High Clear Airways during sleep

[Pugsy]

Either one of those docs (your PCP or lung doc) know anything about sleep apnea and therapy?

[jimnlacy]

Either one of those docs (your PCP or lung doc) know anything about sleep apnea and therapy?

Not my GP. But my other Dr was referred as a sleep specialist. Not sure what he "knows", yet. But he prescribed the sleep study and diagnosed me with severe sleep apnea.

Jim

[Jay Aitchsee]

Here's the detail:

Arousals/SWJ
Raise pressure to minimize hypopneas/OA's, nominally 9.0
EPR and pillows for comfort.
If Central Apnea Index and/or AHI persists above 5.0, See Sleep Doctor/Pulmonologist.
Otherwise
Concur, Pugsy?

[jimnlacy]

Last night was not so great. I turned off EPR which felt okay but my OAs climbed.



Let me know what you think.

Jim

[Pugsy]

Turning off EPR would not cause the obstructive events (in this case seems to be mainly hyponeas) to increase.
It's probably just a coincidence. If anything turning off EPR should better prevent the airway collapse from happening because there wouldn't be any drop in pressure during exhale so the overall pressure is higher and not lower.

Looks like you are going to need around 9 cm to prevent the obstructive stuff maybe a little more if you want to push on the FLs a little.
I have no idea if the pressure you are using is the trigger for the centrals or not. They don't appear to be CSRish though.
They could just be SWJ or arousal related.

If it were me I would proceed with dealing with the obstructive side of things and maybe even address the flow limitations a little more aggressively (a little more pressure) on the off chance that they are a factor in any possible arousals and make sure that I had a long talk with my doctor about all this during the May visit.
There's always the chance that with time and experience that things will settle down by the time you see the doctor.

If you are still seeing central index like this when you see the doctor...the doc may or may not want to get more aggressive in dealing with the centrals but sometimes even pressure triggered centrals will fade away on their own with time.
Right now I don't see anything that is going to reduce the centrals but it doesn't seem like addressing the obstructive side of things is making them any worse...so I would just try to fix what can be fixed or improved upon and talk with the doctor about what is left over.

If by chance those centrals are related to arousals then maybe reducing the potential factors for causing arousals will reduce the centrals. It doesn't look like typical Complex Sleep Apnea to me but then remember I am not a doctor.

Finally one other comment...some time back I had a chance to help someone who had reports similar to yours and she had under gone an in lab sleep titration study and came up with a RX for 15 cpap...and no mention of centrals at that time but she was having a truckload of them at home and at a pressure of 9 which was doing a good job with the obstructive stuff. Nothing we did seemed to have any impact on the centrals so out of desperation we decided why not do what the sleep study recommended and low and behold the centrals totally went away with the pressure of 15. Made no logical sense but the best we could come up with was that the centrals were arousal centrals and the higher pressure fixed whatever was causing the arousal which was likely causing the centrals to be flagged. Now I am NOT telling you to go trying 15 cm...just saying that it wouldn't be impossible for the FLs and obstructive stuff you are seeing to be a factor in arousals which could be a factor in the central flags. I know it's a lot of ifs and woulds and coulds...
bottom line...keep that follow up appointment and you might call up the office and ask to be put on a list to be called if a cancellation happens. I don't think it is extremely urgent at this point but you do need to talk to your doctor for sure.

[Sircadian]

I don't know anything near what the others are telling you but I know what I would try.
Open up the Apap feature and run a pressure range from 8-12. See where it wants to go that night. and try
going back to cpap once I knew what the top number may be. I like cpap (EPR 2) only because it has been good to me and results were better than my Apap trial period.

Just an experiment that wouldn't deprive you of therapy .... if I look at your first posts, the machine climbed to 9
immediately, curious as to where it would have gone. I know pressure can't chase the CA's but I like the idea of knowing where the airway is kept open by the top pressure.

Again, I'd only try this after I'd tried the wiser advice from the others here.

Either way thanks for sharing and find this informative ... you seem determined to manage your own and that alone is a positive step in the right direction.

[robysue]

jimnlacy,

Pugsy has asked me to comment on this thread. So here goes:

Comments on data posted so far
1) You've used a total of 4 different settings for your CPAP therapy since 3/18. That's a lot of changes to make in a one week period. I can understand why you're dial wingin' but it may be time to use ONE setting for a whole week (or more) to see if things start to settle down after giving your body 7-10 days to adjust to the new setting instead of changing a setting every time you've got a higher than desired AHI. More on what setting might be a good starting place in a few minutes.

