First, a little history-Otherwise Healthly Male, Age 50, 6"1" weight of 205 for a BMI of 27.  Within normal limits.
Primary complaint - trouble sleeping for many years with snoring and daytime sleepiness.  Usual bedtime is 9-10PM with awakening at 3-5AM.  No shift work history or frequent travel.  There is a history of loud snoring and restless sleeping along with sleep related breathing adnormaility.  There is significant daytime sleepiness component with the Epworth Sleepiness Scale being markedly elevated at 16.

Polysomnogram data shows lights out at 10:31PM.  During the first two hours the test diagnostics were done.  Sleep latency is normal at 5 1/2 minutes.  Sleep efficiency is good at 92%.  Review of sleep stages distributiuon showed an absence of REM sleep.  6% of the time is spent in Stage I, 80% in Stage II, 13% in Stage III, and 1% in Stage IV.

During this two hour interval there were 83 obstructive apneas, 13 mixed apneas, 10 central apneas and 81 hypopneas seen totalling 186 respiratory events.  The overall apnea hypopnea index is markedly elevated at 99.

Average heart rate is normal at 84.  No significant cardiac dysrhythmias are noted.  Mean oxygen saturation is 93% with approximately 20% of the data failling below 90% saturation.    Most of these desaturations were associated with respiratory events.  There were 98 arousals related to respiratory events.

Snorning was noted for approximately 20% of the time during the initial two hours of the test.

Having fulfilled criteria for split night study, CPAP initiation was begun at approximately 12:30 AM.  With upward titration of CPAP, there was some normalization of sleep architecture.  15% of the time was ultimately spent in REM and 12% in stage III and 7% in Stage IV.

Some central apneas were seen along with hypopneas though there was overall suppression of respiratory events.  Oxygen saturation improved at 95% with only two minutes of data falling below 90% saturation.

Technician noted that high CPAP pressure were needed to supress respiratory events.

Impressions:
Obstructive sleep apnea syndrome, severe, with good response to nasal CPAP

Recommendations:
Give high pressures needed and snoring would consider ENT evaluation to rule out anatomic or obstructive causes of upper airway compromise.

Current guidelines call for treatment of apnea hypopnea index is greater than 20.  Would consider a trial of nasal CPAP at 17 cms of water pressure.  Periodic clinical and lab followup should be scheduled both to assure compliance and to check for continued efficany of the apparatus at the set pressure.

Occasionally patient's will do better with an auto adjusting nasal CPAP device if high pressures are needed consistently.  If patient a cannot tolerate a preset CPAP, would consider auto CPAP.
End of Report

Update:

The Respiratory therapist arrived one week ago today with a CPAP by Puritan Bennett - GoodKnight 420S with a heated humidifier and a ResMed Mirage full face mask.  He helped to set-up the machine and instructed us on it's use as well as cleaning etc, and went on his way.

Later that day my husband came down with a Fever and upper respiratory systems, (cough, sore throat etc), he saw his PCP the next morning and was Dx'd with sinusitis and put on a ZPak (antibotic) and also told to take OTC Mucinex and Tylenol for fever.  This was continued daily and the fever finally broke on Monday night, but he still has a wicked cough and basically what seems to be a very bad cold, slowing improving.  Because of the Sinusitis his doc said NOT to try the CPAP until this had all cleared up, so he has not been able to use it as yet.  He did try to use it once briefly when he was feeling better on Tuesday, but couldn't tolerate the ramp up past about 8, it was killing his ears (popping etc), so he's given up until this cold/sinus congestion is totally gone.  But, the pressure is so high, it's like a tornado blowing into his face, he seemed to have so much difficulty exhaling during the trial with the therapist, so I don't know if this is going to work.  It would seem that this high of a pressure he should be on a bi-level machine or at least a self adjusting machine.  He wants so much to get on a machine and try to finally get some good sleep, its been many, many years since he has slept well.

So that is our report and updated infomation....please provide and comments or input!  Thanks.  

