They aren't going to count the SWJ, there seems to be some o2 desaturation during this period. As a lot of times on the forum, it is the same opinion to reject the SWJ. You are going to have to use the arousal rate to justify anything. I think there is a typo and meant "change your cpap pressure to a pressure of 12" From What They Did there are no medical grounds to change from cpap, other than bpap PS:4 may help with pressure tolerance and definitely none to move to ASV. Of the ahi of 17 that I counted?? I think I'm right, there was CA of under 3. They need to titrate the obstructive first and then look at the CA. Down the road, CA of 3 and OA/H of 3 will get an ASV, if they count SWJ.
I don't think you are going to get much out of a bpap, like epr, bpap will make breathing easier, but may increase CA. Which kind of defeats the purpose, you might as well stay with cpap and epr. I didn't see in your sleepyhead anything that screamed get a bpap.
To work with these people and possibly your next doctor and lab. You are going to have to get use to higher pressure. Most everyone can get use to under 15cm eventually. Use the EPR to help. I really would start increasing your min 0.5 cm at a time. It will improve your obstructive OA/H. If you do this while you are waiting for your medical team to take their next step. You will be able to do a sleep test, as they want it to be done.
RE: BPAP Titration Sleep Study - HalfAsleep - 01-01-2018
There wouldn’t be any downsides to getting a BPAP, though, correct? Because I can set the BPAP with whatever pressure support I want or use it in CPAP mode? I can use it pretty much like my APAP if needed?
I think I’m going to have to attend to this on several levels. First, I have to deal with the dud titration study and its aftermath. Then I’ll decide on treatment direction. I need a sleep doctor who actually looks at sleep and doesn’t just churn out “color by numbers” prescriptions that don’t have any relationship to data or the patient. This might be hard to find...
RE: BPAP Titration Sleep Study - Sleeprider - 01-01-2018
Just be sure to get an auto bilevel so we can use the variable pressure as you do with CPAP.
RE: BPAP Titration Sleep Study - HalfAsleep - 01-02-2018
I decided to write to the sleep doc, covering administration of the titration test and the assessment. I appreciate the support from here with confirmation that I'm reading the test correctly and it's virtually identical number-wise to my diagnostic sleep test.
I can't get over how she decided I was treated with BPAP when I had almost identical numbers on the diagnostic study.
I'll update here when I hear back.
I'm waking up a lot in the night again and I keep throwing my mask off, so evidently something is bothering me sleepwise. I think I'll up the pressure by one to 9/16 EPR 3 and see if I can cruise along again. [The one time I tried 10/16, the flow chart looked hellish. It was like fighting with the devil all night and getting strangled every 5 minutes. So far, I haven't seen anything on here quite like it, but maybe that's the newb-ish in me.] I'll see if I get anywhere with 9/16.
RE: BPAP Titration Sleep Study - SarcasticDave94 - 01-02-2018
Here's hoping you hear results ASAP. FWIW When I did my BiPAP PSG last spring, the doc assessed that the pressure setting range that caused the most Apnea were the optimal settings choice.
Dave
RE: BPAP Titration Sleep Study - HalfAsleep - 01-07-2018
Seriously........
My update from the doc. I'm tearing my hair out. You are encouraged to tell me to stop with the scalping....
Here's the note I wrote collating the input from all the posts above:
Dear Doc:
I have serious concerns about the administering of the titration sleep study and assessment of the data. From what I read in the report, I’m going to need more information before saying yea or nay to a BPAP.
Regarding the data….
I have the BPAP titration sleep study (December 2017) and the diagnostic sleep study (August 2017) summaries in front of me.
When I compare them side by side and look at the numbers, the two studies, without “treatment” and with, have virtually identical outcomes.
For instance, at an AHI of 18 on titration, the numbers have not budged one iota from my diagnostic sleep study. (The CMS number is similarly within the statistical margin of error).
From these numbers, I don’t understand how the BPAP titration demonstrated “reasonably good control of obstructive events.” Nothing happened.
Regarding the administering of the titration test…..
The tech evidently got more sleep than I did.
The first 3 pressure trials were titrated while I was awake. Only 1 other pressure was tested in 5+ hours of sleep.
The final titrated pressure was chosen only 20 minutes into my sleep. NOTHING happened the whole rest of the night.
The titrating stopped at AHI of 18. Generally, an AHI of 18 is not considered “treated”. Plus, I register an AHI of 18 with no treatment at all.
At this time, my at-home overnight APAP pressure cruises at 13-15 (and EPR 3) all night long. This is in my DHMC records. There was no reason to inhibit the titration.