2) While the close ups of the centrals don't look like real Cheney-Stokes respiration to my (non medically trained) eyes, they do look like they might be pressure related. Or they could be post arousal centrals. Or they could be sleep-wake-junk (SWJ) when you're dozing---i.e. sleeping very lightly and going back and forth between light sleep and wake. It would be great if Morbius stopped by to look at those close ups of the centrals. But he hasn't just yet. More on this issue in a few minutes.

3) You changed both the pressure setting and the EPR on 3/23. While you decreased the pressure setting from 9 to 8.6, you also decreased the EPR from 3 to 1. And you decreased the EPR to 0 (Off) on 3/24. What this means is that you have effectively increased the pressure on exhale from 6 to 7.6 and then to 8.6. If those CAs are indeed pressure related CAs, the additional pressure on exhalation might be what's driving the increase in overall AHI on the nights of 3/23 and 3/24. Not only has there been a pretty significant increase in CAs the last two nights, but the Hypopnea Index is also up. And those hypopneas are often mixed in with the CAs. It's possible that some of the hypopneas are also pressure induced----i.e. they might be CA-wannabes instead of OA-wannabes. It would be very useful to see a close-up of the CA/H cluster that starts around 1:40 and ends a bit before 2:00 on the night of 3/24.

4) On several of the nights there is a lot of evidence of plain old sleep fragmentation---i.e. waking up (possibly for no real reason) and not getting back to sleep within a few minutes. Even on the nights where you don't clearly wake up and then turn the machine off and back on a bunch of times, there's still some evidence in the overall shape of the flow rate that you may be waking up and then dozing lightly for 10-15 minutes at a time. And to my eyes, many of those CA clusters appear to be during the time frames where it looks like there is a higher probability that you're dozing rather than sleeping soundly. If that's happening, the CAs are likely sleep-wake-junk and they'll probably disappear in a few weeks if you stick with one set of settings long enough for your body to really get used to them.

5) While there are some Large Leaks present and a lot of smaller leaks present in the data, it is not clear (yet) how big of a problem the leaks actually are. Even the large leaks are short enough in duration to NOT adversely affect the efficacy of the therapy and the accuracy of the data, but all the medium sized (and larger) leaks together with the evidence of sleep fragmentation, raises the question of whether the leaks (large or small) are waking you up enough to disrupt your sleep. If the leaks are causing you to arouse or partially arouse multiple times each night, that may be causing you to spend a lot of time in "sleep-wake-junk mode" where your body is constantly going back and forth between light sleep and wake.


Some questions for jimnlacy
How many times during an "average" night do you remember waking up?

When you wake up in the middle of the night, how long does it usually take you to fall back asleep? Less than 5 minutes? 5-10 minutes? 10-15 minutes? more than 15 minutes?

Do you always or almost always turn the machine OFF and back ON when you wake up?

When you wake up in the middle of the night, do you always or often lie in bed for 5-10 minutes with the mask on before you decide whether to turn the machine off and back on?

When you wake up enough to turn the machine off and back on, do you remember anything about what triggered the wake? Do you think you might be waking up to fiddle with the mask to (subconsciously) address leaks that are disturbing your sleep even though they're not large enough to usually matter to the machine?

The answers to these questions may be very important for trying to figure out whether these CAs are sleep-wake-junk or whether they may indeed be pressure-induced CAs.


My advice to jimnlacy:
Personally, I'd go back to using CPAP = 9 with EPR = 3 and I'd leave it there for a full WEEK regardless of what the data for any individual night indicates. If the AHI > 5 for more than a couple of the seven nights AND the CAI is also high on the nights where the AHI > 5, then I'd re-evaluate what to do. And because of the CAs, I'd be inclined to start by informing the doc(s) about what's going on instead of just doing additional dial wingin'.

Rationale for my advice:
The CPAP pressure = 9 and EPR = 3 setting gave you your best AHI data of the nights posted. Yes, the last night at these settings had an AHI = 5.11 and a CAI = 3.59, but even so, those have been lower than the AHI's and CAI's recorded with CPAP = 8.6 and EPR = 1 or OFF. In addition, jimnlacy wrote this about the night of 3/22 (Sunday night):

The results are better looking. Sunday night was not as restful as Saturday. I worked 10 1/2 hours Sunday on a project with a deadline and I think the subconscious stress leaked into my sleep.