PS:  This all follows day surgery he had done last week for a hernia repair.  Because of the apnea it was done under Spinal Anesthesia with Versed.  All went well with the surgery and he was home that day (Wednesday).  He had hoped that during the time he'd be out of work, he would be able to start on his CPAP and adjust to using it.  Unfortunately, that did not happen and he went back to work today.  Hoping by the weekend he'll be well enough to go on the CPAP some more.



Last edited by Leezza on Mon Feb 20, 2006 6:17 pm; edited 1 time in total

Quote:

It would seem that this high of a pressure he should be on a bi-level machine or at least a self adjusting machine.

I agree, absolutely.  In fact, there is a particular machine that combines both those worlds in one - the Respironics BiPAP Auto with BiFlex.   Works as an auto-adjusting machine AND as a bi-level machine, both at the same time.

Leezza wrote:

First, a little history-Otherwise Healthly Male, Age 50, 6"1" weight of 205 for a BMI of 27.  Within normal limits.
Primary complaint - trouble sleeping for many years with snoring and daytime sleepiness.  Usual bedtime is 9-10PM with awakening at 3-5AM.  No shift work history or frequent travel.  There is a history of loud snoring and restless sleeping along with sleep related breathing adnormaility.  There is significant daytime sleepiness component with the Epworth Sleepiness Scale being markedly elevated at 16.

Polysomnogram data shows lights out at 10:31PM.  During the first two hours the test diagnostics were done.  Sleep latency is normal at 5 1/2 minutes.  Sleep efficiency is good at 92%.  Review of sleep stages distributiuon showed an absence of REM sleep.  6% of the time is spent in Stage I, 80% in Stage II, 13% in Stage III, and 1% in Stage IV.

During this two hour interval there were 83 obstructive apneas, 13 mixed apneas, 10 central apneas and 81 hypopneas seen totalling 186 respiratory events.  The overall apnea hypopnea index is markedly elevated at 99.

Average heart rate is normal at 84.  No significant cardiac dysrhythmias are noted.  Mean oxygen saturation is 93% with approximately 20% of the data failling below 90% saturation.    Most of these desaturations were associated with respiratory events.  There were 98 arousals related to respiratory events.

Snorning was noted for approximately 20% of the time during the initial two hours of the test.

Having fulfilled criteria for split night study, CPAP initiation was begun at approximately 12:30 AM.  With upward titration of CPAP, there was some normalization of sleep architecture.  15% of the time was ultimately spent in REM and 12% in stage III and 7% in Stage IV.

Some central apneas were seen along with hypopneas though there was overall suppression of respiratory events.  Oxygen saturation improved at 95% with only two minutes of data falling below 90% saturation.

Technician noted that high CPAP pressure were needed to supress respiratory events.

Impressions:
Obstructive sleep apnea syndrome, severe, with good response to nasal CPAP

Recommendations:
Give high pressures needed and snoring would consider ENT evaluation to rule out anatomic or obstructive causes of upper airway compromise.

Current guidelines call for treatment of apnea hypopnea index is greater than 20.  Would consider a trial of nasal CPAP at 17 cms of water pressure.  Periodic clinical and lab followup should be scheduled both to assure compliance and to check for continued efficany of the apparatus at the set pressure.

Occasionally patient's will do better with an auto adjusting nasal CPAP device if high pressures are needed consistently.  If patient a cannot tolerate a preset CPAP, would consider auto CPAP.
End of Report

Update:

The Respiratory therapist arrived one week ago today with a CPAP by Puritan Bennett - GoodKnight 420S with a heated humidifier and a ResMed Mirage full face mask.  He helped to set-up the machine and instructed us on it's use as well as cleaning etc, and went on his way.

Later that day my husband came down with a Fever and upper respiratory systems, (cough, sore throat etc), he saw his PCP the next morning and was Dx'd with sinusitis and put on a ZPak (antibotic) and also told to take OTC Mucinex and Tylenol for fever.  This was continued daily and the fever finally broke on Monday night, but he still has a wicked cough and basically what seems to be a very bad cold, slowing improving.  Because of the Sinusitis his doc said NOT to try the CPAP until this had all cleared up, so he has not been able to use it as yet.  He did try to use it once briefly when he was feeling better on Tuesday, but couldn't tolerate the ramp up past about 8, it was killing his ears (popping etc), so he's given up until this cold/sinus congestion is totally gone.  But, the pressure is so high, it's like a tornado blowing into his face, he seemed to have so much difficulty exhaling during the trial with the therapist, so I don't know if this is going to work.  It would seem that this high of a pressure he should be on a bi-level machine or at least a self adjusting machine.  He wants so much to get on a machine and try to finally get some good sleep, its been many, many years since he has slept well.

