Its not significant (IE not score-able) because its a central apnea that has NOTHING to do with the brains inability to get your muscles the message to breathe. For instance, a person may have a central apnea after yawning, however he would NOT be diagnosed with central sleep apnea.
Another example is movement effects on SPO2 values. If a patient moves around, his SPO2 may read at 0%, but techs realize that it isnt "real", thus it is a discounted value.
Thanks, RAM_Sleep. If I understand you correctly, the term "significant" then refers to whether or not they are considered scoreable and does not allude to whether or not they have any physical affect on the patient. That makes sense.
I still have a question. I understand why these events would not be considered "central sleep apnea", and I understand that a random post-yawn apnea has no adverse effects, but if a person is consistently having events at the onset of sleep and after arousals, and let's say these sleep onset and post arousal events occur more than 10 times per hour, is it not having the same physical affect on the body as an apnea event from a closed airway or a bio-signal failure? If not, why not?
Well onset events can be tricky. THere are labs out there that will score them and some that will not. Our "policy" is that if the onset events cease one stage 2 sleep is established, then they are simply a matter of patient acclimation. If the events continue, then they are no longer considered onset events and can be scored. If labs titrated everyone with onset events, then a lot of people would be over titrated. Believe it or not, there are labs that jump from a base 5cm h20 to 8 cm h20 if events arise in the study. What if you are a borderline OSA patient that only needs 5 cm h20, yet you have trouble acclimating to the pressyre, should you be force fed 8 cm h20 at stage 1? That is why some techs use their judgement. Luckily, techs get to see a lot of cases, so they are making educated adjustments, if that makes sense.
As to whether or not the onset events impact the body, well sure. However, most patients "grow" out of them once they get comfortable with their equipment, so they are USUALLY temporary.
But to answer you, yes apneas are apneas. The other issue is that with CPAP, the O2 levels usually do not drop much with the onset events. They are not true apneas. If they are associated with significant desaturation, then they will have a negative impact on the body. Im not sure if this makes any sense. Im in between patients and my mind is kind of off track.
Its not significant (IE not score-able) because its a central apnea that has NOTHING to do with the brains inability to get your muscles the message to breathe.
RAM_Sleep wrote:
Our "policy" is that if the onset events cease one stage 2 sleep is established, then they are simply a matter of patient acclimation. If the events continue, then they are no longer considered onset events and can be scored.
Just to be clear on this, are you saying that you do not score central apneas during sleep onset, if they are post-arousal and/or if they occur during Stage 1 sleep?
Also, is this "policy" used only during CPAP titration or in diagnostic study as well?
Its not significant (IE not score-able) because its a central apnea that has NOTHING to do with the brains inability to get your muscles the message to breathe.
RAM_Sleep wrote:
Our "policy" is that if the onset events cease one stage 2 sleep is established, then they are simply a matter of patient acclimation. If the events continue, then they are no longer considered onset events and can be scored.
Just to be clear on this, are you saying that you do not score central apneas during sleep onset, if they are post-arousal and/or if they occur during Stage 1 sleep?
Also, is this "policy" used only during CPAP titration or in diagnostic study as well?
Thank you for your time.
Ed
If there is a central post arousal, then it may not be scored. Its at the discretion of the tech, although everything must be documented, so that reading physician is aware of the situation.
This protocol is only used during Cpap titration.
We also factor in whether or not the patient has had central apneas during the baseline portion of the test.
This is what we try to avoid:
it is not desirable to increase CPAP pressure in response to open airway
apneas, firstly because this leads to an unnecessarily high pressure, and secondly
because the high pressure can cause open airway apneas, leading
to a vicious circle of pressure increase.
If there is a central post arousal, then it may not be scored. Its at the discretion of the tech, although everything must be documented, so that reading physician is aware of the situation.
This protocol is only used during Cpap titration.
Well, certainly one question would be, "What's the difference between "documenting" and "scoring", but what seems even more important is the double standard this would seem to create. Sleep-onset centrals are scored in diagnostic, but not in titration.
Further, this seems to be in conflict with AASM Scoring Criteria, which is purely objective and not dependent upon "the discretion of the tech".
Or the confusion that may occur if a patient goes to a different sleep laboratory that does adhere to AASM Criteria.
If there is a central post arousal, then it may not be scored. Its at the discretion of the tech, although everything must be documented, so that reading physician is aware of the situation.
This protocol is only used during Cpap titration.
Well, certainly one question would be, "What's the difference between "documenting" and "scoring", but what seems even more important is the double standard this would seem to create. Sleep-onset centrals are scored in diagnostic, but not in titration.
Further, this seems to be in conflict with AASM Scoring Criteria, which is purely objective and not dependent upon "the discretion of the tech".
Or the confusion that may occur if a patient goes to a different sleep laboratory that does adhere to AASM Criteria.
Ed
1- Studies are often re-scored by other techs before reaching the physicians desk. Documenting a problem will point the next tech to the situation. Thats all.