And here's the Sunday night (3/22) data:

Sunday night (3/22) had three clear wakes where the machine was turned OFF and back ON. And notice that worst of the clusters on this night happen within 30 minutes of the first time jimnlacy turns the machine OFF and back ON. If you were dozing/drifting in and out of sleep during those 30 minutes trying to get back to a sound sleep, that could very well mean these events are SWJ "events" that would not be scored on a sleep test. So I'd be inclined to write this night off as a visit from the Aliens, who were aided and abetted by the long work hours on Sunday needed to make the deadline and the resulting stress.

[Pugsy]

Well put Robysue and thank you and I agree with everything you said and as usual you said it so much more clearly than I often do.
Note to self to kick self in the butt for blowing off English comp in college...

[jimnlacy]

Hi Robysue,
You have made some great points and excellent suggestions. I am replying from work on my iPhone so can't quote quite the way I'd like but I'll try to answer and address some of topics.

I wake up lots at night. Before Cpap therapy to turn over to my other side when my arm goes to sleep and awakens me. That is still happening. I sleep on my sides mainly because I don't snore when I do. I go back to sleep immediately.

I usually use the bathroom once a night. Sometimes twice if I drink water after 8. But I back to sleep quickly. Less than 5 minutes.

I was awakened numerous times last night by leaks. I changed my pillow size and plan to go back to medium Additionally I will be going back to 9cm and 3 EPR. And I'll stay there for at least a week.

That setting seemed to give me the best therapy.

I met with my GP today for another reason but went over my recent results amc asked for a referal. I will have to drive 60 miles to see a specialist but it will be good to go over all this with a new Dr. My original pulmonoligist is leaving. Which is good. I was going to change anyway.

Again Thanks. I know what I need to do.

Jim

[AMK]

Jimnlacy, forgive me if this has been answered, but I've been reading your thread with interest and I wanted to ask, why do some of your graphs show the machine being turned off and on so many times if you don't actually get up more than once or twice a night? Are you using the on/off as a sort of marker for when you are awake? I have thought of doing that.

[jimnlacy]

When I get up I take off the mask. The machine does whatever it does. I do not turn it off. Upon returning I put the mask on and when I start breathing it fires up again and I go back to sleep.

Jim

[jimnlacy]

Robysue,

Here is a detail of the area you asked to look at:

[jimnlacy]

From last night:



I had swelling in my nasal passage and change out my pillows for the full face mask during the night. Not a great sleep. First feeling like I was suffocating and then like I was rebreathing my own breathe. Not a big fan of the full mask but what else can you do. Thanks all.

Jim

[robysue]

Robysue,

Here is a detail of the area you asked to look at:

This shot is a bit too close up: It doesn't show the H's that immediately precede and follow this cluster of CAs.

These CAs don't look like the classic Cheney Stokes pattern. But they're sufficiently regular where they could indeed be pressure induced. Or if the H that occurs right before this cluster is an obstructive H, they could be post arousal or transitional CAs. There's no way for us non-experts to say for sure.

[robysue]

I had swelling in my nasal passage and change out my pillows for the full face mask during the night.

You did the mask swap around 0:00 or 0:10 during one of the breaks in the Flow Rate curve. My guess is that you were awake for a short while before you decided to make the swap and since you say:

Not a great sleep. First feeling like I was suffocating and then like I was rebreathing my own breathe. Not a big fan of the full mask but what else can you do.

my guess is that you didn't get back to sleep until around 0:40. So my guess is that most (maybe all) of the events scored between 23:50 and 0:35 are sleep-wake-junk or transitional.

As for what you can do: I'd suggest tackling the swelling in your nasal passage so that you can use the pillows mask if at all possible. If the swelling is plain old congestion caused by allergies or an upper respiratory illness, using a neti pot and the appropriate antihistamines or decongestants should help clear the nose enough to be able to use the pillows mask. If the swelling occurred after masking up, that might indicate that you still need to work on finding the sweet spot for the humidifier setting. If the humidifier is already on its max setting, you might try turning it down a notch or two.