HELP AGAIN! ASV or APAP?

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
sleepinow
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Re: HELP AGAIN! ASV or APAP?

Post by sleepinow » Wed Apr 16, 2014 2:19 pm

robysue wrote: Most adult Americans have lousy sleep hygiene. Can you describe your sleep hygiene?
Yes. Okay, I go to bed nearly the same time every night. I never drink any caffeine, alcohol, or take drugs. I am gluten free, wheat free, dairy free, egg free, soy free, nut free and do not eat processed foods. I only use my phone for setting up an alarm clock before bed. This means no computer use, phone use, television use, at least by more than two hours. In fact, I rarely ever use these unless it is for something important like responding to this thread.
On the split study test the tech increased the pressure from 4cm to 5cm well before you managed to fall asleep with the mask. You can see this by looking at the graphs on page 6 of the split study. It looks to me like the tech increased the pressure from 4 to 5cm about 30 minutes after the titration started. You feel asleep for a short bit when the pressure was at 5cm. At 6cm you actually slept for almost an hour before waking up. The wake and restlessness lasted about 30 minutes or so before you fell back asleep for the last few minutes of the sleep test.


Is it plausible then if my pressure was at 6.5 or 7.0 that I might have slept even longer?

Also the ASV Titration little sleep because of the high pressure and the warm temperature. When I am at home, I do dream. How do I know? Because I remember having them, and on some rare occasions, on days where I have not had exercised I feel more well rested.
You did get into REM on the ASV titration---but the percent time in REM was not much better than the estimated percent REM on the home sleep test.
Yes, the home sleep study REM was I believe mostly disrupted by the position of my body (my back), exercise use (I might have exercised during this time, I'm not sure), no machine, and no elevation of my upper back/head
And again you mention the connection between exercise and bad sleep. This is something that you need to be open and honest about with the sleep doc (the old one or a new one if you decide to start over.)
Funny thing is, when I heard the nurse practitioner explain the exercise situation both, either one or both of them laughed. I felt bad, and thought that it was hopeless at finding out if I am ever going to be treated well. I thought that there was no help available to help me.
I also think you need to be considering the sleep continuity problems as being caused by other things in addition to the SDB that you happen to have. It's important to understand that the CPAP and ASV treat only the SDB issues: they don't fix bad sleep that is bad for other reasons. And since the data you've posted from your ASV machine seems to indicate that whatever SDB you do have is well controlled by the ASV, it's time to start considering other things that you need to address.
Yes, but as someone suggested before, that my ASV data shows a pressure support throughout the data and that it may cause my wakefulness.
I'm not saying you don't need the ASV. I'm saying that there may be MORE to your wakefulness than sleep disordered breathing.
If the only underlying cause of your sleep problems was SDB, then the number of spontaneous arousals on the home sleep test and the number of wakes during the diagnostic part of the split study would not be so high.
Can the spontaneous arousals be caused by a too low pressure along with the pressure spikes of the ASV?
(And yes, I know you want to blame the wakes on the conditions in the lab test, but the very fact that you are such a light sleeper is indicative of a large number of arousals, and the data indicate that many of your arousals are NOT respiratory related.)
Oh okay so if my arousals have nothing to do with my breathing, then please disregard the above question that I proposed.
But in the meantime, the pressure changes (with the ASV in particular), the potential for leaks, the noise of your own breathing, the sensation of air being blown down your throat, and the simple sensation of the mask on your face can all cause short term disruption to your sleep. But dial wingin' doesn't usually fix these problems; time does. And in fact, once the data shows that the AHI is low enough and the leaks are under control, dial wingin' can perpetuate adjustment problems because it takes time to get used to each and every change in settings.
Okay. I feel like I am much better adjusted to the machine.
Memory is not as reliable as we want to think it is. You want the log to be easy to keep. All you need to do is design a spreadsheet or even a paper form to fill in. Ideally it should take you less than 10 minutes to fill in the log.
I guess its time to take my sleep journal log back out
I'd suggest designing a spreadsheet or paper form to fill in that lets you quickly write down the following information at the end of each day just before you go to bed:
  • What kind of exercise did you do?
  • When did you exercise?
  • How long did you exercise?
  • Relatively speaking, how intensely did you exercise for you?
The next morning you need to add this information to the log:
  • What time did you go to bed?
  • How long did it take you to fall asleep? (Estimate this----do NOT look at a clock)
  • Do you remember any wakes or restlessness? If so, how many wakes or restless periods?
  • When did you wake up for the morning? When did you get out of bed?
  • Estimate how much sleep you go during the whole night.
  • How rested do you feel on waking?
  • Do you remember dreaming? (This is optional)
After a few weeks of data you may see some patterns that are not apparent now. It could be that the time of day you exercise has more to do with how the exercise affects your sleep than you think it does. It could be that some forms of physical activity are more disruptive than other forms are. Or it could be that exercising too long or too hard adversely affects the sleep. In other words, keeping the log may help you discover a way of getting the exercise you crave while minimizing the adverse affects on your sleep patterns.
[/quote]

