One Month Follow Up + Questions

[Kittamaru]

Hello all! I'm a month into CPAP treatment and I feel better; not feeling great yet (still a bit groggy and such but, well, I can't make up 10 years of bad sleep in a month!) but I had a question:

My number of Apnea events seems to be slowly continuing to decrease (probably as I acclimate to the machine), but my hypopneas are always high. As an example (this data is from Dreammapper - I'm at work atm, and don't have access to my SD Card or Sleepyhead):

Over the last few days:
Sunday: Clear Apneas: 0 Obstructive Apneas: 30 Hypopneas: 38 AHI: 8.1 Usage: 8:25hrs
Monday: Clear Apneas: 0 Obstructive Apneas: 3 Hypopneas: 26 AHI: 4.7 Usage: 6:12hrs
Tuesday: Clear Apneas: 1 Obstructive Apneas: 23 Hypopneas: 27 AHI: 6.5 Usage: 7:49hrs
Wednesday: Clear Apneas: 1 Obstructive Apneas: 48 Hypopneas: 20 AHI: 16 Usage: 4:12hrs (I was having really bad allergies this night)
Thursday: Clear Apneas: 0 Obstructive Apneas: 13 Hypopneas: 51 AHI: 8.4 Usage: 7:37hrs

I'm guessing there is a good chance my pressure will need upped?

Once i'm home tonight, I'll pull the data into SleepyHead: What specifically should I provide from there?
Oh, and my follow up is currently set for July 1st.

[Pugsy]

viewtopic/t103468/Need-help-with-screen-shots.html

This thread above has some examples of reports so you can see what we usually like to see.
Mainly...on the left side the AHI bar graphs and the statistics (you can turn off the pie chart and hide the calendar).
On the right side....these graphs (you can rearrange or hide the unneeded graphs) so that only these show up and you can resize them so that these 4 show in one nice easy to see image.
Events
Flow Rate
Pressure
Leak

Assuming your leaks aren't an issue then most likely you are correct in that you need a little more baseline pressure. Probably not a whole lot as hyponeas are usually pretty easy to fix.

[Kittamaru]

That's good to hear! I do know my breathing is a little odd (it tends to be a bit slower than most of my friends/family, but I always attributed that to being a singer and breathing deeper than a lot of them *shrug*) Dunno if that would be confusing the machine at all or not

I'll post the SH data ASAP!

[Kittamaru]

Sorry about the delay - busy last few days!

Here's this past week thus far:













I'm not sure what happened last night - but I woke up with the mask sitting on its holder on my nightstand so... yeah. I know the last few days have been REALLY bad in terms of allergies but I've been using Pseudoephedrine to keep my nose clear.

[Kittamaru]

Oh, and the overview:

[Pugsy]

We have to toss out last night.

I see you are using cpap mode fixed at 9 cm.
With the increased OA and hyponea events we usually see an increase in Flow Limitations but in cpap mode the FL flagging is turned off so the absence of any FLs on these reports doesn't really mean much. I bet you had some and they just didn't get flagged.

If you wish to continue with a fixed pressure and want to monitor the Flow limitations...just go to apap mode and set the minimum to equal maximum pressure. That way the FL flagging is turned on but the pressure will still remain fixed.

It does appear that you likely need more pressure for some of the night and not so much the other parts of the night...those times where you see clustering of OAs and hyponeas you needed more pressure. The time where you don't have any events flagged the pressure of 9 is doing its job.
The 2 most common causes for needing more pressure at some times and not others are sleeping on your back or REM stage sleep. It's very common to need more pressure when supine sleeping or during REM stage sleep.
So at some point you might want to consider apap mode with a small range so that the machine can go up only as needed as opposed to increasing the pressure for the entire night if you continue with fixed pressures.

The nasal congestion and "allergies"....is this something totally new to you or is this something that you have a long history of and not just starting with the start of cpap therapy?

