These are the results from my split night study:

Time in Bed            138.5 minutes
Total Sleep Time:    101.5
Sleep Period Time:  119.5
Stage 1                    11.5 min
Stage 2:                   81.0
Stage 3 and 4:           0
Total REM Sleep:        9.0
Total Wake Time:    37.0
Total Wake Time after Sleep Onset 28.5

Sleep efficiency:          73.3%

Obstr. Apnea     26 Nrem   0 Rem
Mixed Apnea       2 Nrem   0 Rem
Central Apnea     0
Obsrt, Hypo      94 Nrem    4 Rem

Longest OA                    20.7 sec
Longest Ob. Hyp             23. 1 sec
Lowest Desaturation       36.9%
Avg SaO2 During Wake   93.6%

Total AHI           79.1 Nrem        26.7 Rem 74.5 Total
Avg O2 Desat    85.3 Nrem         59.2 Rem  84. Total
Lowest O2 Desat  51.8% N Rem  36.9 Rem 36.9 Total

PLMs  0

Arousals
Resp.  117 #    69.2 Index
Spont.   3   #     1.8 Index


I know the o2 numbers are pretty low.  

Some of the other numbers I have seen discussed in other posts weren't included on my summary report.

I am getting a machine on Friday and looking forward to some improved sleep.  Is there anything else these numbers tell besides my severe need for treatment?

Thanks!

Hi FMichael4!
I have nothing to add to what you have submitted, the results of the CPAP titration aren't there, we can talk about those if you get them.

Those oxygen numbers are not "pretty low", they are "critically low".  CPAP will literally be the best thing that happened to you in your life.  Check back in.
sleepydave

Hi Sleepydave.  

I wasn't sure what else could be gleaned from those numbers.  I literally tired out after typing the first results in.  I am hoping for great results from the cpap in dealing with that permanent tiredness I have had for so long.

These are the titration results from my split night study:

Time in Bed            302 minutes
Total Sleep Time:    253.5
Sleep Period Time:  280.0
Stage 1                    5.0 min
Stage 2:                  122.5
Stage 3 and 4:           0
Total REM Sleep:      126.0
Total Wake Time:    48.5
Total Wake Time after Sleep Onset 30.0

Sleep efficiency:           83.9

Obstr. Apnea      1 Nrem   0 Rem
Mixed Apnea       1 Nrem   1 Rem
Central Apnea     0
Obsrt, Hypo      23 Nrem    8 Rem

Longest OA                    16.8 sec
Longest Ob. Hyp             27. 1 sec
Lowest Desaturation       91.0%
Avg SaO2 During Wake   96.2%

Total AHI           11.8 Nrem         4.3 Rem       8.0 Total
Avg O2 Desat    93.8 Nrem         95.6 Rem    93.9 Total
Lowest O2 Desat  91.1% N Rem  95.0 Rem    91.1 Total

PLMs               85  # 20.1 Index
PLMs w/Arousal  3 #  0.7 Index
 

Arousals
Resp.   12 #     2.8 Index
Spont.   8   #     19 Index

Treatmt   Time     Sleep      REM     SWS     OA     MA     CA     OH     Index
level        (min)     (%)       (%)       (%)      #       #       #       #       #/hr
4.0          20.0        7.5         0           0         0       0        0       0         0.0
6.0          13.0       92.3        0           0         1       0        0       5        30.0
8.0            9.5      100.0       0           0         0       0        0       7        44.2
10.          20.5       65.9        0           0         0       0        0       2         8.9
12.          28.5      100.0      91.2        0         0       0        0       4         8.4
14.          84.0       91.1       45.2        0         0       0        0       7         5.5
16.         126.5      88.5       49.0        0         0       2        0       6         4.3

The lab recommendation was for cpap at 16 cm h2o.

Clearly I did better with the cpap.  I felt it the morning after the sleep test even though I was sleepy for several hours after I got up, I wasn't as tired.  From reading many posts here and other places, I know that isn't as crazy as it sounds.

Hi FMichaelF4!
Those CPAP results show you had a fabulous response to CPAP.  Some things of note:

The lowest oxygen level seen during the study is 91%, and even that was probably during one of the earlier pressures.  You really need the whole thing to be over 90% at least, with mostly >94% or so, so that's great.

We want the AHI, or Apnea-Hypopnea Index (number of respiratory events per hour) to be less that 5.0.  Yours is 4.3 on the 16 cmH2O, also great.

Frequently, with severe OSA, people have a very low percentage of REM or dream sleep, because all the apneas keep destroying the sleep continuity. Normally, you should 20% of the night as REM.  So, if you sleep 7.5 hours, you should have 1.5 hours or 90 minutes of REM.  Also frequently, in this type of person, a successful CPAP titration will result in greater than normal quantity as sleep is allowed to be continuous and the body "catches up".  So let's see, 9 minutes without CPAP, 126 minutes with CPAP-- and that's with only half a night!!!  That's called Rebound, if it ever happens to come up in a crossword puzzle.