This is a great idea. I will print this information out so I can use most of it or all in my sleep journal. The problem with exercise is that, even a small amount will make my therapy worse which is why I try to not raise my heart rate, so in the rare occasion that I do do exercise, it would be logged in a journal which would help. Thanks

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Min EPAP: 13.0 CmH20
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Max EPAP: 25.0
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sleepinow
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Re: HELP AGAIN! ASV or APAP?

Post by sleepinow » Wed Apr 16, 2014 2:38 pm

robysue wrote:Out of curiosity, does your AHI go up or stay the same on the night after exercising? Or is it just that the sleep deteriorates because the number of wakes goes up and the restlessness goes up?
Truthfully, I haven't checked, but I do wake up much more often which increases my restlessness. Sometimes I wake up so much times that it is hard for me to go back to sleep.
And when you wake up from the dreams, are you waking up from bad dreams? Is there any chance that nightmares or night terrors are potential sleep problems for you? (Night terrors is a NREM sleep disorder)


I wouldn't say they are a problem. If I remember clearly, it is an indication that I am not breathing. I would say most nights I do not have nightmares.



When you say you "breathe harder" during the days after an exercise day, do you mean that you are panting and short of breath?
No, it feels like I breathe better and like my airway is more opened.
Do you mean you are breathing more rapidly than on the exercise day?
I am not sure I am breathing more rapidly but definitely more deeply. It feels actually good vs having shorter breaths

And does this happen during the DAYS after the exercise day as well as at night(s)?


Yes, about two days after and then it gets weaker and shorter.
If there is a DAYTIME breathing problem on the day(s) following an exercise day, then you need to be examined for DAYTIME breathing problems such as asthma. (There is one version of asthma that can be triggered by too much exercise in fact.) And if there is a DAYTIME breathing problem on the day after you exercise, you need to bring this up with your primary care physician. You may need a referral to pulmonologist to investigate the DAYTIME breathing problem if exercise is affecting your DAYTIME breathing on the day after you exercise.


I think my breathing is better after exercise.
I definitely also breathe harder during these three days which might mean that I need a higher pressure from my machines because my breathing is too strong for the weak 5.5 EPAP pressure that I have.
I'll be honest, I'm not following all of this. When you say you are "breathing too strong for the weak 5.5 EPAP pressure", you've lost me. The EPAP pressure only needs to be high enough to prevent your airway from collapsing in an OA. Higher EPAP pressures make it harder to exhale against the pressure, and that makes it harder to breath (when you are awake at least) rather than easier to breathe.
Okay so basically what I am trying to say is that my breathing feels more stronger and the resistance of the EPAP pressure feels weakened.
The CSA problem that ASV's are designed to fix is more accurately described as "not breathing strongly enough" to blow off enough CO2: Essentially CSA is caused by an undershoot/overshoot cycle in the CO2 levels. The cycle starts when the brain has trouble interpreting the CO2 levels and "forgets" to send a signal to breath deeply enough and the breath becomes shallower and shallower and not enough CO2 is exhaled (the undershoot part of the cycle); eventually the brain forgets to send a signal to inhale for a long enough time for a Central Apnea to be scored. And while the breathing is becoming shallower and shallower, the CO2 levels are growing because you're not exhaling enough CO2 during the exhalations. Eventually (after the CA), the brain realizes that it needs to restart the breathing, typically because of the drop in O2 connected with the CA. But at this point the brain also notices that the CO2 levels are too high and so it sends a signals to breath very deeply, which blows off too much CO2 (the overshoot part of the cycle) and then the cycle starts over: As the CO2 level goes too low, the brain starts forgetting to send a signal to breath deeply enough and the breaths start to become shallower and shallower again.

