APAP experiment without official OSA/UARS

[rosie1231]

Hi experts!

I’m new and seeking opinions on whether I demonstrate enough flow limitation to warrant trying PAP therapy. I’m 36/F with a long history of sleep onset insomnia, EDS, restless legs, and nocturia. After years of various failed strategies/pharmaceuticals, I finally recently had an in-lab sleep study. It came back clean in terms of breathing: AHI of 1 and 0 RERAs. I did have 26 periodic leg movements per hour, and I did not reach slow wave sleep at all. The sleep doc said the leg movements are preventing me from reaching deep sleep and gave me ropinirole.

I’m now trying the ropinirole but cannot shake the physical sensation that I am not breathing well at night, so I decided on a whim to try an experiment: I dusted off my husband’s abandoned Airsense 10 Autoset and took it for a one-week spin. I set the min pressure to 4 and left the max at 10. My hypothesis was that if I didn’t have a sleep breathing problem, the pressure would remain at 4 all night. Conversely, if I did have a breathing problem that my sleep study missed, the pressure would auto-adjust upwards as flow limitations develop.

The results of my experiment indicated the latter, with median pressure of 7.8. I’m attaching last night’s Sleepyhead data, including a zoom-in on a time frame when the pressure sat at the max of 10 for a while, plus my sleep study results. Does anyone think that this Sleepyhead data could indicate airway resistance despite my squeaky clean PSG? I find the sensation of APAP weirdly relaxing and I’d like to continue, but I wanted to see what the pros think about my data. I appreciate any thoughts on this matter!

[Miss Emerita]

How interesting! Yes, you do have an active FL graph, as well as flow-rate shapes indicative of FL. What this may mean for you is that you are needing to exert yourself more to inhale, and that extra exertion may be keeping you from cycling through sleep stages in a normal manner. With reduced FLs, you might sleep better.

All of that is hypothetical, of course, but to me the kicker is that you find using APAP "weirdly relaxing." I would encourage you to keep using it for a while and see whether you notice positive trends in your ability to sleep better throughout the night. We quite naturally sleep differently from one night to another, so I think giving this a good trial (a month?) would make sense.

If you do find your are experiencing improvement, another step might be to consider a machine like the ResMed Vauto that can give you even greater pressure support (equivalent of EPR), which might reduce your FLs considerably.

I also hope the drug will help with your restless legs. That too would be a big help, wouldn't it!

[slowriter]

My hypothesis was that if I didn’t have a sleep breathing problem, the pressure would remain at 4 all night. Conversely, if I did have a breathing problem that my sleep study missed, the pressure would auto-adjust upwards as flow limitations develop.

Smart, and is an approach consistent with this research study, which documents using APAP machines to diagnose UARS.

But the thing that's weird is your in-lab study (I missed that part initially) showed 0 RERAs, which is pretty much the hallmark of UARS.

In any case, just looking your graphs, if I were in your position, I'd raise the pressure to 7, and the max to 15 or 20, and see what it does, and how that impacts your FL graph.

Also, I agree with this:

If you do find your are experiencing improvement, another step might be to consider a machine like the ResMed Vauto that can give you even greater pressure support (equivalent of EPR), which might reduce your FLs considerably.

[palerider]

The results of my experiment indicated the latter, with median pressure of 7.8. I’m attaching last night’s Sleepyhead data, including a zoom-in on a time frame when the pressure sat at the max of 10 for a while, plus my sleep study results. Does anyone think that this Sleepyhead data could indicate airway resistance despite my squeaky clean PSG? I find the sensation of APAP weirdly relaxing and I’d like to continue, but I wanted to see what the pros think about my data. I appreciate any thoughts on this matter!

If I were you, I'd set the pressures to min 8, max 20, and see what happens. I wouldn't call your PSG "squeaky clean"... you didn't even have any SWS (n3, the restorative sleep).

Something besides FLs is bumping up your pressure, likely snoring (but you didn't include that graph).

There's more to SDB (Sleep Disordered Breathing) than just apneas and hypopneas. Flow Limitations (and snores) are both disruptive to sleep (no matter what some members of the forum might say), they increase the effort of breathing, and that can kick you out of the sleep stages you're moving through.

https://www.youtube.com/watch?v=-gie2dhqP2c

[Geer1]

Seems like higher minimum and maximum would be ideal as others are stating. What I would be interested in is seeing the data with settings at minimum(4 I believe) to get an idea of how much of an improvement adequate CPAP treatment seems to be making on your sleep/breathing.

If it is significantly worse then probably a good indicator CPAP is worthwhile even though you don’t fit what is considered the normal criteria.