Let me use this test to point something out, too.  There's another post going around that talks about changing CPAP pressures without the benefit of a follow up sleep study.  In this example, there's a wealth of information that would allow the doctor to scientifically decide what can and cannot be safely done.

Quote:

CPAP                                              AHI
12.      28.5  100.0 91.2 0 0 0 0 4   8.4
14.      84.0    91.1 45.2 0 0 0 0 7   5.5
16.     126.5   88.5 49.0 0 0 2 0 6   4.3

These are the 3 highest pressures that were tested.  The last column is the AHI that we were talking about.  That really has to be less than 5.  Now, a 10% weight DROP will, on the average, cut the severity of AHI by half.  So lets say you drop 20, 30 pounds, whatever, and you say "Doc, the CPAP's great, but the pressure is a little much, what can we do about that."  Now he can say, "Aha! With that weight loss, we may be able to safely drop that CPAP to 14 or maybe 12 and still be good in the AHI, your oxygen was good throughout so that's gonna be OK, and there was some REM time in the pressure that we're working with, so that should be safe, too."  OSA is almost always worse in REM, so you need make sure you have REM in the pressure that you're considering to use to be safe.

All CPAP titrations have this list in some form, and this is what the doctor is using to determine your level.  So when I say you can drop the pressure a cm or two in some specific instances, it really isn't being done arbitrarily, it can (and should be) done quite scientifically.
However, the 10% weight change (in our lab anyway) is pretty much the cutoff before you need another study.  Then the variables start to take over and it's much more difficult to predict.  I know there's time, expense, etc. with sleep studies, but you start guessing too much and you end up with an ineffective treatment plan.  You can see in this case the precision with which you can set CPAP pressures.  Frankly, I think it's worth it.

Thank you for sharing this excellent case.
sleepydave



Last edited by sleepydave on Sun Aug 28, 2005 7:21 am; edited 1 time in total

Something you might want to consider, FMichael, is talking to your doctor about a trial on autopap.   Particularly an autopap with C-Flex.  C-Flex can give some drop in pressure each time you exhale.  

It's very possible that an autopap might handle preventing "events" (apneas/hypopneas) for you with pressures much lower than the straight 16 that is probably going to be your prescribed pressure from the sleep study. The autopap machine could be set for a range of pressure say, 7 - 18 for a trial for you.  

An autopap senses from a person's breathing when there are subtle signs that your throat is beginning to close, and the machine will automatically raise the pressure some to keep the throat open.  Automatically varying the pressure throughout the night, as needed.   Ideally, an autopap doesn't "wait" for an hypopnea or apnea to happen and then take action (a common misconception about autopaps).  Autopaps don't suit everyone, but they suit a lot of people very well.  The only way to know if it suits you is with a trial period, perhaps a one month rental of an autopap.
  
If a trial on autopap showed that you could spend most of your sleep with the machine handling things for you using varying pressures lower than 16 most of the night, and had to use 15 or 16 only for a few minutes off and on (or even not at all!) during the night...well, you can see how it might be more comfortable to use an autopap machine.   The lower the pressure that can get the job done (the "job" being -- keeping the throat open) the less likely you'll be battling mask air leaks and other things.

There's no way to know if autopap would work well for you unless you can try it for awhile.  Now's the time to ask the doctor if he'll let you try an autopap, before you get locked in to whatever machine the home health care people want to give you.  You may, or may not, have any say in the matter of choice of machine.  But if it were me, and I were looking at probably being prescribed a straight cpap pressure of 16, I'd want at least a trial on autopap.

I'm not a doctor or anything in the health care profession.  Just a very well treated autopap user.  

Thanks Sleepydave.  That was very helpful and useful information.

RG, I appreciate  your suggestions.

Actually, my insurance is a high deductible plan with a health savings account.  Bottom line is that I'll have to cover the whole cost of the machine myself, whether I stay in the PPO network or not.  

After waiting 3 weeks for the sleep study results, I was getting very impatient.  I tried speeding along the DME process and my doc's secretary thought she had lined up someone to come fit me that same night as my apt....2 days ago.  Well, it turned out that the DME she lined me up with didn't accept my insurance (so I wouldn't get the price break) and the ones that would required two trips into their office, one for paperwork and the second for fitting.  

I didn't waste the last 3 weeks, though.  I have been reading as mich as I could, especially here and some of the other forums.  Deep down, I wanted the PB 420E.  I did talk to my doc, who is my primary care physician, about an auto machine but didn't get a great reception to it. She thought I ought to get EXACTLY what the sleep study called for.  She did not say "no" but didn't consider the internet a great place to buy a machine.