It's this undershoot/overshoot cycle on the CO2 levels that an ASV is designed to fix and the way an ASV fixes this undershoot/overshoot cycle is that it monitors the depths of the inhalations. When the the depth of the inhalations fails to meet the target ventilation, the ASV rapidly and drastically increases the IPAP pressure to "trigger" an inhalation and insure that enough air is inhaled to insure proper gas exhange in the lungs, which stabilizes the CO2 levels and prevents the undershoot/overshoot cycle from getting started in the first place. But those drastic increases in IPAP do take some getting used to, and until you do, they can be a source of additional wakes and arousals.
Thanks for making me understand this better

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System One Respironics Bipap AutoSV Advanced Quattro Fx

Min EPAP: 13.0 CmH20
Min Pressure Support: 3.5
Max EPAP: 25.0
Max Pressure Support: 5.0
Max Pressure: 20.0
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sleepinow
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Re: HELP AGAIN! ASV or APAP?

Post by sleepinow » Wed Apr 16, 2014 3:05 pm

You still haven't answered my question. What time of day do you exercise?
Umm, I used to do it early in the morning, upon waking up, then I pushed it to the noon because I needed to sleep longer, and then noon/afternoon/evenings. The reason I kept pushing it is because my tiredness was increasing to the point. I hardly ever exercised before four hours of bedtime and never, at least to what I can remember 2-3 hours before bed.
Also look at things like caffeine consumption. We tend to consume more caffeine than we realize and we tend to drink it later in the day than we think---particularly when we're feeling excessively sleepy or tired during the day.
I had Zero caffeine (No chocolate, coffee, soda, tea, etc.) for over two years
Good.
Now: What about alcohol? What about sugar? What about carbs? All of these things too close to bed can also adversely affect sleep.
No alcohol, no added sugar; only what is naturally found in foods, and I would say 90-160 grams of carbs a day. Sometimes I could have some carbs before bed because it would help me fall asleep, like having cereal with rice milk.
And are you on any daily medication for other medical problems?
Nope, I do take some melotonin which helps me from waking up so often
Vitamin D levels are low in lots of people regardless of diet.


I take supplemental Vitamin D probably like 15,000 IU. And on some days have salmon which have a very good source of Vitamin D
Scheduling a good thorough physical after you are done with your semester is a very good idea. Be sure to mention all the problems with exercise at that physical too.


I will definetely do a physical. This information is being copied too into my word document
Unfortunately self-titrating an ASV by dial wingin' is a whole lot harder than trying to self-titrate an APAP or CPAP; there are a whole lot more therapeutic settings that have to be set and the data you've posted doesn't really indicate that anything is obviously "wrong" with your settings. In other words, the main problem seems to be that you just are not yet feeling as well as you should be feeling and your sleep is still bad in terms of the number of unwelcome wakes and in terms of not feeling rested when you wake up.


Correct
This raises a question that I have. What is the downside of having a slightly higher CPAP or ASV setting than is needed? Will it cause harm? If so, how and why?
If central apneas are a problem, then a higher than needed CPAP pressure can trigger additional CAs. On the ASV side if the settings are not correct it can aggravate the CSA problem rather than fix it.