If this is totally new to you..it might be related to whatever humidity you are using and adjusting the humidity could maybe help.
If you have a long history of seasonal allergies then it's unlikely that the congestion is cpap related.

[Kittamaru]

We have to toss out last night.

Yeah, I'm not sure what I ended up doing there XD

I see you are using cpap mode fixed at 9 cm.
With the increased OA and hyponea events we usually see an increase in Flow Limitations but in cpap mode the FL flagging is turned off so the absence of any FLs on these reports doesn't really mean much. I bet you had some and they just didn't get flagged.

If you wish to continue with a fixed pressure and want to monitor the Flow limitations...just go to apap mode and set the minimum to equal maximum pressure. That way the FL flagging is turned on but the pressure will still remain fixed.

To be honest, I'm not sure why I'm not in APAP mode - I think that was set by the DME based on the info from my neurologist? I think I'd prefer it to be able to adjust and compensate but... I'm going to guess that isn't something I should just do myself, but rather talk to my provider about? (I have my first follow up July 1st)

It does appear that you likely need more pressure for some of the night and not so much the other parts of the night...those times where you see clustering of OAs and hyponeas you needed more pressure. The time where you don't have any events flagged the pressure of 9 is doing its job.
The 2 most common causes for needing more pressure at some times and not others are sleeping on your back or REM stage sleep. It's very common to need more pressure when supine sleeping or during REM stage sleep.
So at some point you might want to consider apap mode with a small range so that the machine can go up only as needed as opposed to increasing the pressure for the entire night if you continue with fixed pressures.

I seem to sleep roughly 70% of the time on my back once I'm actually asleep, about 20% on either side, and maybe 5% on my stomach (I have an odd tendency to wake up now and again basically face down with just my forehead on the pillow and my face hanging over the edge of the pillow... yeah, I dunno) according to what I can recall and what my wife has observed. She had noticed in the past that when my breathing got really bad, I tended to roll from my back onto my sides but it seems with the CPAP I'm staying on my back more (and not moving around nearly as much).

The nasal congestion and "allergies"....is this something totally new to you or is this something that you have a long history of and not just starting with the start of cpap therapy?

If this is totally new to you..it might be related to whatever humidity you are using and adjusting the humidity could maybe help.
If you have a long history of seasonal allergies then it's unlikely that the congestion is cpap related.

Unfortunately no - I've had nasal allergies and asthma for as long as I can recall, and was formally diagnosed around 4 year old. I also have eosinophilic esophagitis and oral allergy syndrome - basically, my seasonal allergies and immune system have some kind of covert plan to try and kill me heh. Last time it got real bad culminated in a week long stay in the hospital (long story short, the EE resulted in a bit of food getting stuck in my throat due to swelling and my esophagus looking more like corrugated tube than smooth tissue - first hospital I went to messed up badly, tore my esophagus, and transferred me to another hospital where I spent a week recovering and was formally diagnosed with eosinophilic esophagitis and oral allergy syndrome). After that, I met with an allergist a few times as well as the gastroenterology team, and they put me on Omeprazole (for acid reflux), Allegra, Singulair, and Zyrtec for my allergies (I'm on generics, but yes, all three at once), as well as Flonase nasal spray and recommended I use pseudoephedrine during any real bad flare ups (like right now, when the trees are dumping pollen so thick it's turned my damn car yellow). The only one I'm not currently on is the singulair, because I need to meet with my PCP and get a new script for it.

... yeah... having typed that all out, holy shit I'm a bit of a mess when it comes to allergies.

ANYWAY, the nice thing with the CPAP is that the humidifier and filters have certainly helped my allergies a lot - some nights are certainly better than others, but eh, it happens. Generally, if I have to take the pseudoephedrine, my nose clears out and I'm fine.

I guess my big question is - is there any reason not to set my machine to APAP myself? And if not, how would I go about doing so (I didn't see any options for that looking through the basic menus and the user guide that came with it was a little lacking). I'm sure I could Google hack it but... well, I really don't want to risk pissing off my insurance company heh.