2- Like I said, if the patient exhibits central apneas in the baseline portion, then it is likely that he will exhibit them during titration. If the patient exhibits NO central apneas during the baseline portion, they why would he/she all of a sudden have a problem with central sleep apnea? There are many factors that come into play, but even the Atlas of Clinical Polysomnography (2 Volume Set) indicates time where Central Apneas are not scored.
If scoring criteria was purely objective, then techs would not be needed.
--
Trust me, I get your point. I feel like you disagree with how our lab practices, which is fine, but as much as the AASM is trying to standardize the field, it is never ever going to be black and white. There are always shades of grey.
...if the patient exhibits central apneas in the baseline portion, then it is likely that he will exhibit them during titration.
This is exactly my point. If your "policy" allows techs to now arbitrarily dismiss sleep-onset centrals in titration, then the report would now indicate improvement of centrals during titration, and that simply wouldn't be the case.
RAM_Sleep wrote:
If the patient exhibits NO central apneas during the baseline portion, they why would he/she all of a sudden have a problem with central sleep apnea?
That's the whole topic of this thread, how initiation of even low-level CPAP begins to generate central apneas. And certainly the entire basis of CompSAS.
RAM_Sleep wrote:
There are many factors that come into play, but even the Atlas of Clinical Polysomnography (2 Volume Set) indicates time where Central Apneas are not scored.
Unfortunately, that reference is not the Standard of Practice. 2008 AASM Scoring Criteria is.
...if the patient exhibits central apneas in the baseline portion, then it is likely that he will exhibit them during titration.
This is exactly my point. If your "policy" allows techs to now arbitrarily dismiss sleep-onset centrals in titration, then the report would now indicate improvement of centrals during titration, and that simply wouldn't be the case.
RAM_Sleep wrote:
If the patient exhibits NO central apneas during the baseline portion, they why would he/she all of a sudden have a problem with central sleep apnea?
That's the whole topic of this thread, how initiation of even low-level CPAP begins to generate central apneas. And certainly the entire basis of CompSAS.
RAM_Sleep wrote:
There are many factors that come into play, but even the Atlas of Clinical Polysomnography (2 Volume Set) indicates time where Central Apneas are not scored.
Unfortunately, that reference is not the Standard of Practice. 2008 AASM Scoring Criteria is.
Ed
Quick question, then im done because its not going anywere.
If you are titrating a patient, and I assume that you are a technician, what do you do with this patient?
A patient comes in for a split-night study. He sleeps for 3 hours, has 150 events, no central apneas. You place him on 5 cm h20 and he begins to have central apneas lasting for 10-15 seconds a piece. The patient finally gets into stage 2 and the central apneas are gone. He proceeds into slow wave sleep (which he had none of prior to CPAP application) and REM sleep (with NO events, other than those initial centrals). He stays in REM rebounding. He wakes out of REM and begins having central apneas again. What do you do?
A) Titrate him while awake, essentially *because he continues to wake up every 10 seconds*
Quick question, then im done because its not going anywere.
Well, I disagree with that, too, I think there may be important information to be gained here. If your scoring reference ("Atlas of Clinical Polysomnography - 2 Volume Set") is from 1996, which precedes even the 1999 Scoring Criteria, I'd certainly want to look to see if the way I was doing things was appropriate.
RAM_Sleep wrote:
I assume that you are a technician...
Actually, I just read a lot. But I'll bite...
RAM_Sleep wrote:
If you are titrating a patient, and I assume that you are a technician, what do you do with this patient?
A patient comes in for a split-night study. He sleeps for 3 hours, has 150 events, no central apneas. You place him on 5 cm h20 and he begins to have central apneas lasting for 10-15 seconds a piece. The patient finally gets into stage 2 and the central apneas are gone. He proceeds into slow wave sleep (which he had none of prior to CPAP application) and REM sleep (with NO events, other than those initial centrals). He stays in REM rebounding. He wakes out of REM and begins having central apneas again. What do you do?
A) Titrate him while awake, essentially *because he continues to wake up every 10 seconds*
B) Allow him time to adjust to the pressure?
C) Insert your own answer
---
I'm probably going to go with "C", but before I answer, what software package do I have? Is it capable of those "supplemental" parameters discussed earlier in this thread, like "R-R Intervals" and "TcpCO2"? Also, what machine am I using to titrate? Do I have access to a PAPGAM?
Quick question, then im done because its not going anywere.
Well, I disagree with that, too, I think there may be important information to be gained here. If your scoring reference ("Atlas of Clinical Polysomnography - 2 Volume Set") is from 1996, which precedes even the 1999 Scoring Criteria, I'd certainly want to look to see if the way I was doing things was appropriate.
RAM_Sleep wrote:
I assume that you are a technician...
Actually, I just read a lot. But I'll bite...
RAM_Sleep wrote:
If you are titrating a patient, and I assume that you are a technician, what do you do with this patient?
A patient comes in for a split-night study. He sleeps for 3 hours, has 150 events, no central apneas. You place him on 5 cm h20 and he begins to have central apneas lasting for 10-15 seconds a piece. The patient finally gets into stage 2 and the central apneas are gone. He proceeds into slow wave sleep (which he had none of prior to CPAP application) and REM sleep (with NO events, other than those initial centrals). He stays in REM rebounding. He wakes out of REM and begins having central apneas again. What do you do?