Moreover, no backup/timing was trialed in an effort to improve on the 18 AHI, minimize arousals, and shorten event length. In short, to do ANYTHING that might address my sleep quality.
Sleep quality was so poor during the titration, I had to spend the entire next day in bed. That’s what happens when the AHI is 18.
Regarding pressure assessment…..
There is no evidentiary basis for the recommended patient BPAP pressures: they were never tested during the study while the patient was asleep.
Earth to Doctor…..
I don’t breathe properly when I sleep. EVER: in this study, in the diagnostic study, at home every night. I’m spending most of my night transitioning back and forth between sleep and wake, not breathing (often for a minute at a time), almost not breathing, recovering, arousals arousals arousals.
The few lines of assessment in the study seem cursory and based on an incomplete and ineffective titration (see above).
Also, I can’t help but wonder why “mild obstructive events that did persist” covers an untreated AHI of 18 and an untreated event where my breathing is severely inhibited for almost a minute, a regular feature of my sleep at home and in the diagnostic study (a hypopnea of 77 seconds ).
In that vein, where are there observations, data support, and implications as they relate to my sleep quality? Poor sleep quality is why I was sent for a titration sleep study.
Where is it explained why BPAP specifically would be helpful and what treatment goals you have in mind? How will we know if those benchmarks have been met?
What are next steps if BPAP proves unsuccessful?
The answers to these questions are the purpose of a sleep study, no? Which my insurance company pays high fees for? So a patient can sleep soundly and be rested? And mitigate related health issues?
It’s a reasonable expectation that a sleep study be performed carefully and my situation advanced. I’m not seeing that here at all.
Please address my concerns so I can move forward with treatment decisions.
Thanks in advance for your help.
Dr. HalfAsleep
Also, would you mind assigning me to a frontline specialist who is not Nancy [the nurse] ? She treats me like a kindergartner; this is not a good match.
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That about covers it for the posts upthread, correct? I tried to remove all the snark. Sometimes I can't leach it out 100%, though. SAD.
See what she does not with just content, but with tone..... Won't use my title, either.
Hello Ms. HalfAsleep
You are certainly correct that the highest pressure tested did not fully control the obstructive sleep apnea. There was evidence of subtle, albeit persistent mild obstructive sleep apnea events at the highest pressure tested.
I think there may have been a couple reasons why the technologist did not push the pressure a little higher. It appeared from the communications you had in the chart that you were having some tolerance problems with the CPAP pressure (such as difficulty exhaling at higher pressures). They may have been concerned about causing more tolerance problems.
Also, the sleep apnea events that were scored on the final study were subtle. It can be difficult for the technologist to identify more subtle limitations in airflow in real time -- we have the benefit of looking at the complete study to look for patterns and more subtle information that may not be readily apparent as the information is being collected.
For these reasons, I think it would be reasonable to proceed with a BIPAP pressure slightly higher than the one tested, as this would likely improve many of these subtle events.
I did not see any abnormalities in your breathing pattern other than the sleep apnea events that were described. There are normal variations in the breathing pattern when one is transitioning between wake and sleep (including periods of breath-holding known as central apneas). Sometimes these events can be accentuated by CPAP or BIPAP, although they are not dangerous and generally would not otherwise change treatment.
It may be helpful to know that BIPAP is not better than CPAP for treating obstructive sleep apnea-- it's really going to come down to whether you feel one is more comfortable or tolerable than the other. I would also put out there that the downloads/information reported from the PAP machines can be misleading and is often not accurate. The information can be very helpful in the correct context, but in isolation it can be problematic and unreliable.
I hope this information was helpful.
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This seems to be the Sleep Center for kindergartners.....
Are you tearing out your hair, too?
RE: BPAP Titration Sleep Study - Walla Walla - 01-07-2018
Many have said it before. Time to move on to another Doctor and Sleep Center.
RE: BPAP Titration Sleep Study - HalfAsleep - 01-07-2018
That's easier said than done, Walla Walla. That's part of the problem. I'd have to get a second opinion, and I'm not sure if that's possible.
She's being thoroughly patronizing, right? Or am I seeing a tone that's not there?
I wrote back asking her to prescribe the Resmed Auto BPAP, but that might not really solve the problem. Or, it might get me a wider variety of settings, so I can proceed from there?
RE: BPAP Titration Sleep Study - HalfAsleep - 01-07-2018
Does anyone have any ideas how to get a second opinion or a study do-over or whether it's even possible? I'm on Medicare.
RE: BPAP Titration Sleep Study - Walla Walla - 01-07-2018
HalfAsleep,
You do what you have to. The road your on now leads to nowhere.