So I just received the results from my follow-up test.  I am going to be seeing my PCP to go over these, but I would be interested in opinions and any other info as I am not sure this would be my PCP strong point.  

Here is the link to my previous post that has data from original post.  http://www.apneasupport.org/viewtopic.php?t=15246

Thanks,




Patient Name :    Morgan, Keith    Height :    6'2"    PCP/Referring:    Catherine Veilleux, FNP
Study Date :    Feb. 24, 2008    Weight :    195.0 lbs.    Sleep Specialist :    Barry Krakow, MD
Date of Birth :    Feb. 18, 1971    B.M.I. :    25.0 kg/m2    Sleep Technician:    Mary Pacheco, RPSGT
Age :    37    Evening/Bedtime Medication(s) :    Depakote    Psychotropic Medication(s) :    Depakote
Study Indications :    SDB
BIPAP TITRATION
                    







Bilevel Titration Polysomnogram
 
Current Sleep and Medical History:  Mr. Morgan is a 37-year-old male patient who had a diagnostic on 12/9/07, which revealed moderate SDB with a mixed hypopneas and UARS pattern with clear worsening in REM sleep and occasional oxygen desaturations into the 80% range during REM sleep only with a lot of fluctuation of oxygenation in NREM sleep.  PLMD was absent in this patient who reports leg movement symptoms.  He returns for a titration study during which PLMD will be reassessed.

Interpretation: Mr. Morgan

1.    Moderate SDB that responds well to bilevel pressures of 14/7 cmH20, but which may not be definitive given pressure intolerance.
2.    Some pressure intolerance in the form of central apneas emerged at higher pressures.
3.    Oxygenation stabilized above 90% with PAP therapy.
4.    PLMS were frequent during REM in this patient who reports leg movement and parasomnia symptoms.  This apparently REM-state specific increase movement activity may be due to sub-optimal pressures or ‘initial phase’ PAP acclimation.  However, a separate, REM movement disorder may be present.

Patient Impression and Motivation:  On the morning questionnaire, Mr. Morgan reported sleeping slightly worse, “as far as staying asleep”; and indicated he would have no difficulty adapting to the mask.  

Recommendation: Mr. Morgan

1.    Initiate PAP therapy with bilevel of 14/6 and follow closely for clinical changes, the lower EPAP may reduce pressure intolerance.
2.    A repeat titration should be conducted in about 1 month to determine definitive pressures and reassess leg jerks.
3.    Serum ferritin and CBC should be checked as low iron storage is linked to PLMD and RLS.  Ferritin below 50 may be an indication for supplemental iron treatment.
4.    The patient’s parasomnia symptoms should be reassessed once stabilized on PAP therapy.

Prescription: Bilevel of 14/7; Heated humidifier; Quattro full face mask, size medium

Technician’s Study Narrative (reviewed and edited by Dr. Krakow): [Tech: Mary Pacheco, RPSGT]
Pt chose the Quattro full face mask, size medium.  Pt desensed and tolerated bipap well.  Pt fell asleep quickly and for first hour and a half had some respiratory events on lower bipap pressures.  Pt then entered first REM with few events.  P then went into NREM for an hour and a half on 9/6 with some REM events in second REM.  Pt then went into NREM on 10/6 for an hour and a half with only few events then entered third REM with flow limitations then went into NREM with few events then entered fourth REM with few events and bipap raised again and pt now having centrals on higher pressures.  Pt then started fifth REM on 14/7 with no events then awoke.
Mask:  Quattro full face mask, size medium
Pressure:  Bilevel of 12/7 - 14/7

Technical Profiles
Type of Sleep Study:  This was an attended positive airway pressure titration polysomnogram using a 16 channel digital acquisition device with 4 leads of EEG, 2 of EOG, 1 of chin EMG, right and left leg EMG, EKG, body position.  Oxyhemoglobin saturation and heart rate via pulse oximetry.  Thoracic and abdominal strain gauges were used to measure respiratory effort.  A pressure transducer inside the PAP machine was used to monitor airflow, and a microphone place on the neck was used to monitor snoring.  The sleep study was performed by Mary Pacheco, RPSGT and scored by Mary Pacheco, RPSGT.

Sleep Profile:  The sleep recording started at 10:14:40 hours and ended at 06:52:46 hours. Total time in bed was 518.1 minutes; total sleep time was 498.5 minutes; sleep efficiency of 96.2%. Sleep onset latency was 0.1 minutes; latency to persistent sleep was 0.1 minutes.  Stage 1 was 12.9%; stage 2 was 64.8%; stage 3 was 6.2%; stage 4 was 0.0%; REM sleep was 16.1%.

Respiratory Profile:  The patient’s AHI was 21.8 events / hr and RDI was 27.8 events/hr.  During the diagnostic study, the patient’s AHI was 45.4 events / hr and RDI was 58.8 events/hr.  

Oximetry:  Mean awake oxyhemoglobin saturation was 94.5%.  The mean sleep oxyhemoglobin saturation was 93.6% with an oxygen nadir 87.3%.  