For someone who doesn't have problems with pressure induced central apneas, the biggest problem with too much pressure is that too much pressure can lead to additional adjustment problems, such as more problems with leaks, dry mouth, aerophagia, and overall discomfort. And all of these additional problems can and do lead to more spontaneous arousals, which in turn can lead to additional sleep problems.
Considering my low pressure, while it may take time to adjust to a higher pressure, it would seem unlikely that a slightly higher pressure would cause much more problems. But if lets say I have a pressure of 13.0, then increasing the pressure would seem more likely to cause further problems because that pressure if pretty high.
And by the results of these tests, there is no way to tell what machine I should be using under which pressure?
I'm not a doctor or a sleep tech. I'm just a well read OSA patient who uses a plain old BiPAP Auto.
Very well read indeed

Keeping that in mind, I think that the ASV and CPAP titrations are both problematic mainly because you don't have an accurate diagnosis. The CPAP titration also has no REM sleep and the ASV titration has no supine REM sleep.
If the home sleep study is correct, then CPAP/APAP ought to be fine and the CPAP titration part of the split study indicates that a pressure of 6 should be a sufficient starting point. And if wanted to dial wing with the APAP it would be reasonable to set the APAP up in Auto mode with a range of 6-8 or 6-10 if you wanted to see if the machine wanted to increase the pressure. (If you're not comfortable breathing at 6 cm, you could up the starting pressure to 7cm without too much risk of causing additional problems.)
I was thinking of purchasing an APAP just to test if it is enough of what I would need.
If the data in diagnostic part of the split study is correct, then an ASV machine is probably more appropriate and the ASV titration says that the settings that came out of that test are appropriate. And if those are the settings you are currently using on the ASV, I don't think I'd mess with them.


Yeah me either.
If the CAs in the diagnostic part of the split study should have been scored as OAs (and there is no way for us to determine that), then the CPAP titration part of that study indicates that CPAP at 6cm should be suficient, but again since there was no REM sleep, it might be reasonable to set the APAP up in a narrow auto mode of 6-8 or 6-10 cm.

As for which is the right thing to do? I'd say you need to talk to a sleep doc who's seen the data. If that cannot happen until your semester is over, you're stuck with what makes you feel the best? You've said that its the ASV machine. It may be that you simply need to give it more time since learning to sleep with an ASV is not easy.

And it's now almost 20 minutes after my "official bedtime" of 1:30AM and I'm starting to yawn. Which means it's time for me to go to bed. I probably won't read anything here tomorrow because I've got a long day at work.
Well since I could not of read this in time before you went to sleep, I thank you and good night to the next time you go to sleep

_________________
Mask: Quattro™ FX Full Face CPAP Mask with Headgear
Additional Comments: Trying my best to get quality rest. PR System ONE REMstar BiPAP Auto SV Advanced
System One Respironics Bipap AutoSV Advanced Quattro Fx

Min EPAP: 13.0 CmH20
Min Pressure Support: 3.5
Max EPAP: 25.0
Max Pressure Support: 5.0
Max Pressure: 20.0
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sleepinow
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Re: HELP AGAIN! ASV or APAP?

Post by sleepinow » Wed Apr 16, 2014 3:14 pm

Sludge wrote:
sleepinow wrote:
robysue wrote:2) It's not at all clear why the doc agreed to an ASV titration.
It was more of a recommendation from forum users on here.
Who recommended that?
I do not think it is important to give out names. If you are still interested however, then it can be found in two of my threads.

P.S I tried P.Ming you but you have restrictions on private messages

_________________
Mask: Quattro™ FX Full Face CPAP Mask with Headgear
Additional Comments: Trying my best to get quality rest. PR System ONE REMstar BiPAP Auto SV Advanced
System One Respironics Bipap AutoSV Advanced Quattro Fx

Min EPAP: 13.0 CmH20
Min Pressure Support: 3.5
Max EPAP: 25.0
Max Pressure Support: 5.0
Max Pressure: 20.0
Flex Setting: Bi-Flex - 3
Backup Rate:Auto
Humidification Mode:off
Humidifier Setting:c5

musculus
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Re: HELP AGAIN! ASV or APAP?

Post by musculus » Wed Apr 16, 2014 4:00 pm

sleepinow wrote:
musculus wrote:Yeah, now I see where 43 comes from. Note what OP's sleep doctor wrote in the last sentence of the 'sleep study findings' section, totally misleading interpretation.
http://s14.postimg.org/8ba1aes7l/DSC05640.jpg

I guess 43/hr was higher than the true arousal index since heart rate will fluctuate in normal undisturbed sleep, also 43/hr will most likely make OP feel like a zombie during the day and have ZERO energy for exercise.
I do not know what was misinterpreted I apologize
43 was an index and he said 43 was the number of arousals. Can you PM me your tongue score (see the PDF link in my first reply, keep your head straight, stick your tongue to the lower teeth and open you mouth wide)?