I really appreciate the insight though Pugsy!

[Pugsy]

Your insurance company could care less what mode of operation you are using. They only care about the number of hours each night. Now your DME might squawk but probably not too loudly if you just make a tiny change...they might not even notice.

You can change the settings yourself if you want to. It's easy.
See this page
http://www.apneaboard.com/dreamstation- ... structions

and while you are at the apneaboard you might as well get a copy of the clinical/provider manual because it has some information in it that isn't in the user manual.
Just make sure to request the appropriate machine.
https://www.cpap.com/productpage/resmed ... chine.html

[Kittamaru]

Your insurance company could care less what mode of operation you are using. They only care about the number of hours each night. Now your DME might squawk but probably not too loudly if you just make a tiny change...they might not even notice.

You can change the settings yourself if you want to. It's easy.
See this page
http://www.apneaboard.com/dreamstation- ... structions

and while you are at the apneaboard you might as well get a copy of the clinical/provider manual because it has some information in it that isn't in the user manual.
Just make sure to request the appropriate machine.
https://www.cpap.com/productpage/resmed ... chine.html

Alrighty, I set the machine to Auto mode, bumped the max pressure up to 15 and the minimum to 6. Enabled opti-start (starts at previous sessions 90% pressure). I've emailed them to ask for the clinician manual (it was one of the ones that wasn't available for direct download) so I hope to have that in hand soon

Thanks so much Pugsy!

[Kittamaru]

So, just finished my second month... things are definitely improved, but I still seem to be more tired than I should be. Headaches are pretty much gone, and I' not nearly as stuffy and dry in the nose and throat as I used to be.

I have noticed that I seem to have a LOT of hypopneas though... thoughts? (graphs below)



Lets look at last night, just as an example. I pretty typically hover between a 3 and a 6 for AHI, averaging about a 5 over two months of treatment. I've currently got my APAP settings set with a minimum of 6 and a max of 18 because from what I'd seen on the graphs, it looked like I had times when I needed far more pressure (and, to be honest, the higher pressure doesn't bother my much, at least as far as I can tell when I'm awake)

One thing I have noticed is every now and then, I'll wake up with the nasal pillow having slipped because the straps around the back of my head have migrated to the top of my head, and it isn't holding it against my face right (and once in a while, I'll wake up with the mask sitting on the nightstand beside me... I'm still trying to figure out when, why, and how I'm doing that in my sleep) - last night was one of those nights, as you can see (between 3am and 3:20am) - I can only presume that perhaps I got up to use the bathroom? I don't recall doing that but... well, I don't always wake up 100% to do so (which, heh, has gotten me in trouble anytime I'm somewhere other than my own bed... hotels can be hellish for me sometimes XD)







Any thoughts on this? Am I doing about as well as would be expected for someone two months in (I know, I know... patience... I'm not good at that lol)

[Pugsy]

How long does it normally take for you to go to sleep once you turn the machine on?
How long does it maybe take for you to go back to sleep if you have turned the machine off or removed the mask for some reason?

The reason I asked is that on this report above you had a cluster of OAs pretty much immediately when you turned the machine on at the beginning of the night and I wonder if you fell asleep that quickly.
Then there's the cluster of hyponeas right after the 3:40.

I am wondering if you were awake during those clusters OAs and hyponeas) and the machine just flagged some Sleep/wake/junk by mistake. If those are indeed awake events getting flagged by mistake then they are likely skewing the AHI upwards and if you removed those events from the calculations then the AHI wouldn't be quite so remarkable and maybe a little less ugly.

