Obstructive apneas persist despite high pressure (20/16 cm)

[NapsZ]

Hi everyone! I was recently diagnosed with Obstructive Sleep Apnea (AHI 29). This took a while to happen since I don't fit the usual profile -- I am a younger male (32) with a low BMI (6'1" and 155 lbs = BMI 20.4), and I scored low on the Epworth Sleepiness Scale. But in retrospect, I've probably had the condition for a long time, since I remember complaining about my headaches (the same ones I get to this day) to my classmates in first grade over 20 years ago! The morning headaches, nighttime urination, and memory loss have gotten much worse in recent months, and I'm delighted to know that it may all soon be a thing of the past.

The sleep technician titrated me to a Bilevel pressure of 20/16 cm H2O, and the doctor who saw me afterward sent me home with a (non-data capable) Bilevel machine the very same day. But after a week, I was even more tired than ever, and decided to investigate this matter further myself. I got a data-capable machine and plotted out what was happening to me overnight.

BOTTOM LINE: Even at a pressure of 20/16 cm, and with zero mask leaks, I am getting regular obstructive apneas that are over a minute long.

Last night I set the IPAP max to 20 cm, EPAP min to 10 cm, and the pressure support PS to 4 cm. Results are below.

Here is a plot showing a cluster of obstructive events -- 16 in 30 minutes. During this train of events, the pressure was 20/16 cm, and the mask leaks were minimal.



Here is the longest apnea, zoomed-in. It lasted 79 seconds. I cannot imagine how this is possible! I tried holding my breath just now, and the longest I could last was 30 seconds, and I was gasping a lot afterward.



There seems to be a funny pattern to my breathing too, where it will start strong, then diminish away to an apnea. This happens repeatedly. At first I thought the high pressures were inducing central apneas and maybe Cheney-Stokes respiration, but this seems to occur even at minimal applied PAP pressures (like 9/5 cm, during the ramp cycle):



Does anyone have any suggestions on what to try next? It's my first day with the new machine, so my current inclination is to keep the settings fixed to gather more data of greater statistical significance.
Then I will systematically
-- start reducing the pressure support (PS) down from 4 to 3, then to 2.
-- try different masks to minimize leakage
-- increase the maximum allowed pressure

I'm not too enthused about even higher pressures though, because it is already giving me painful sinus headaches (that instantly vanish once the pressure is removed). It feels like I'm going to blow out an eyeball.

Any thoughts? Anything I have missed?

Thanks much everyone.

[cflame1]

first things first... you've got some spikes in your leak line that are going above the red line... control them.

Then work on the AHI

[john_dozer]

first things first... you've got some spikes in your leak line that are going above the red line... control them.

Then work on the AHI

As long as the machine is able to achieve the desired pressure, and his events are happening outside the leaks as well, I think he can work directly on the apnea issue.

NapsZ, at that pressure I think you have two possible issues.

Complex sleep apnea where at first blush you get the impression more pressure is what you need. Partly because there's a OSA component to the event that more pressure will overcome.

After studying myself for a while, I'd look at traces, conclude I need more pressure because my events appear to be resolved by increased pressure. But if I increase my upper and lower pressure limits, I actually am worse overall. I found that I need to allow higher upper limit pressures to address events when they do happen, but otherwise need to have a reasonable lower limit for pressure to fall back down to which prevents more events from occurring. I'm over due taking this information to a professional, admittedly. Basically if I set 10-12, its not good, if I set 12-14, its not good. If I set 10-14, I'm ok most days. Basically if I am above a minimum of 10 or 11, I get more periods where I have several AI events within those 'periods'. Ironically these events are mitigated by high pressure levels. Levels that probably need to be above 14 to get resolve all of them once they start.

Before I see a professional, I want to get a better mask that won't leak on me above 14 and then try 10-16, 12-16, etc.

The other issue is that you have abnormally difficult OSA. Perhaps something unique about your airway. In which case, you might consider surgery to bring your breathing inline with a more normal range. I'm not even sure there are machines that go above 20. There are also nuclear options which have drawbacks that you to judge against having an overall more healthy and normal lifespan if you do them.