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sleepinow
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Re: HELP AGAIN! ASV or APAP?

Post by sleepinow » Wed Apr 16, 2014 4:23 pm

musculus wrote:
sleepinow wrote:
musculus wrote:Yeah, now I see where 43 comes from. Note what OP's sleep doctor wrote in the last sentence of the 'sleep study findings' section, totally misleading interpretation.
http://s14.postimg.org/8ba1aes7l/DSC05640.jpg

I guess 43/hr was higher than the true arousal index since heart rate will fluctuate in normal undisturbed sleep, also 43/hr will most likely make OP feel like a zombie during the day and have ZERO energy for exercise.
I do not know what was misinterpreted I apologize
43 was an index and he said 43 was the number of arousals. Can you PM me your tongue score (see the PDF link in my first reply, keep your head straight, stick your tongue to the lower teeth and open you mouth wide)?
Yes. I will print the document out now and read it and send it to you, I have to go to Whole Foods now so I will have it ready when I get back

_________________
Mask: Quattro™ FX Full Face CPAP Mask with Headgear
Additional Comments: Trying my best to get quality rest. PR System ONE REMstar BiPAP Auto SV Advanced
System One Respironics Bipap AutoSV Advanced Quattro Fx

Min EPAP: 13.0 CmH20
Min Pressure Support: 3.5
Max EPAP: 25.0
Max Pressure Support: 5.0
Max Pressure: 20.0
Flex Setting: Bi-Flex - 3
Backup Rate:Auto
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robysue
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Re: HELP AGAIN! ASV or APAP?

Post by robysue » Wed Apr 16, 2014 4:25 pm

sleepinow wrote:
On the split study test the tech increased the pressure from 4cm to 5cm well before you managed to fall asleep with the mask. You can see this by looking at the graphs on page 6 of the split study. It looks to me like the tech increased the pressure from 4 to 5cm about 30 minutes after the titration started. You feel asleep for a short bit when the pressure was at 5cm. At 6cm you actually slept for almost an hour before waking up. The wake and restlessness lasted about 30 minutes or so before you fell back asleep for the last few minutes of the sleep test.
Is it plausible then if my pressure was at 6.5 or 7.0 that I might have slept even longer?
Maybe, maybe not.

There was no obvious reason to increase the pressure during the time you were asleep at 6cm, and the wake appears to be a spontaneous wake. It's also worth noting that first chunk of sleep time (about 60 minutes) at 6cm of pressure appears to be the longest stretch of genuinely solid sleep that you had on either of the in lab sleep tests. There are no obvious arousals/wakes during that hour AND it contained a nice chunk of Stage 3 sleep, which was missing from the ASV titration. The tech may very well have thought that increasing the pressure with no good reason might have put you at some risk of having some spontaneous arousals simply caused by the pressure change. In other words, given that you had finally fallen soundly asleep, why risk disturbing that sound sleep by increasing the pressure?

Compare that one hour of solid, sound sleep on the CPAP titration to the sleep you got on the the ASV titration. On the ASV titration it looks like you had four chunks of sleep, all of which look to be less than an hour in length. The first, second, and fourth chunks of sleep have you bouncing between Stage 2 and Stage 1 sleep; the third chunk has you bouncing between Stage 2 and Stage 1 and also includes two (brief) REM cycles separated by Stage 2 and a small wake.
Even so: On the ASV titration, there were 25 awakenings and 24 spontaneous arousals in spite of the ASV treatment. On the split test, there were NO spontaneous arousals on either part of the night, but there were 24 awakenings, most of which occurred during the diagnostic part of the night. So while the spontaneous arousal index on the in-lab tests may be less than the home sleep test, there's still an obvious problem with sleep continuity that doesn't seem to be associated with SDB.
Is it quite possible that the CPAP got rid of the awakenings? And is it also possible that the sleep technician did not include spontaneous arousals for whatever reason it may be?
It's QUITE possible that the CPAP did get rid of (some) of the awakenings. If you have some kind of SDB and the CPAP is smoothing out the breathing, then the sleep has a chance to improve. And (ideally) the improved sleep leads to less spontaneous arousals and less full wakes.