So that is our report and updated infomation....please provide and comments or input!  Thanks.  

PS:  This all follows day surgery he had done last week for a hernia repair.  Because of the apnea it was done under Spinal Anesthesia with Versed.  All went well with the surgery and he was home that day (Wednesday).  He had hoped that during the time he'd be out of work, he would be able to start on his CPAP and adjust to using it.  Unfortunately, that did not happen and he went back to work today.  Hoping by the weekend he'll be well enough to go on the CPAP some more.

Just on the CPAP machine. 17 is a very high pressure to start on and your husband will need help. An APAP or even BiPAP machine might be more appropriate as exhaling against 17 cms of pressure is not pleasant. A copy of the titration report might be helpful.

He needs to get comfortable with the mask. I don't use a Full Face Mask myself, but I have read posts here where they report that there can be leak problems at higher pressures. He will also need a lot of support from you ( I can see you are supportive, but he may noe need a little kick also   ).

Best of luck.

Daniel.


_________________
The untreated Sleep Apnoea sufferer died quietly in his sleep.......
Unlike his three passengers who died screaming !!!!!!

(Anon)

Last night (finally the cold is improving), my husband did a full 7 hours on his CPAP....not so great results...he was still up and downstairs at 4AM this morning and doesn't feel rested at all.

He used the ramp over and over and over....every time the machine got to the set pressure (or close to pressure - his is 17), he had to start it over, so needless to say, it wasn't a good night's sleep.  

I noticed that once he resets the ramp, all goes OK for about 15-20 minutes (his is set at 30), then I can hear him struggling it seems to exhale, I can also hear a change in the sounds coming from the mask etc.

We'll try again tonight....just wondering how long will the therapist make him use this machine before they let him try an auto or bi-level instead??

Leezza wrote:

We'll try again tonight....just wondering how long will the therapist make him use this machine before they let him try an auto or bi-level instead??

Leezza, don't count on the therapist contacting you after a set amount of time to see how things are going.  

I'd be getting on the phone the instant the DME's office opens (DME=durable medical equipment...message board shorthand for the home health care provider).

Call them.  Either you or your husband should tell them politely, but in no uncertain terms, that he absolutely CANNOT handle that kind of pressure.  Ask them to please let him switch to any one of these machines:

Respironics REMstar Auto with C-Flex
Respironics BiPAP Pro 2
Respironics BiPAP Auto with Bi-Flex

Make it clear to them that he is going to have to stop treatment, and that the only chance he might continue is if he can try a machine that gives some kind of exhalation relief from that high pressure he's been prescribed.

If the therapist hems and haws making these kinds of sounds:  "Well, he should try it a little longer - a lot of people finally get used to the pressure..."  don't accept that.  Turn your attention to your husband's doctor's office and make your plea for a new Rx to be faxed as soon as possible to the DME, ordering a different machine.

You really do need to be a squeaky wheel in this matter.  It's inexcusable for your husband to have to fight that kind of straight pressure when there are machines that could be far, FAR more comfortable for him to use.

Good luck!

Morning to all and thanks for all the wonderful input.  Can't say enough how much I have learned about apnea in just a few short weeks--primarlily due to this board.  It's a wonderful resource and greatly appreciated.

