One year -- whazzup with these numbers?

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
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RubySnooze
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One year -- whazzup with these numbers?

Post by RubySnooze » Sat Jun 06, 2015 4:21 pm

Hi CPAP pros,

I started on the PR APAP Oct 20th, after in-home oximeter test followed by a one-night in-the-lab sleep study. I've had some problems adjusting: small mask leaks, allergic to headgear, and decades-long insomnia. Thought I had two of those solved: started using a padacheek mask liner (stopped almost all small leaks that were waking me up) and sleeping in a hoody so none of the headgear touches my skin. Slowly started feeling a little more energetic. Was even doing some hiking in early March.

But the last couple of months I've had noticeable energy loss. On June 1st, Sleepyhead told me my AHI was "horrible" (18). I saw my sleep specialist who seemed unable to offer any real advice, except that I should try a dental appliance. My APAP has never been adjusted; been running on auto 4-20. After refusing the dental appliance, and bugging her for awhile, she agreed to up the minimum pressure from 4 to 6. So I've slept with 6-20 pressure the last five nights.

I thought it might be helpful to see some Sleepyhead totals by month, so made an Excel doc showing monthly totals followed by daily averages (in red). Hoping to get it attached here!

Any thoughts about what is going on? Can I provide other info that would be helpful?

Any input will be most appreciated! Thank you!

http://imgur.com/91piiaC
Image

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Last edited by RubySnooze on Sun Oct 18, 2015 12:13 am, edited 1 time in total.

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Sheriff Buford
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Re: Seven months -- whazzup with these numbers?

Post by Sheriff Buford » Sat Jun 06, 2015 6:46 pm

Your minimum (lower) setting on apap should be a couple nubers l ower than your 90/95 percentile. If it is set too low, The machine has to "ramp" the pressure up to treat an apnea event. Maybe the delayed time to detect, ramp up and treat the event is enough to make you feel lousy the next day.

Sheriff

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RubySnooze
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Re: Seven months -- whazzup with these numbers?

Post by RubySnooze » Sat Jun 20, 2015 4:17 pm

Thanks, Sheriff Buford. Your comment pointed me to a lot of info on setting minimum pressure.

My 95% pressure over the past month or so ranges from @ 7 to 12. After a week at 6 / 20, I bumped up the minimum to 7. Not seeing much difference. Fwiw, my titration study came in at 13.

I think leaks (both large and small) are a problem. I started with a Quattro FX FFM last October and had difficulty with small leaks that would wake me up. A padacheek maskliner helped some. Recently tried switching to a Mirage Quattro FFM. And this week have been trying AirFit P10 for her nasal pillows. Thought the nasal pillows might be worth a shot because my face is cheekbone-y and the FFMs leak under the cheekbones.

But my SH numbers continue to be bad. Or as SH likes to say: "horrible." Here's a screenshot of last night's numbers (I hope). I'm on a teeny laptop, so not sure all the charts get included.

Image

Both my "sleep specialist" and DME are awful; no help there.

Really confused about how to proceed. And absolutely ditzy from lack of sleep, which isn't helping. Hoping someone can offer direction. Thank you!

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Pugsy
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Re: Seven months -- whazzup with these numbers?

Post by Pugsy » Sat Jun 20, 2015 5:03 pm

I don't know why you aren't sleeping but the minimum pressure is still not optimal at least in those wee hours of the morning where you see all that ugly stuff happening.
Normally I might blame REM stage sleep but I don't know that you are getting much REM you are getting with such horrible sleep fragmentation.
Pressure is okay at the beginning of the night and then things go down the toilet.
Are you maybe ending up on your back or something?

Looks like the recent AHI is about 1/3 Central/CA and 1/3 Obstructive apnea and 1/3 hyponea.
The OA and hyponeas should respond to more minimum pressure
Since there are centrals present even at lower pressures I don't think that the higher pressures are triggering the centrals but it wouldn't be totally impossible. More probable given the sleep fragmentation is that likely those CAs might be awake/semi awake junk getting flagged by the machine.

While I don't see, at least on this report, a need for 13 cm pressure....I am thinking that the 7 cm minimum is too low and most likely at least 9 cm minimum will be needed at least during the time frame where you see the OA and hyponea clustering for whatever reason....the usual suspects being REM stage sleep or supine sleeping where with either it is common to have OSA be worse and/or need substantially more pressure.

Have you ever tried fixed cpap pressure or apap with a tight range?

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RubySnooze
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Re: Seven months -- whazzup with these numbers?

Post by RubySnooze » Sat Jun 20, 2015 6:30 pm

Here are stats on the three previous nights:

June 18
Image

June 17
Image

June 16
Image


Pugsy, thank you so much!! Can't tell you how grateful I am for the input.

No, have never been on fixed pressure or a tighter range. Until June 1st, when I badgered my "specialist" into increasing my minimum, I had been on 4/20 the entire seven months. She didn't seem to have any problems with my numbers, even though the night before I saw her I peaked out at 52 incidents at one point. And didn't have a single night where I slept through. And I was clearly exhausted. Aaargh.