It seems highly unlikely for a sleep tech to simply forget to score sponataneous arousals.

But as we've noted before there's enough other stuff that's strange on the split study that it is worth asking if the study could be rescored. I'd suggest letting the sleep doc know that you've noticed that the diagnosis on the split test was for OSA, but all but one of the apneas scored were scored as CAs and that you're wondering if there's some kind of error in the sleep test report and whether the test should be rescored.

It's not clear if you have a sleep disordered breathing problem that is pronounced enough to be worth treating
The ASV did very significantly help me not be tired. So in my opinion I think it is worth treating. I was on the verge of quitting school because of my tiredness and anticipated leaving my job because I was too tired. The ASV has saved me from doing that. But is an ASV what I need? Who knows?
(the home test's result) or whether you have a problem with severe CSA
Isn't CSA and sleep disordered breathing completely related to each other?
CSA is one form of sleep disordered breathing. OSA is another. And UARS is yet another. Some people would argue that very loud, disruptive snoring is another form of SDB.
I came here thinking that a sleep study would diagnose what is wrong with me. So far it has just slightly given me a better idea of what could possibly be wrong, yet I am still very much bewildered.
It's no wonder you're bewildered: Your diagnostic tests are not consistent. The home sleep study shows very mild OSA---so mild that it might not be worth treating with PAP. The write up on the split study talks about more severe OSA and makes it clear that it should be treated with PAP. The actual data on the split study (if it is accurately portrayed as CAs) points to severe CSA and no OSA to speak of, which would indicate that it would be worth treating with an ASV machine.

We just don't know which of the three things (mild OSA, moderate-severe OSA, or severe CSA) is the correct diagnosis.
If you do decide to do another sleep test, I'd suggest a plain diagnostic test---a test without a PAP or ASV for the entire night. I would also strongly recommend that you focus on doing what you can to insure that you actually sleep during the study. In other words, if I were you I'd seriously consider NOT exercising on the day of the in-lab test.
The reason why I did it is because someone mentioned that I should be at my worst by exercising to get a pressure that I would need that would help me more when I do exercise since I plan on doing it once I treat whatever is wrong with me. It made sense at the time to do it, but we were not fully aware that I did not sleep much at all.
Thing is: You actually have to sleep during the sleep test. It's better to get a (relatively) good nights sleep that actually contains a lot of real sleep than to get so little sleep that it's hard to see what actually might be going on when (if) you ever reach Stage 3 sleep or REM. If you do another diagnostic test, don't worry about trying to trigger apneas while you're asleep. Worry about making sure that you get to sleep and stay asleep so that the necessary data can be gathered. If you've got a SDB problem it will show up if you get enough sleep during an in-lab test.
I'd also suggest sleeping in your preferred sleeping position when you are at home in your own bed.
My preferred sleeping position is on my back, but sleeping on my back worsens my therapy to a big extent.
The reason they define an "optimal titration study" as including at least 15 minutes of supine REM sleep uninterrupted by SDB arousals/desats is that if therapy is genuinely optimized, then the patient should be able to sleep in their preferred position---even if that is flat on their back.

If you sleep on your back at home, but your titration pressures were done only on your sides, then it is quite possible that the titrated pressure is not sufficient to control your apnea in your own bed. If you do more in-lab sleep studies (either diagnostic or titration), it's important to try to keep the sleep as normal as possible in the sense of it looking like a typical night's sleep for you. That means sleeping in the position you favor sleeping in at home.

The other comment I want to make is this: It can be very hard to learn to sleep in a new position. As a very light sleeper, if you are constantly trying to avoid your back when that's the position you really want to sleep in, then the very fact that you are constantly trying to avoid your back can create additional wakes---wakes where you wake up just enough to check if you are on your back or not.

In other words, one lesson it's important to learn is to relax a bit about your sleep---you've got to get to the point (eventually) where you can just let the sleep come---and enjoy the sleep regardless of whether it's on your back or not. The point of the PAP/ASV machine is to allow your body to do that without the SDB being an issue that disrupts your sleep and harms your body.