[palerider]

. What I would be interested in is seeing the data with settings at minimum(4 I believe) to get an idea of how much of an improvement adequate CPAP treatment seems to be making on your sleep/breathing.

That's a waste of time.

[Geer1]

That's a waste of time.

She wants to know if CPAP is worthwhile, easiest way in my eyes is to see what happens without adequate CPAP pressure(no pressure would be ideal but can't be done). I am definitely not a pro so take my comments with a grain of salt but when reviewing this data I see that most of the night the CPAP was operating at a pressure it was happy with and a fairly smooth consistent flow graph. The instance of zoomed in data is from the worst part of the night and it only indicates minor flow limitation and no obvious abundance of arousals/awake time.

My thoughts are that raising the pressure settings is likely ideal but that will probably only give minor improvements. Definitely try it and see what happens.

If she reduces the pressure there are two potential scenarios.

1) Flow limitations increase, short hypopnea like events might become visible on flow graph and maybe even some hypopnea/apnea events are flagged. Indicates that disordered breathing is an issue and that the CPAP usage is worthwhile.

2) There are minimal changes in the results. CPAP maybe not making a significant difference.

I think the sleep study actually supports some minor sleep apnea. Sleep studies underestimate AHI because all the equipment etc keeps you from getting into a normal sleep, she was awake for over 40% of the study so that seems to have been the case. 4.14 AHI during supine sleeping means the 3 hypopneas probably happened in the supine position which at most she was in for 43 minutes. There was also minor oxygen desaturation present too dropping below 88% momentarily, probably due to one of the hypopneas.

If it was me I'd "waste" a night just out of curiosity.

[zoocrewphoto]

That's a waste of time.

She wants to know if CPAP is worthwhile, easiest way in my eyes is to see what happens without adequate CPAP pressure(no pressure would be ideal but can't be done). I am definitely not a pro so take my comments with a grain of salt but when reviewing this data I see that most of the night the CPAP was operating at a pressure it was happy with and a fairly smooth consistent flow graph. The instance of zoomed in data is from the worst part of the night and it only indicates minor flow limitation and no obvious abundance of arousals/awake time.

My thoughts are that raising the pressure settings is likely ideal but that will probably only give minor improvements. Definitely try it and see what happens.

If she reduces the pressure there are two potential scenarios.

1) Flow limitations increase, short hypopnea like events might become visible on flow graph and maybe even some hypopnea/apnea events are flagged. Indicates that disordered breathing is an issue and that the CPAP usage is worthwhile.

2) There are minimal changes in the results. CPAP maybe not making a significant difference.

I think the sleep study actually supports some minor sleep apnea. Sleep studies underestimate AHI because all the equipment etc keeps you from getting into a normal sleep, she was awake for over 40% of the study so that seems to have been the case. 4.14 AHI during supine sleeping means the 3 hypopneas probably happened in the supine position which at most she was in for 43 minutes. There was also minor oxygen desaturation present too dropping below 88% momentarily, probably due to one of the hypopneas.

If it was me I'd "waste" a night just out of curiosity.

It may help with a little curiosity, but it would be a night without any treatment, and it we can already see from the data that the pressure needs to be higher. It maxes out at the 10 several times. And it never goes below 6 while the minimum is 4. So, it is pretty clear that the machine is responding to flow limitations and probably snores. Rather than see a night of poor results to see what a poorly treated night looks like, why not dial in to more ideal settings and FEEL what treated feels like. That is the best test of whether a cpap will help in this situation.

[palerider]

That's a waste of time.

She wants to know if CPAP is worthwhile, easiest way in my eyes is to see what happens without adequate CPAP pressure.... I am definitely not a pro so take my comments with a grain of salt

Which is why I stated that it's a waste of time.

The data that's already there shows that she should benefit from an APAP.

but when reviewing this data I see that most of the night the CPAP was operating at a pressure it was happy with and a fairly smooth consistent flow graph. The instance of zoomed in data is from the worst part of the night and it only indicates minor flow limitation and no obvious abundance of arousals/awake time.

Referring back to the 'not a pro'.

If she reduces the pressure there are two potential scenarios.

You forgot the most likely scenario...
3) She'll spend the night feeling like she's not getting enough air at a pressure of 4, like many people, who feel suffocated at 4.
Again... back to 'not a pro'.

...ramblings...

If it was me I'd "waste" a night just out of curiosity.

And you're *perfectly" welcome to waste all the time you like.

I recommend the OP ignore your 'advice'.

Of course, she's welcome to do whatever she likes, too.