A) Titrate him while awake, essentially *because he continues to wake up every 10 seconds*
B) Allow him time to adjust to the pressure?
C) Insert your own answer
---
I'm probably going to go with "C", but before I answer, what software package do I have? Is it capable of those "supplemental" parameters discussed earlier in this thread, like "R-R Intervals" and "TcpCO2"? Also, what machine am I using to titrate? Do I have access to a PAPGAM?
In terms of what we use as a scoring reference, we use materials provided by Nic Butkov. The latest book that he worked on is: Fundamentals of Sleep Technology: Endorsed by the American Association of Sleep Technologists (AAST) (Hardcover) [May 2007]. Its not a perfect world, nor do we have every piece of monitoring equipment available.
While I await your answer (Im honestly curious as to what you have to say because of your intelligence), here is a different scenerio
A patient presents with daytime sleepiness. He has had 2 previous sleep studies, this being his third. The previous studies have shown no indication of OSA with AHIs under 4. He was not staifised and decided that the third time was a charm.
He slept for 2 hours with zero apneas and one hypopnea. However, he had > 15 RERAs per hour of sleep. The on-hand physician ordered treatment via CPAP.
The patient was fitted with a full face mask, leak rate of 13 LPM on a pressure of 5 cm h20. He started having central apneas immediately, while awake and into stage one. No snoring was heard, however arousals followed every central apnea. What do you do?
A) increase to 6 or 7 cm h20
B) Wait for acclimation
C) Other
--
Same as before in terms of what data you have available.
---
Sorry for the quiz, but I am curious as to what you are thinking.
Where is this place, Flintstone Memorial Hospital in Bedrock?
You at least got electricity out there?
That hardware may as well have been from 1996, too.
Trash the BiPAP Plus for an Omni (I need Servo capability), the Stellate for Sandman (to track autonomic arousals), and I'll need an NPB 70 (it's not that expensive)(hey, I coulda asked for a Tosca 500)(we're gonna try some EERS). You can't be expected to do a job without the proper tools. Without these tools, you are not "titrating", you are "screwing around".
RAM_Sleep wrote:
A patient presents with daytime sleepiness. He has had 2 previous sleep studies, this being his third. The previous studies have shown no indication of OSA with AHIs under 4. He was not staifised and decided that the third time was a charm.
He slept for 2 hours with zero apneas and one hypopnea. However, he had > 15 RERAs per hour of sleep. The on-hand physician ordered treatment via CPAP.
The patient was fitted with a full face mask, leak rate of 13 LPM on a pressure of 5 cm h20. He started having central apneas immediately, while awake and into stage one. No snoring was heard, however arousals followed every central apnea. What do you do?
A) increase to 6 or 7 cm h20
B) Wait for acclimation
C) Other
--
Same as before in terms of what data you have available.
Sorry for the quiz, but I am curious as to what you are thinking.
Where is this place, Flintstone Memorial Hospital in Bedrock?
You at least got electricity out there?
That hardware may as well have been from 1996, too.
Trash the BiPAP Plus for an Omni (I need Servo capability), the Stellate for Sandman (to track autonomic arousals), and I'll need an NPB 70 (it's not that expensive)(hey, I coulda asked for a Tosca 500)(we're gonna try some EERS). You can't be expected to do a job without the proper tools. Without these tools, you are not "titrating", you are "screwing around".
RAM_Sleep wrote:
A patient presents with daytime sleepiness. He has had 2 previous sleep studies, this being his third. The previous studies have shown no indication of OSA with AHIs under 4. He was not staifised and decided that the third time was a charm.
He slept for 2 hours with zero apneas and one hypopnea. However, he had > 15 RERAs per hour of sleep. The on-hand physician ordered treatment via CPAP.
The patient was fitted with a full face mask, leak rate of 13 LPM on a pressure of 5 cm h20. He started having central apneas immediately, while awake and into stage one. No snoring was heard, however arousals followed every central apnea. What do you do?
A) increase to 6 or 7 cm h20
B) Wait for acclimation
C) Other
--
Same as before in terms of what data you have available.
Sorry for the quiz, but I am curious as to what you are thinking.
I'll go with "C" again.
Ed
So, every patient that needs CPAP treatment is getting BiPap? Never going to happen.
Also, Stellate has new software that is a bit more updated than the software released in 1996.
In any event, if you honestly think that all sleep labs have top of the line equipment, then you are fooling yourself. In fact, I bet if you did enough reading, you will see that the majority of labs do not offer what you THINK you need to properly conduct studies.
But enough of that. You have to consider real life scenarios, not best case scenarios.
Heck, look at the studies that are posted on here. Some of them are as basic as you can possibly get. I wish that they all measured Pes, ETCO2, Etc, but they dont and they arent likely to do so anytime soon.
Take care.
--
It is a fact that pressure can cause central arousals. I have read, and experienced, onset events as well as over titrated pressures. There is even a syndrome called Complex OSA, but, in my opinion, the verdict is still out on it. We'll see what comes out of it as more research pours in.
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