I had no REM sleep and no CAs during my sleep study. (A total of two hours for qualification and two hours for titration.) AHI was 17. Insomnia and fatigue were my only symptoms prior to diagnosis. I didn't snore or make noises or roll around. I wasn't obese. Okay, maybe the age thing applied . I was so still and quiet my husband used to check to make sure I was breathing.

I do have killer insomnia and take small amounts of OTC sleep aids and zolpidem. Some chronic joint pain keeps me from staying on one position for the whole night. So yeah, I could certainly be on my back during those rough spells. I feel like when I do sleep, it's so lightly that almost anything will wake me up. Like the small mask leaks.

A big part of my frustration is that my numbers are all over the place. Sometimes the "ugly stuff" happens much earlier in the night. Hypopneas are definitely increasing; other events are more up and down. But the big picture trend is definitely worse than it was in March-April.

Do you think it could be helpful to try a fixed pressure? Or bring down that 20 maximum pressure? Or should I start by just bumping the minimum up to 9? And keeping an eye on the CAs.

If the "ugly stuff" can be reduced, is that likely to improve my sleep? I can't tell which is the chicken and which is the egg here.

Thank you again for all the info and assistance. I really have been increasingly desperate and frustrated. And tired!

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OSAHell
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Re: Seven months -- whazzup with these numbers?

Post by OSAHell » Sat Jun 20, 2015 7:14 pm

Hi RubySnooze,

I'will had +1 to Pugsy's comment.

I was also curious if you ever have been on fixed pressure or a tighter range in pressure, thanks for the answer.
If I've read correctly, in your answer to Sheriff you wrote that your titration study came in at 13. Did you mean at "a pressure of" 13?
Did your Sleep Specialist ever explained why they didn't set your APAP to the result of your titration? To me it make no sense that you would have a titration study but that your APAP was never set/adjusted by the DME or Sleep Specialist to the titration result... But you wouldn't be the first to have that kind of experience and reading your comment about them might explained a lot.

In your screenshot of sleepyhead you should replace the Resp. Rate and Tidal Volume graphs with the Pressure and leak graphs, it would give us more usefull infos for now.

As for your pressure I will go with Pugsy's suggestion of bumping the minimum to 9. And yes, keep a eye on the CAs!

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Pugsy
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Re: Seven months -- whazzup with these numbers?

Post by Pugsy » Sat Jun 20, 2015 7:48 pm

Reducing the maximum pressure really won't do much. It's the minimum pressure that is the most critical pressure setting. The machine has to have a good enough head start to hold the airway open better in the first place and then get to where it needs to go within a time frame to prevent what you are seeing happen in those ugly clusters.

The fixed cpap question was me thinking that maybe the pressure changes are disturbing your sleep quality. I doubt it is the entire problem though. I bet you have some plain ordinary, can't figure out what to blame, insomnia going on to.
Though it wouldn't hurt to maybe consider visiting fixed pressure or maybe a really tight apap range just to see if the insomnia lessened any. How much pressure if you were to do cpap or maybe a tight 1 cm range (Flow limitations are turned off in cpap mode so I like to use apap mode with a tight range to mimic cpap mode so that we don't lose FLs flagging...just in case)? I don't know yet. Would need to see more pressure graphs and see what an increase to 9 cm minimum does.
And yes...seeing the pressure graph and leak graph are much more important...respiratory rate and tidal volume aren't much help.

All I know to offer is try to fix what is an apparent problem and see what happens once the obstructive stuff is better managed. Then work on what's left to deal with once the known problem is better controlled. Right now that is the obstructive apneas and hyponeas. The insomnia may or may not be related to those apnea events. Won't know until you fix them. I don't know what to make of the centrals/CAs at this point but for sure keep one eye on them while we are trying to fix the other stuff. More pressure won't fix centrals if those centrals are real.
Now if those centrals are post arousal centrals from maybe waking up because of an apnea event then maybe reducing those known culprits might give us a nice secondary prize with a reduction in centrals as a byproduct.

So I would leave maximum where it is right now. The machine won't go where it doesn't think it has a good reason to go and often if the minimum pressure is more optimal the pressure doesn't go as high trying to fix something after the fact. Prevention is better than fixing. I think you are likely going to need more than 9 cm minimum but I would suggest trying 9 cm first if that is comfortable for you. If it isn't...try 8 minimum and give it a few days and then try 8.5 or 9.0. No harm in working up slowly because we sure don't want you to be uncomfortable with the pressure change. Your sleep is already fragile as it is. No sense in adding to the problem.

If you increase the minimum and the centrals go wild..back off and we need to have a different discussion.

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RubySnooze
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Re: Seven months -- whazzup with these numbers?

Post by RubySnooze » Sun Jun 21, 2015 12:54 pm

Here are SH charts for last night (used minimum pressure of eight), plus pressure and leaks for the previous four nights:

Image

Image

Image

Image

Image

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Last edited by RubySnooze on Sun Jun 21, 2015 1:24 pm, edited 1 time in total.