Someone spare me from these newbies who know NOTHING, haven't gotten their own therapy working *at all* (if they even have a machine), and yet feel they need to come in here and argue with people who know things, who've been doing this for *years*... and telling other people how to do "stuff"

[Dog Slobber]

I don't like the idea of sticking her on straight CPAP at 4cm because of what palerider said.
She's likely to feel very suffocated, and she's going to have a real bad night.

CPAP is tough enough for some people, we don't want to create a huge negative association and giving her another obstacle to overcome. Cripes, there's people here that tried APAP 20 years ago, had a bad experience, blamed it on some "abrupt" pressure change and are running around to this day telling people to use CPAP over APAP.

[rosie1231]

Thanks all for the suggestions for what pressure settings to try. I'm going to bump them up tonight and see how it goes.

Smart, and is an approach consistent with this research study, which documents using APAP machines to diagnose UARS.

Really cool, good to know. Makes me think my strategy here isn't totally out to lunch.

Something besides FLs is bumping up your pressure, likely snoring (but you didn't include that graph).

Oops, should have mentioned snoring. I hadn't included snoring because I didn't show any. My husband has offered additional confirmation over the years of no snoring. I'm attaching last night's Sleepyhead with the snoring pane visible this time. My lack of snoring is actually what caused years of delay in getting a referral to a sleep study!

Seems like higher minimum and maximum would be ideal as others are stating. What I would be interested in is seeing the data with settings at minimum(4 I believe) to get an idea of how much of an improvement adequate CPAP treatment seems to be making on your sleep/breathing.

I had actually intended to do exactly this, but I felt so great after the first few nights that I couldn't bear to sacrifice a night to low pressure!


I'm still so curious about the 0 RERAs scored from my study. As best I can tell, they scored RERAs based on variance in movement of the chest/abdominal bands, if such variance was associated with an arousal. Is it possible to have flow limitations WITHOUT variance in effort? In other words, is it possible to just have low-grade but constant flow limitation? And another question: can micro-arousals cause sleep stage fragmentation?

I'm sure you're thinking "who cares? If APAP makes you feel better, just do it and move on." But I felt so bad for so long that I can't help but want to keep digging...

[Geer1]

You forgot the most likely scenario...
3) She'll spend the night feeling like she's not getting enough air at a pressure of 4, like many people, who feel suffocated at 4.

This has me curious and I'll have to look this up. Do you know of any reports, data, specific forum posts etc discussing this that I can review? In a physical sense increasing the pressure should ease breathing unless there is another aspect of CPAP machine design causing this feeling (maybe \the expiration system?).

I could see how people that have been on successful CPAP treatment would feel suffocated at a lower pressure. For someone new to CPAP it seems like even minimal pressure should be helpful but I'm thinking about this from an engineering first basics point of view and may be missing variables like issues with expiration etc.

For the record I was planning on trying this myself... So like I say any info appreciated.


Disclaimer: If anyone tries a test at minimal pressure and feels like they are suffocating. Stop...

[slowriter]

You forgot the most likely scenario...
3) She'll spend the night feeling like she's not getting enough air at a pressure of 4, like many people, who feel suffocated at 4.

This has me curious and I'll have to look this up. Do you know of any reports, data, specific forum posts etc discussing this that I can review? In a physical sense increasing the pressure should ease breathing unless there is another aspect of CPAP machine design causing this feeling (maybe \the expiration system?).

I could see how people that have been on successful CPAP treatment would feel suffocated at a lower pressure. For someone new to CPAP it seems like even minimal pressure should be helpful but I'm thinking about this from an engineering first basics point of view and may be missing variables like issues with expiration etc.

For the record I was planning on trying this myself... So like I say any info appreciated.


Disclaimer: If anyone tries a test at minimal pressure and feels like they are suffocating. Stop...

This is widely known here, and on other forums. You only need to try it yourself while awake to see why.

[slowriter]

I'm still so curious about the 0 RERAs scored from my study. As best I can tell, they scored RERAs based on variance in movement of the chest/abdominal bands, if such variance was associated with an arousal. Is it possible to have flow limitations WITHOUT variance in effort? In other words, is it possible to just have low-grade but constant flow limitation? And another question: can micro-arousals cause sleep stage fragmentation?

They should be scoring arousals, based on the EEG brain wave data, and then as RE-related based on those sensors that measure your breathing effort.

I haven't looked, but your report should have both numbers.

Yes, micro-arousals almost by definition, it seems to me (I don't know how medical experts technically define it), leads to sleep fragmentation.

[palerider]

Yes, micro-arousals almost by definition, it seems to me (I don't know how medical experts technically define it), leads to sleep fragmentation.

Yup.