Need Another Titration in the Lab: Who Decides, You or Your Sleep Doc?

 With the growth of the HST model, sleep apnea patients are increasingly complaining about the lack of opportunities to undergo a titration in the sleep lab when their responses are suboptimal to PAP.  In our second opinion practice, we occasionally meet sleep apnea patients dissatisfied with their care at a sleep center in another state; and, believe it or not, some of these patients have never spent a night in the lab. A sleep study was never recommended, or if a patient requested a titration it was refused. Despite their best efforts to express their suboptimal responses, the sleep professionals they dealt with argued back that nothing new would be gained by a titration or retitration in a sleep lab. In this brave new world of auto-adjusting devices, we are informed that the sleep lab is essentially obsolete.

Just last month, I underwent a titration (my 6th in 11 years) in my own sleep lab to check my pressure settings on my RESMED ASVAuto device. Usually, I complete a retitration study about once every two to three years, because I am inclined to believe the actual science of PAP therapy use, which purports pressurized airflow settings do and will change over time for myriad reasons, a most common one being aging—that inflexibly bad habit from which few escape. Sometimes, the reason for change is nearly inexplicable. To be clear, change in pressures over time is the norm, not the other way around.

Unlike most of my other titration studies, I was shocked to discover much larger changes than I have usually experienced. My Min EPAP on my ASVAuto device needed to be dropped from 13.4 down to 12. And, my Max PS needed to be raised from 11.6 up to 13.0. The initial shock and disappointment arose from not being able to sense the requirement for this amount of change. The later shock and surprise is that such changes led to very noticeable and tangible changes in outcomes. For me, some mild, albeit sporadic, sleepiness I had been experiencing for the past year instantly responded to the new settings…reminding me once again for the need to pay more attention to the biblical adage…“physician, heal thyself.”

What symptoms or outcomes should ordinarily prompt you as a patient to seek new observations about your current pressure settings? And, how might your progress or lack thereof be conveyed to the staff at your sleep center to persuade them to bring you to the sleep lab for an overnight titration? While, in our own practice, we find certain telltale relationships indicating a nearly automatic need for a retitration study for many patients, it is perplexing how many sleep professionals appear not to make these connections. 

We’ll save the most obvious symptom set, daytime fatigue and sleepiness, for last (in Part II of this post), because the nuances within each of these states—being tired or being sleepy—may often require complex decision-making, particularly in cases where the patient also suffers from mental health symptoms like depression or anxiety. As we specialize in mental health patients with sleep disorders, our experience has taught us to err on the side of retesting more frequently in some individuals, but I must confess that the results do not always yield superlative changes in outcomes. Fortunately, this latter outcome is seen in the smaller proportion of patients who not only suffer multiple mental health conditions but are also using multiple psychotropic medications for their psychiatric illness. In this relatively small group, in comparison to the much larger group of mental health patients we treat, minimal, gradual improvements in outcomes are the norm.

So instead of starting with the obvious, let’s start with my favorite sleep apnea symptom—nocturia, or trips to the bathroom to urinate a night. I say favorite, because I have used this single symptom and its pathophysiology more than any other symptom to persuade patients to initiate PAP therapy or to return to the sleep lab to better their outcomes, that is, further reduce their nocturia. If you watch the video here, you’ll see that sleep apnea directly causes your heart to release a natural diuretic into your bloodstream, which makes the kidneys work overtime while you sleep. The net result is more urine in your bladder and thus more trips to the bathroom, regardless of whether you wake up at night with the obvious urge to urinate or whether you simply awaken for other reasons and notice you need to pee. 

So, when a patient returns in the daytime for a clinic appointment with me or one of our sleep technologists, we always inquire about the current status of nocturia episodes. Now, most of our patients have already watched our videos on this topic, so they know to consider the consequences of persistent trips to the bathroom. Of course, there are always the possibility of other factors in play such as bladder or prostate disease, past genito-urinary surgeries, and current treatments with diuretics or other medications, like Lithium, that cause the side-effect of frequent urination. Then, there’s the old stand-by that virtually everyone without any knowledge of the connection between sleep apnea and nocturia will raise: “I drink too much fluid in the evening or near bedtime.” To which I proclaim, “I typically drink between 20 and 30 ounces of fluid within the last two hours before I sleep, sometimes within the last hour before bedtime, and still do not arise for a trip to the bathroom.” To which a few patients have replied, “well, don’t wet your pants about it!”

Seriously, many sleep apnea patients do not conceive of the possibility there can be zero trips to the bathroom, and we are amazed at how many patients with prostate or bladder problems in particular still reap fantastic results, which greatly improve their qualify of life. It is a big deal to go from 4 to 5 trips a night down to just one. It is a very big deal, especially for an insomnia patient where nocturia can trigger a new bout of sleeplessness or for an elderly individual who is nervous about falling.