Since I couldn't get something from a DME without a lot of hassle, I decided to order the machine that seemed most impressive to me, so today, my PB 420 E arrived.  I was so excited I came home early from work to get it set up and try it out.  I did take an hour nap with it.  I also got a full face Ultra Mirage mask.  It seems like the mask leaks a bit at higher pressures but perhaps I can adjust it.  I think I was too tired when I ordered it because I had intended to order the Activa.  Oh well.  

Perhaps I could have given more consideration to CFlex.  I did think about that but the size, software and other features of the PB won me over.

Michael

IF you feel comfortable with it you can purchase online and possibly save some money.  Do the numbers and see if you will come out ahead.  I avoided the local DME (not something I suggest for first time cpap users unless you really feel comfortable with doing it) and purchased everything online.  I was reimbursed, but I saved a few hundred dollars over the local DME.  HOWEVER, the one thing that you can't do over the internet is try on more than one mask.  This is the one time  the local guys have a chance to beat the online folks.  IF  you PM me I can give you more info on what I did.  We do not allow commercial links posted on the board so I can not link to stores, but I will be happy to point you to a few that I have dealt with if you are interested.


Curious, where did you have your sleep study done?  Mine was at Potomac Hospital...

Quote:

HOWEVER, the one thing that you can't do over the internet is try on more than one mask.  This is the one time  the local guys have a chance to beat the online folks.

Yep, Mike,  and you chose a good operative phrase... "the chance".   Unless they have a selection of the better masks ("better" can be subjective ..heh) then there's no real advantage to trying on 3 or 4 not-so-good masks.  "Here's our most popular..."  LOL!!!

Even if the local DME stocks some of the "better" masks, it's still not a big advantage unless the DME lets you do more than try it on sitting up for 5 minutes.   I've heard of a few that let you actually try the mask at home for several nights, bring it back if it doesn't suit, try another one at home, etc. until you find one that really works comfortably for you.  Now,  that's when a DME could really shine.  Unfortunately we also read about DMEs that say, "you open it, it's yours."

Quote:

so today, my PB 420 E arrived

Good for you, Michael!!  The 420E is a wonderful autopap, imho.  I love the detail the Silverlining software gives.  Hope you got the software too, or are planning to get it.  Hope you have many, many nights of good sleep.    

Hi guys!
OK, actually, here's a case where I think AutoCPAP will or at least might not be appropriate, and make things substantially worse.

We're talking about a desaturation to 36.9% without CPAP, so if you guess wrong, you have the potential of big trouble here.

Do you see in the first study where there was only 9 minutes of REM?  It is undoubtedly because every time he went into REM, the OSA became more severe, and kept bumping him out of it.  And if the OSA is severely REM-dependent, this is gonna happen quick.

So what you have to hope for is that the AutoCPAP will identify and respond to the change in OSA severity quick enough that there will be few or no arousals that would delay or defeat REM.  And the body is going to try only so long, and then you could end up skipping REM periods entirely.  Then you don't have the normalized sleep architecture that you seek in successful CPAP titration.

That low O2 sat should be of great concern, I don't see anything in your titration results that suggest anything less than 10 cmH2O as the low pressure can be done safely.  Given your history, I can understand the concern of your physician and I would get her approval for your low limit.  And without a a sleep study on AutoCPAP, you run the risk of messing up the architecture or having dangerous desats, so overall I'd agree with her.  Stay in touch.
sleepydave

Quote:

IF you feel comfortable with it you can purchase online and possibly save some money.
.....
 HOWEVER, the one thing that you can't do over the internet is try on more than one mask. This is the one time the local guys have a chance to beat the online folks. IF you PM me I can give you more info on what I did. We do not allow commercial links posted on the board so I can not link to stores, but I will be happy to point you to a few that I have dealt with if you are interested.

Curious, where did you have your sleep study done? Mine was at Potomac Hospital...

Mike:

I did PM you as suggested.  Even though I already purchased via internet after doing a lot of reading on these boards, my biggest concern before was the mask.

Look forward to hearing from you.


Michael

RG

Quote:

The 420E is a wonderful autopap, imho. I love the detail the Silverlining software gives. Hope you got the software too, or are planning to get it. Hope you have many, many nights of good sleep.

I did get the software!  That was another big selling point for me.  


SleepyDave

Quote:

OK, actually, here's a case where I think AutoCPAP will or at least might not be appropriate, and make things substantially worse.

.......

That low O2 sat should be of great concern, I don't see anything in your titration results that suggest anything less than 10 cmH2O as the low pressure can be done safely. Given your history, I can understand the concern of your physician and I would get her approval for your low limit. And without a a sleep study on AutoCPAP, you run the risk of messing up the architecture or having dangerous desats, so overall I'd agree with her.
 

I appreciate the information about the possible concerns with Auto for my case.  I figured, though, that I would always have the option to use it in regular CPAP mode if that was necessary but still have the possibility of taking advantage of the auto features without having to buy another machine.  