Update---I called the DME yesterday and explained (very nicely) how difficult the CPAP was for my husband at 17, but as everyone here has indicated, he started by telling me he needs to try it longer (around a month).  I told him that did not make any sense to me, especially since his sleep study report had indicated that this pressure would be difficult and he may need an auto-adjusting machine.  He then told me auto machines are not covered?, but he would "try" to order a Bi-level if he could get insurance to cover it (HMO Blue Cross).   I know we have $1,500 a year of Durable Medical coverage, but I don't know exactly how this all works with BC, especially where we are currently using a rented machine.  I'll probably have to call them, as well, to be as informed as possible.  ---  He (DME) then told me to call back on Thursday and he would let me know how it was going on getting the Bi-level.  I told him I would do that and that my husband would continue to try and use this CPAP for now, as best he can.  He did say that the Bi-level machines I told him had been suggested are "very" expensive, thus another potential insurance issue.  Nonetheless, I tried to be as firm as possible without coming off as a know-it-all and basically I told him that it is vital to me that my husband continues treatment for his 'severe' apnea.  My husband is so easy going, he'd probably never complain, but I will and I will continue until I feel he has the appropriate machine.  In the meantime, it was also suggested he consult an ENT and I made that appointment today.  He never had has tonsils/adenoids out as a child, so that may or may not be an option.  Have any of you done so as an adult?  And it help your apnea at all?

So--that's where we are.....and I will continue to pursue the absolute best medical care for my husband.  Luckily, we have a superb primary care doc, who always is willing to listen and send us wherever he can to obtain the best care.  He was the one who was able to get my husband to the sleep lab and quickly, once he realized apnea was a possibility.  It took less than a month to get into the Lab, which we've been told is super fast for our area....so we are thankful for that.  I won't hesitate to call on him for help should we have any problems with the DME or Blue Cross.  I also told the DME I would call our doctor today, if necessary and have the RX changed, he said that I wouldn't be able to do that, only he could.  I not sure sure on that, but I will give him that chance for now, as he seems to be willing to work with me to get things moving quickly.  I will however call if we have any problems with getting the Bi-level ASAP....like you all have said...the squeaky wheel gets more attention.  I certainly don't want to be pushy, just firm and concerned about getting the best available to us.

Any comments, as always are appreciated.

Leezza

....



Last edited by another_guest on Tue Oct 31, 2006 10:05 pm; edited 1 time in total

Yeah, I was thinking the insurance is probably not all of the issue here.  I worked for many years in the Patient Accounts Dept. of our local hospital, so I'm very familiar with BC contracts and their contracted rates etc.  But, not at all familiar with how this all works with durable medical equipment - this is my first experience in that end of things.   I know for surgery, procedures, labs and xrays etc., the hospitals and doc's get paid far less than the actual billed amount, depending of course, on their contract with the insurer.  As an example - my husband's sleep study (facility charges) were billed out at $2,108.00 but BC only "allowed" and paid about $700, and we have no co-pays etc., so you can see in this example alone that medical charges are way over the allowed amount.  I think this is horrible -- what happens to someone who is self-pay has no contact....they'd be stuck with a $2,100+ bill.  Personally, I don't like the way health insurance works most times  --  we pay far too much for insurance premiums, but then when you really need it, it doesn't cover nearly what I feel it should.  .....Anyway, you gave me some interesting details about how the DME wouldn't be paid the difference on Auto-Pap vs CPAP, and I'm aware the Bi-levels are far more expense, but to me it's not a matter of cost it's a matter of receiving the best possible treatment, even if we have out-of-pocket expenses above $1,500.  I'm going to call BC and see if I can get a more 'specific' idea of how our particular plan works on medical equipment charges etc., especially while we are in the trial/rental mode.  In addition I'd like to find out if we were to eventually buy our own machine online, if they would reimburse.  I want to be certain he's set up on the right machine first and that it's working, before I'd take a chance of buying on our own....I don't feel educated enough to do so at this point.

Thanks for you input!  -- I'm learning more all the time!

PS:  I was fairly certain the DME wasn't giving me "all" the correct info regarding the AutoPap as well as me getting the RX changed....like I said, we have a great relationship with our family doc and I'm sure if we called him, he'd change it for us without any problem...I was simply trying to give the DME a chance, to see if he's really willing to work with us on this...if not I'll start making calls, and if that doesn't work we'll change DME's.....whatever it takes!  I am a firm believer that you must be your own advocate for your own medical care....if you want the best, you need to work with the best.