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Pugsy
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Re: Seven months -- whazzup with these numbers?

Post by Pugsy » Sun Jun 21, 2015 1:21 pm

Slight improvement with the 1 cm increase in the minimum when compared to the better of the prior reports and substantial improvement when compared to the worse nights.
We don't know if last night would have been a better night without the change. We all have good nights and bad nights and that's why we say that when we make a change to keep that change for a few nights to see if we spot a trend unless the results were horrible.
Interesting no CAs.
Pressure didn't fluctuate much at all. Those little spiky saw tooth things are the machine doing is normal test pressure probes.

My suggestion is use the current settings for a few more nights (your choice depending on adjustment process and how you feel but maybe 3 to 5 nights) and then try 8.5 minimum and see what happens.

I know we didn't fix the insomnia wake ups but then I really didn't expect that miracle. Still see at least 2 breaks in therapy where you turned the machine off. How was the sleep quality otherwise? Did you have a lot of awakenings where you just lay there but didn't turn the machine off?

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OSAHell
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Re: Seven months -- whazzup with these numbers?

Post by OSAHell » Sun Jun 21, 2015 2:07 pm

Thanks for the updated charts RubySnooze. Pugsy made good observation and gave you good suggestions there, she has help A LOT of people on this forum and probably A LOT MORE than she can imagine...

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RubySnooze
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Re: Seven months -- whazzup with these numbers?

Post by RubySnooze » Sun Jun 21, 2015 3:14 pm

Hi OSAHell,

Thanks much for the input and suggestions. Yeah, my titration study came in at a pressure of 13. During the study, I was never asleep more than two hours and had no REM.

I'm still laughing over your comment about the sleep specialist ignoring the titration. Seems so obvious now that you've pointed it out. Duh.

I doubt I'll be going back to this specialist. She was completely unhelpful. On top of leaving my APAP pressure wide open for seven months.

And yes...I have a serious girl-crush on Pugsy!

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RubySnooze
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Re: Seven months -- whazzup with these numbers?

Post by RubySnooze » Sun Jun 21, 2015 3:41 pm

Hi Pugsy,

No, no other awakenings. I try to not run the machine when I'm awake. I do have spells during the night when I'm somewhat aware, but not all the way awake. Overall quality of sleep last night was pretty good. The minimum pressure of eight didn't bother me.

I did succumb to the dreaded post-cpap morning snooze. Woke up, removed the mask, roamed around the house a little, laid back down and woke up two hours later. These little episodes amaze me because I have no sense at all that I could possibly fall asleep. And yet...there it is. I'm such a non-sleeper. Have never been able to nap in the daytime. Rarely able to sleep at night without meds. And yet these morning snoozes have popped up since starting CPAP.

Thought the zero CAs was interesting, too. Went back and found two nights in the past 30 days where that happened.

I'll stay here at minimum eight for the next few nights. Maybe upload a couple charts before increasing to 8.5?

So grateful for your guidance, Pugsy. Thankyouthankyou!

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Pugsy
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Re: Seven months -- whazzup with these numbers?

Post by Pugsy » Sun Jun 21, 2015 3:54 pm

I will be happy to look at a couple more reports but I want you to be able to feel confident in what you are doing too.
My goal isn't to try fix you but to help you learn how to try to fix yourself.
That's why I sometimes write novels explaining why I think so and so instead of just saying "try this" without explanation.

If you can get 3 more "good" nights like last night where the AHI is stable and not in that double digit "worse" category then I would feel more confident that we are going in the right direction....yes, proceed with another increase in that minimum.
You can choose how rapid and/or how big of a change you are comfortable with.

Please note...I have family coming for an extended period the end of this next week so I won't be on the forum as much...probably not even on the computer as much but I will send you a private message shortly with my personal email so you can contact me that way if the need arises. I usually will check private emails once a day or so.

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OSAHell
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Re: Seven months -- whazzup with these numbers?

Post by OSAHell » Sun Jun 21, 2015 4:16 pm

No problem and if I made you laugh in the process I guest that a plus!

There might be "some" reasons (that I don't know) why they ignored the titration... But going from a titration of 13 to wide open (4-20), even with no REM in the titration, his puzzling to say the least!

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Re: Seven months -- whazzup with these numbers?

Post by Pugsy » Sun Jun 21, 2015 4:27 pm

OSAHell wrote:There might be "some" reasons (that I don't know) why they ignored the titration... But going from a titration of 13 to wide open (4-20), even with no REM in the titration, his puzzling to say the least!
So far I haven't seen any real reason to warrant 13 cm fixed cpap titration suggestion. Maybe they used the magic 8 ball or something. Maybe they padded it a little to cover potential REM needs. Maybe the tech was a cousin to the idiot dumb ass sleep tech I had during my titration study. The night from hell that was but that's another story.

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