Cardiac Profile: N/A  

Limb Movement Profile: The patient’s independent PLMS index was 2.4 lm/hr.
 
Diplomate, American Board of Sleep Medicine
Medical Director, Maimonides Sleep Arts & Sciences


 
Sleep Architecture
Recording Start Time :    10:10:45        Sleep Onset 2:                    0.1    min.
Recording End Time :    06:54:50                        Persistent Sleep Onset 3:    0.1    min.
Total Recording Time (TRT) :    524.1    min.    Total Stage Shifts :                   134    
                                            Stage 1 Shifts :                    50    
Analysis Start Time – Lights Off :    10:14:40        Awakenings (during sleep period) :    10    
Analysis End Time – Lights On :    06:52:46        REM Periods :                    5    
Effective Time in Bed (ETIB) 1:    518.1    min.    REM Latency :                    81.5    min.
Total Sleep Time (TST) :    498.5    min.            
Sleep Efficiency :    96.2    %            

1.    Effective TIB = Time from Lights Off to Lights On (not including “Indeterminate” stage-scores)     2. Sleep Onset = Time from Lights Off to beginning of first sleep episode (i.e. first sleep-scored epoch ≥ 30 sec.)     3. Persistent Sleep Onset = Time from Lights Off to beginning of first episode of at least 10 contiguous epochs of sleep (i.e. first contiguous sleep-scored epochs ≥ 5 min.)


Stage Distribution    Duration (min.)    % TST    Normative %TST    Latency (min.)
Wake (after sleep onset) :    19.5    –    –    –
Stage 1 :                                    64.5    12.9    2 – 5%    0.1
Stage 2 :                                    323.0    64.8    45 – 55%    2.5
Stage 3 :                                    31.0    6.2    3 – 8%    23.5
Stage 4 :                                     0.0    0.0    10 – 15%    0.0
REM :                                     80.0    16.1    20 – 25%    81.5


Sleep Fragmentation Summary                    events / hr.        Total Event Index    events / hr.
Respiratory Disturbance Index (RDI) :    27.8        Supine sleep :                   43.9
Independent PLM Index :                     2.4        Non-Supine sleep :                    0.0
Spontaneous EEG Arousal Index :    13.7        REM :                                   57.0
Total Event Index :                                    43.9        Non-REM :                             41.4


Body Position Results    Duration (min.)    % TST
Supine sleep :    498.5    100.0
Non-Supine sleep :    0.0    0.0
    Left-Side :    0.0    0.0
    Right-Side :    0.0    0.0
    Prone :    0.0    0.0

 

Apnea Hypopnea Index (AHI) = 21.8 events / hr.
Respiratory Disturbance Index (RDI) = 27.8 events / hr.

All Respiratory Event Types    Count    Index    Avg. Duration
(sec.)    Non-REM
Index    REM
Index    Supine
Index    Non-Supine
Index
All Apneas :                    76    9.1    15.3    10.6    1.5    9.1    0.0
All Central Apneas :                   68    8.2    15.1    9.5    1.5    8.2    0.0
All Obstructive Apneas :    5    0.6    16.0    0.7    0.0    0.6    0.0
All Mixed Apneas :                    3    0.4    17.6    0.4    0.0    0.4    0.0
All Hypopneas :                    105    12.6    16.5    12.5    13.5    12.6    0.0
All Apneas + Hypopneas :    181    21.8    16.0    23.1    15.0    21.8    0.0
All RER events* :                     0    0.0    N/A    0.0    0.0    0.0    0.0
All Flow Limited events :    50    6.0    23.8    4.4    14.2    6.0    0.0
Respiratory TOTAL :                   231    27.8    17.7    27.5    29.2    27.8    0.0
* Note:    All RER events = Respiratory Effort-Related Awakenings (RERAw) + Respiratory Effort-Related Events (RERE) + Respiratory Effort-Related Arousals (RERA) + Respiratory Effort-Related Micro-Arousals (RERMA).

Respiratory Awakenings    Count    Index    Avg. Duration
(sec.)    Non-REM
Index    REM
Index    Supine
Index    Non-Supine
Index
Apneas + Hypopneas :    0    0.0    N/A    0.0    0.0    0.0    0.0
RERAw :                                    0    0.0    N/A    0.0    0.0    0.0    0.0
Flow Limited events:                    0    0.0    N/A    0.0    0.0    0.0    0.0
TOTAL :                                    0    0.0    N/A    0.0    0.0    0.0    0.0

Respiratory Arousals    Count    Index    Avg. Duration
(sec.)    Non-REM
Index    REM
Index    Supine
Index    Non-Supine
Index
Apneas + Hypopneas :    181    21.8    16.0    23.1    15.0    21.8    0.0
RERA :                                     0    0.0    N/A    0.0    0.0    0.0    0.0
Flow Limited events :                     50    6.0    23.8    4.4    14.2    6.0    0.0
TOTAL :                                    231    27.8    17.7    27.5    29.2    27.8    0.0