[cflame1]

I disagree John... his spikes are happening prior to his events.

[john_dozer]

The spikes occur after his period of limited or no breathing during the make-up breathing event where is peak to peak flow from inhale/exhaust is at its highest. Probably because he's opening his mouth much wider than normal or gasping so deeply, he's momentarily loses seal on his mask. The leak events are extremely short lived and while he is breathing deeply.

[BlackSpinner]

You may also want to get a recording oximeter to see what your O2 levels drop to.

Realize that for insurance reasons you may need to "fail" the bipap before they will allow you to have an ASV - the next step up.

[Pugsy]

Any notations in sleep study reports as to anything that makes the events worse? Like sleeping on your back or while in REM stage sleep? This pattern looks a lot like REM pattern. Of course we can't tell for sure but it sure looks like it. REM typically starts about 90 minutes into sleep cycle and then comes and goes but becomes more frequent and lasts longer in the wee hours of the morning.

If related to REM..not much you can do except try different pressure.. If related to sleeping on your back you can try staying off your back. If higher EPAP pressures don't increase Centrals I would be trying higher EPAP before I tried higher IPAP.

[jamiswolf]

Hi,
Sorry you're having this difficulty, but at least you've taken the steps to get treatment. I'm new and have no experience reading machine data. But I agree with Spinner that an oximeter would reveal the O2 sats during those apneas. Seems like you're probably heading for an ventilator type machine that will initiate a breath and not allow those dangerous long apneas.

One thing I don't see discussed much is sleep position. I have an auto cpap machine and when I'm flat on my back, I run pressures upward of 14 but if I can manage to sleep way over on my side, the machine idles along at 4 cm. Almost like I have positional apneas.

Do you sleep on your back all the time?
Jamis

[NapsZ]

Wow, I open up my browser this morning to all these great replies. Thanks everyone. Replies:

* Leaks (cflame1, john_dozer) -- A new Fisher/Paykel 431 FF mask is on the way. I've tried the Quattro FX and my existing Quattro, and both are quite unstable at 20/16 cm, subject to leaks at even the smallest provocation. At night when I strap it on (quite tightly) it is perfectly sealed, even tested at max pressure. However, over time it becomes increasingly sensitive to even small nudges.

What was interesting to me from the traces though was that even when I am fully paralyzed and not moving about, and the mask leaks are infrequent, I am still get OSA events that are unaffected by pressure. Perhaps there are smaller scale leaks that are compromising the effectiveness of the pressure though. I will post more data when I get a better fitting mask.

* Recording oximeter (BlackSpinner, jamiswolf) -- I have a CMS50H I have been trying to use. Problem is I end up tossing it off my finger in the middle of the night, and when I get up in the morning the data is gone (Record set to OFF). But I will figure out how to get it to work.

In my initial sleep study, my min SpO2 was 83%, and in the titrated study, it was 96%. So I'm probably as long as some pressure is there, I will be okay. My only concern is that the apnea events I'm observing are longer than the ones that showed up in either study ..

* Sleep position (pugsy, jamiswolf) -- I sleep soley on my back. I've tried sleeping on my side (prior to PAP therapy) and it had no effect on the headaches/grogginess. I would like to try sleeping on my side while using PAP but any shifts in position tend to cause my mask to leak and hiss, so I avoid them. Once I get a better mask I will try sleeping on my side again.

* Possible airway issues (john_dozer) -- I may try to see an Ear/Nose/Throat doctor to see if I have any unusual anatomical issues which need to be addressed for PAP therapy to be effective.

* More advanced treatment (BlackSpinner, JamisWolf) -- I found two interesting papers, titled "Complex Sleep Apnea: It Isn't Really a Disease" (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2576324/) with a rebuttal "Complex sleep apnea: it really is a disease." The first paper suggests that PAP induced centrals tend to self-resolve over time, and that more advanced treatments are unnecessary. So probably (and certainly from an insurance standpoint) I would need to be on my current therapy for a much longer period before I can go in that direction. What's amusing is that the first paper was written by doctors funded by Resperonics, while the second was written by a doctor funded by Resmed! I'll keep it in mind when talking with my doctor next time.