Otherwise you might think about a little more minimum pressure as it might hold the airway open a little better..
I don't know that it is a critical urgent need but maybe consider trying around 7 cm minimum if you feel you were asleep when those events happened or if you just want to see if the AHI will come down a little more.
It's the minimum pressure that is the most critical setting. Its purpose is to hold the airway open for most of the time and still give the machine a good enough starting point when it does need to go higher. Maybe if it could get to where it needs to be a little faster it could do a little better job preventing things.

[Kittamaru]

Most nights I seem to fall asleep within half an hour or so - typically I put it on, read for a few minutes, then roll over and try to get some sleep... I'll start trying to keep better track of that though, because I know some nights I can be awake for upwards of an hour with it on, just waiting to drift off (depends largely on how things have gone at work that evening... days I work both jobs, I'll get home and basically go straight to bed, and sometimes it takes me a little to unwind).

If I wake up in the middle of the night, such as to use the restroom, it typically only takes me a few minutes to fall back asleep - I don't notice any discomfort or problems with the pressure that I can think of... well, there is one, but that's more me than the treatment - I almost never have both nostrils clear. I almost always have one blocked up and breathe through the other (I say nostril - it's actually further back, probably more in the turbinate area) - this is with my allergy meds, and has been something I've had all my life (I've actually been considering getting checked for deviated septum and/or turbinate reduction to see if that helps at all). I've been pairing the mask with breath-right strips which has seemed to help in that regard.

My wife has said that the only times she can recall me snoring at all the last few weeks is when I have removed the mask during the night for some reason - yet there seems to be a lot of snore events on there.

Is there something more I could do to help the machine more accurately understand what I'm doing?

I'll kick the pressure up a bit - probably to 8 or 9, which seems to be my median pressure, and see how that helps.

I appreciate your input Pugsy! There's a lot I still have to learn to make this as successful as it can be!

[Pugsy]

No there is no way to make the machine know what you are doing. It measures air flow and it doesn't/can't know if you are asleep or awake. About the best you can do is if you find yourself awake for a prolonged period of time is reach over and turn the machine off and back on immediately. Then you can see the little break in the pressure or therapy line and know that if you see anything flagged prior to that little break then you know for sure that awake breathing irregularities got flagged and you can for sure remove them from your mental AHI and evaluation.

The snores likely are an indication that the airway tissues are trying to collapse and while they may not collapse to the point of earning one of the apnea flags... they may or may not be all that significant but again usually a little more pressure is all that is needed to better hold the airway open and prevent some of the collapse that is causing the vibration. Worth trying anyway. Your pressure needs for the most part are fairly low as it is so you have considerable room to play with the pressure and not get it up very high at all.

I never really could figure out a way to quantify the snores on a ResMed machine. I think that the taller it is the louder it is but we are never really told what or how much snoring means loud enough to worry about.
Generally speaking if I see much snoring (of any volume) I tend to think....airway trying to collapse a bit and we fix that by increasing the pressure a little. Most of the time unless the snores are massive...all it takes is usually 0.5 or 1.0 or thereabouts increase in that minimum. Just a little more baseline pressure to stent the airway open a little better.
Respironics snoring is easier for me to evaluate...they flag snores like they flag events and it's a lot easier to get an idea how many times the machine thinks you snored. Personally in my mind a snore is a snore no matter what the volume level and I would want to try to reduce them if I could without causing other problems.
Snores by themselves that don't progress into apnea events of some sort and don't wake you up or wake spouse up...might not be all that big of a deal but when seen and reviewed in context of the other stuff showing up...makes another point for trying a little more pressure.
Meaning if your AHI was well below 1.0 all the time and you were sleeping great and feeling great during the day then snoring might not mean much at all and not worth trying to reduce them but when seen along with the OAs and hyponeas pushing the AHI to the high limit of "acceptable" then we sort of think a little harder about them but more because of the rest of the picture and not just the snores all by themselves.

At least that's how I look at snores and it helps me decide if I want to be a little more aggressive or not with the pressures. I treat the Flow limitations the same way...they aren't part of the AHI but they could be an indication that the pressure is maybe not optimal.