A more amazing thing about nocturia is its reliability in predicting whether pressurized airflow settings are too low. And, here’s where the science directly related to nocturia seems to suggest aspects about sleep apnea that are still poorly researched or understood. Here’s what I mean: if you had to guess which symptom, nocturia or sleepiness, would improve faster when you treat sleep-disordered breathing, which would you guess? Nearly all people predict sleepiness, because it is such a well known symptom of OSA or UARS. However, the truth as far as I can tell (because I’ve never seen a research publication on this topic) is nocturia drops off rapidly even when sleepiness symptoms have not budged. Yes, a person could arrive at our center reporting no change whatsoever in their sleepiness and then mention in passing (or more likely through our probing) that he used to suffer 2 or 3 nocturia episodes per night and now it’s down to a couple times per week.

In other words, there is something about this unusual pathophysiology where the heart chamber muscles are stretched by the excess venous blood flow triggered by the effects of sleep apnea such that just a small improvement in the sleep breathing problem results in less nocturia. We have observed this sequence in hundreds if not a thousand patients wherein the nocturia improves before the sleepiness, which again reveals why this symptom has such a prominent role to play in educating patients on how to rate the level of success they have achieved in their treatment regimen. Clearly, if the nocturia is not getting better, that almost assuredly indicates an automatic need for the retitration unless some other circumstances are in play. However, if the nocturia is improving but the sleepiness is not, a not uncommon scenario, the patient needs to hear something like, “so perhaps your sleep apnea is 70 to 80% treated, which is why your nocturia got better, but there’s an excellent chance there’s more to be gained.” In this circumstance, we often find persistent flow limitation (discrete UARS events) on the data download from the PAP device; and we recommend another trip to the sleep lab to find new pressures to address these subtle breathing disturbances with the expectation daytime sleepiness will further improve. 

What other types of symptoms warrant a follow-up retitration or at least a clinic appointment with a sleep tech to problem solve? Very persistent issues like mouth breathing, mask leaks, and dry mouth we attempt to solve with simple, daytime sleep tech appointments, but the truth is that those who suffer from these problems chronically almost invariably must return for a retitration study or a PAP-NAP to gain a precise solution to these nagging complications. 

Delving into other areas of medicine, a patient should be strongly advised to evaluate their PAP settings when: blood pressure medicine doesn’t seem to be working well; cardiac arrhythmias or heart failure are under poor control; morning and other headaches resolved initially and then return; antidepressant medications are not working despite repeated changes in type or dosage; and, restless legs or leg jerks are still active or were seen on a previous study without ever having been addressed.

Still other areas involve what are describe as psychosomatic and related pain symptoms. For example, many fibromyalgia patients suffer from UARS, and until this breathing condition is successfully treated, the FMS patient is unlikely to achieve optimal results. Yet, many FMS do not even know about their underlying breathing condition; and, among those who have such awareness, many report difficulties using PAP therapy. All the more reason to bring these individuals back to the sleep lab to try and try again to use positive airway pressure therapy, because it could make a large difference in the qualify of their lives.

As you can see, the gist of this discussion is that a host of symptoms, some directly linked to the sleep apnea condition and others indirectly linked might all benefit by fine-tuning pressure settings on your PAP device.   But, if the sleep professionals with whom you work do not understand this global perspective about sleep apnea, you will be frustrated in your efforts to convince any staff at the sleep center, including your sleep doctor, about your need for a titration or retitration study in the sleep lab. This perspective is most unfortunate and undoubtedly leads to less than optimal responses in many patients seeking care.

In addition to the above points, one other consideration is whether or not you can take your business elsewhere. In larger metropolitan areas, there is usually greater access to different sleep centers. But, you might discover the sleep center that’s right for you is also one that does not take your insurance. Still, I would venture that an excellent retitration study is worth its weight in gold even if you are the one who pays. Before you proceed, though, please review my other posts (here, here, and here) on the advantages of dual pressure systems with auto-adjusting features, all of which can be manually titrated in the sleep lab. If you can find a center that will employ this degree of precision in the retitration, there’s a good chance you’ll qualify for another device, far superior to CPAP, and the new pressure settings will most likely provide you with some new and clearly noticeable treatment gains.

In Part II, we will pick up the discussion and focus on how the symptoms of sleepiness, tiredness or fatigue should and can be measured and understood to facilitate decision-making in your quest to spend another night in the sleep lab.


Barry Krakow MD

Author

Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.



1 Comment

Caroline
Caroline

April 02, 2015

Thanks so much for this article! It tells me that I really do need to “bite the bullet” and have a re-test. It has been 7 years since my only overnight test and I am tired of waking up for the bathroom twice per night. I love my C-Pap as it has made a huge difference in my energy level and therefore I now feel my true age. It would be lovely to sleep through the night again.
Sincerely,
Caroline S.

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