* REM stage sleep and position dependence (Pugsy) -- Yes, in both sleep studies the events got much more frequent (30/hr --> 50/hr) during REM sleep. They didn't allow me to sleep in other positions, so I don't know if there is a positional dependence, but just from my self-experiments the problem still occurs even when I'm on my side. Sleeping with a stack of pillows seems to help somewhat though! And my naps in the library sitting upright are always very refreshing ... (though of course I can't spend an entire night sleeping in a sitting position) ..

These are all great suggestions. Thanks everyone. I'll put more data in the next post from last night's sleep.

[NapsZ]

More data from last night:

[*] Apneas rolling in like clock-work:



[*] Transition to apneas as I fall asleep:



I'm curious about the apparent shift in breathing pattern, from something nice and regular to something more periodic, and finally to regular apneas. Is there any way to distinguish Cheney-Stokes respiration from just a bunch of closely spaced Obstructive Apneas during REM sleep?

[NapsZ]

Just came back from talking to some people at the sleep center:

[*] Sleep study interpreter was pretty adamant that a 20/16 cm titration + Quattro FX FF mask worked for me during his sleep study, and should continue to work for me now. Ran me through the raw data, and showed me there were absolutely no centrals, just pure obstructive events eliminated at the 20/16 pressure. Suggested I try a nasal mask (Resmed Mirage Micro) to more directly apply the pressure within a smaller space.

[*] Respiratory therapists suggested things similar to the forum members above -- (1) should find a way to sleep on my side and (2) should see an Ear/Nose/Throat doctor to see if there are any unusual anatomical issues.

I'll try the nasal mask tonight, then ff + side sleeping, then nasal + side sleeping. Every day a new experiment! Thanks everyone.

[BlackSpinner]

Just came back from talking to some people at the sleep center:

[*] Sleep study interpreter was pretty adamant that a 20/16 cm titration + Quattro FX FF mask worked for me during his sleep study, and should continue to work for me now. Ran me through the raw data, and showed me there were absolutely no centrals, just pure obstructive events eliminated at the 20/16 pressure. Suggested I try a nasal mask (Resmed Mirage Micro) to more directly apply the pressure within a smaller space.

But that is not happening now and he only saw you one night in a lab setting.

[archangle]

I'm in way past my depth, but Cheyne Stokes Respiration occurred to me, too.

[NapsZ]

Hi BlackSpinner, yes, it's true that what is happening now could be different than what was happening in the sleep study. The mask they used (Quattro FX) is a bit different than the one I have now (Quattro). I'm going to try to borrow an FX to see if it improves things ..

I've been reading up on CR type respiration and it seems it can be influenced by the exhaled CO2 is rebreathed, which depends on the headspace within the mask. Last night, following the sleep center guy's instructions, I tried using a nasal only mask. Of course because I have allergies and primarily breath through my mouth, the instant I began to fall into a deeper stage of sleep, my mouth would drop open, and the mask would become useless. But what was interesting was before that would happen, my breathing was nice and regular, punctuated by some short centrals (10-30 sec). So this reinforces my notion that playing around with the mask size and type would be useful.

[ozij]

I disagree John... his spikes are happening prior to his events.

The spikes are short and negligible. It's not a leak problem.

More data from last night:

[*] Apneas rolling in like clock-work:

Most of what I see on the above are catch up breaths after an obstructive apnea. In CS respiration the cycle is rounded:


CS: Apnea, gradually rising breathing, gradually diminishing, repeat. In your case: apnea (osbtructive), large catchup breathing, and expected diminishing because of the catchup. Then another obstruction.

[*] Respiratory therapists suggested things similar to the forum members above -- (1) should find a way to sleep on my side and (2) should see an Ear/Nose/Throat doctor to see if there are any unusual anatomical issues.

Yes, do that. Find and excellent Ear/Nose/Throat, and have a thorough examination. Sometime, sleep apnea is a result of anatomical problems that can only be solved by surgery - not UPPP. But tonsilectomy makes a difference to both OSA and pressure needs if you tonsils are huge, and there is also far more serious surgery that may be necessary to solve anatomical problems - see here viewtopic.php?p=610327#p610327 for someone who has had it.