Respiratory Micro-Arousals    Count    Index    Avg. Duration
(sec.)    Non-REM
Index    REM
Index    Supine
Index    Non-Supine
Index
Apneas + Hypopneas :    0    0.0    N/A    0.0    0.0    0.0    0.0
RERMA :                                    0    0.0    N/A    0.0    0.0    0.0    0.0
Flow Limited events:                     0    0.0    N/A    0.0    0.0    0.0    0.0
TOTAL :                                    0    0.0    N/A    0.0    0.0    0.0    0.0

 


Arousals                    Count    Index        Micro-Arousals    Count    Index
Respiratory-related :    231    27.8        Respiratory-related :    0    0.0
Ind. PLM-related :    0    0.0        Ind. PLM-related :    0    0.0
Spontaneous :    114    13.7        Spontaneous :    0    0.0
TOTAL :                     345    41.5        TOTAL :    0    0.0


Periodic Limb Movements
(by event type)                        Non-REM               REM              TST
                                   Count    Index    Count    Index    Count    Index
Independent PLMs :                     13    1.9    7    5.2    20    2.4
Ind. PLMs w/ Arousals :    0    0.0    0    0.0    0    0.0
Ind. PLMs w/ Micro-Arousals :    0    0.0    0    0.0    0    0.0
Ind. PLMs w/o Arousals :    13    1.9    7    5.2    20    2.4
Respiratory-related PLMs :    0    0.0    0    0.0    0    0.0
TOTAL :                                    13    1.9    7    5.2    40    4.8


Periodic Limb Movements
(by sleep stage)    Independent    Respiratory-related
    Count    Index    Index    Count
Stage 1 :    9    8.4    0    0.0
Stage 2 :    4    0.7    0    0.0
Stage 3 :    0    0.0    0    0.0
Stage 4 :    0    0.0    0    0.0
REM :    7    5.2    0    0.0
Total Sleep Time :    20    2.4    0    0.0

 


Oximetry Analysis    Wake    Non-REM    REM    TST
Mean SaO2% :    94.5    93.5    94.4    93.6
Min. SaO2%:    86.8    88.7    87.3    87.3
Max. SaO2%:    98.0    98.0    97.1    98.0
    % Time in range
90 – 100%:    79.6    99.7    99.8    99.7
80 – 89%:    2.6    0.3    0.2    0.3
70 – 79%:    0.0    0.0    0.0    0.0
60 – 69%:    0.0    0.0    0.0    0.0
50 – 59%:    0.0    0.0    0.0    0.0
< 50%:    0.0    0.0    0.0    0.0
Artifact / Bad Data:    17.8    0.0    0.0    0.0
 
Oxygen Desaturations    Relative Desat    Absolute Desat    TOTAL
                   Count    Index    Count    Index    Count    Index
Supine sleep :    7    0.8    0    0.0    7    0.8
Non-Supine sleep :    0    0.0    0    0.0    0    0.0
REM :                    0    0.0    0    0.0    0    0.0
Non-REM :                    7    1.0    0    0.0    7    1.0
Total Sleep Time :    7    0.8    0    0.0    7    0.8

Table 1.  Titration Analysis
Treatment
Level
(cm. H2O)    TIME    RESPIRATORY    OXIMETRY
    Total
(min.)    REM
(min.)    NREM
(min.)    Wake
(min.)    Obs.
Apnea    Cen.
Apnea    Hypop-pneas    Flow
Limited    RER
Events    Resp.
Total    RDI    Mean
SaO2%    Min.
SaO2%
Bi-Level = 6/4    25.1    0.0    25.1    0.0    1    0    21    2    0    25    59.7    91.7    88.7
Bi-Level = 7/5    14.7    0.0    14.2    0.5    0    0    6    0    0    6    25.4    92.3    89.2
Bi-Level = 8/6    60.3    9.5    48.3    2.5    1    2    27    9    0    39    40.5    93.4    90.7
Bi-Level = 9/6    93.5    6.4    87.1    0.0    2    3    17    4    0    26    16.7    92.9    90.7
Bi-Level = 10/6    118.7    10.1    96.6    12.0    1    8    15    6    0    30    16.9    93.5    89.2
Bi-Level = 12/7    80.7    16.5    64.2    0.0    0    7    8    17    0    32    23.8    94.3    87.3
Bi-Level = 13/7    48.4    17.7    29.7    1.0    0    6    7    9    0    22    27.8    94.4    90.7
Bi-Level = 14/7    76.3    19.8    53.0    3.5    0    42    4    3    0    50    41.2    95.0    86.8

What questions might you have?

Looks like they will be giving you a bilevel (also called bipap).  And it looks like they will do a repeat titration in about a month.
Have you gotten the machine yet?

You might ask that they give you an auto bilevel machine for the first month, at least.

Using an auto is a kind of titration.  But ask why the second titration is necessary.  I didn't get through all of this, but it might be to see if your leg movements are lessened or cease with use of a bipap.

Good luck!


Linda


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