I will definitely keep these concerns in mind.  

One comment though, even though my doc was astute enough to recommend the sleep study, I did not get the impression that she was all that comfortable in getting deep into the detailed results.  Even though I never talked with the dr who signed off on the study, I guess he would be the appropriate person to ask about setting a low limit.  It seems to me, though, until then if I set the low at 10 for now, I'd still be better off than no cpap, right?

Now that I've responded to some feedback, let me share a few observations from last night.

First, I definitely notice more energy today than a non-xpap night.  On a typical Saturday morning, I would have gone back sitting in my easy chair.  I don't feel like doing that at all.  

On the other hand, I woke up several times with mask leakage.  Hopefully, I will figure out how to better deal with that in the middle of the night without taking off the mask completely, turning off the machine, making adjustments and putting it back on.  Then again, on the plus side, I did keep putting it back on and other than those interruptions pretty much slept through the night.

Start date : 08/26/2005
End date : 08/26/2005
Period : 1days

Compliance :
Compliance (h/d): 6h51min
Compliance(h/d.Period): 6h51min


Used pressures (Average) :
Average pressure : 13.4 cmH2O
Low pressure : 7.0 cmH2O
High pressure : 18.0 cmH2O
Pressure efficient more than 90% of time :17.0 cmH2O

Events :
Number Apneas : 10
Index/h Apneas : 1.5
Number Apneas/CA : 1
Index/h Apneas/CA : 0.1
Number Hypopneas : 12
Index/h Hypopneas : 1.8
Number Acoustical Vib. : 93
Index/h Acoustical Vib. : 13.6
Number Runs (FL): 199
Index/h Runs (FL): 29.1

Cycle states :
Normal cycle : 68 %
Intermediate cycle : 11 %
Flow Limited cycle : 21 %
Invalid cycle : 0 %

Last settings of the period :
 ( 0 setting change )
Mode : Pilot : A+AV+IFL2+IFL1
Min. pressure : 6.0 cmH2O
Initial pressure : 16.0 cmH2O
Max. pressure : 17.0 cmH2O
Max. press. for command on Apnea  : 10.0 cmH2O
Ramp duration : 20 min

Pressure (cmH2O)
Time % - 7 cmH2O : 3
Time % - 8 cmH2O : 4
Time % - 9 cmH2O : 8
Time % - 10 cmH2O : 8
Time % - 11 cmH2O : 5
Time % - 12 cmH2O : 12
Time % - 13 cmH2O : 1
Time % - 14 cmH2O : 14
Time % - 15 cmH2O : 5
Time % - 16 cmH2O : 12
Time % - 17 cmH2O : 28


Above are the results I got from the Silverliing software.  The flow limitation number seems to be high but I am not sure I understand what this means.

Hi Michael,

You are exactly right about this, imho:

Quote:

I figured, though, that I would always have the option to use it in regular CPAP mode if that was necessary but still have the possibility of taking advantage of the auto features without having to buy another machine.  

You have two machines in one.  With an autopap you always have the option of operating it as a straight cpap machine.  With a straight cpap machine...that's all you have.  Not that straight cpap can't treat people perfectly well, but with an autopap and the software to monitor what's happening, you have better tools at hand.  

I'm not a doctor.   I'm not in the health field in any way.  I'm not an expert about these machines, the software, the data, etc.  That said, if I were were looking at that data from your first night with the 420E,  I'd experimentally try this:

1.   turn OFF IFL1 (in the advanced settings.)

2    leave IFL2 on (in the advanced settings.)

3.   leave  "maximum pressure for command at apnea" on the default of 10 (also in the advanced settings.)

4.   set the pressure range at 10 - 18.

5.   turn ramp OFF.

6.  set initial pressure at 10.


I'd try it like that for a few nights to see if turning off IFL1 might decrease these numbers:

A.  the number of "runs"

B.  the number of "flow limitations"

C.  the amount of time spent up near the top of my pressure setting range.


I'd use the 96 hour graph in the "Detailed" tab, being sure to click the magnifying glass icon at the bottom to make the graph big,  and by clicking over  to the farthest righthand side of the graph to see the most recent session.

I'd pay special attention to the "leak" line on the graph.  If the leak line was yo-yo'ing up and down a lot, and if it was approaching or touching the pink horizontal line in the leak section of the graph, I'd be concerned that I was getting mask leaks or mouth air leaks.   Of course, if a person takes the mask off without turning off the machine first, there will be a huge vertical spike upward in the leak line, along with a simultaneous huge vertical spike downward in the pressure being used.   But a lot of jagged up/downs in the leak line would be an indication of mask or mouth air leaks that need to be addressed.  Mouth air leaks especially can wreak havoc with cpap treatment - with any machine.

Good luck.