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Re: HELP AGAIN! ASV or APAP?

Post by robysue » Wed Apr 16, 2014 4:52 pm

sleepinow wrote:
robysue wrote: Most adult Americans have lousy sleep hygiene. Can you describe your sleep hygiene?
Yes. Okay, I go to bed nearly the same time every night. I never drink any caffeine, alcohol, or take drugs. I am gluten free, wheat free, dairy free, egg free, soy free, nut free and do not eat processed foods. I only use my phone for setting up an alarm clock before bed. This means no computer use, phone use, television use, at least by more than two hours. In fact, I rarely ever use these unless it is for something important like responding to this thread.
So you have most of the big things covered. But one question remains: Do you get up at (roughly) the same time every day---all seven days each week?

Also the ASV Titration little sleep because of the high pressure and the warm temperature. When I am at home, I do dream. How do I know? Because I remember having them, and on some rare occasions, on days where I have not had exercised I feel more well rested.
You did get into REM on the ASV titration---but the percent time in REM was not much better than the estimated percent REM on the home sleep test.
Yes, the home sleep study REM was I believe mostly disrupted by the position of my body (my back), exercise use (I might have exercised during this time, I'm not sure), no machine, and no elevation of my upper back/head
My point is that on the ASV test when you were NOT on your back, you had the machine, and your upper back and head were elevated, the percentage of REM sleep was just about the same. And recall you know that you exercised before the ASV study.

REM on home sleep study: 13.6% of the total sleep time (TST)
REM on ASV titration study: 13.7% of the total sleep time (TST)

The ASV, the different body position, and elevating your back and head did NOT increase the percentage of REM you got.

And again you mention the connection between exercise and bad sleep. This is something that you need to be open and honest about with the sleep doc (the old one or a new one if you decide to start over.)
Funny thing is, when I heard the nurse practitioner explain the exercise situation both, either one or both of them laughed. I felt bad, and thought that it was hopeless at finding out if I am ever going to be treated well. I thought that there was no help available to help me.
That's why you need a log. You show the log and you say, "I didn't think it mattered, but look at how much worse my sleep is on the nights following exercise." That way what you're saying is not a crazy sounding hypothesis with no data to back it up---it's a reasonable observation about data you've actually gathered.

Can the spontaneous arousals be caused by a too low pressure along with the pressure spikes of the ASV?
Some people are mighty uncomfortable sleeping at relatively low pressures. And anything that causes discomfort can lead to spontaneous arousals or wakes. Spikes in the IPAP pressure on the ASV are decidedly noticeable physical sensory stimuli and they can also lead to discomfort (from pressure or leaks in the mask or noises from leaks in the mask) and all of those things can cause spontaneous arousals or wakes. But if you genuinely NEED an ASV or a PAP to manage SDB, then sleep with the machine long enough and your brain will eventually learn to tune out the sensory stuff coming from the machine (including the pressure spikes) and no longer arouse or awake every time the machine seems to do something or the mask springs a tiny leak. Likewise you eventually get to where you don't have to wake up just to turn over without tangling the hose up.
(And yes, I know you want to blame the wakes on the conditions in the lab test, but the very fact that you are such a light sleeper is indicative of a large number of arousals, and the data indicate that many of your arousals are NOT respiratory related.)
Oh okay so if my arousals have nothing to do with my breathing, then please disregard the above question that I proposed.
There's more going on with PAP and ASV therapy than just fixing your breathing. The machine sends out a lot of sensory stimuli in the form of pressure, pressure changes, blower noise, the sound of your own breathing, the exhaust flow, the feel of the mask on your face, mask leaks, mouth leaks, and hose tangling. It takes a while for the brain to quit noticing all that stuff. And until it does, the PAP/ASV machine itself can trigger a fair number of spontaneous arousals and wakes.

The fact that you had no spontaneous arousals and so few wakes during the CPAP titration as compared to the ASV titration may indicate that you might just do better at a fixed pressure setting---i.e. straight CPAP rather than something with varying pressures (like APAP or ASV). Did you ever try straight CPAP or did you jump immediately to APAP when you first started out?

Memory is not as reliable as we want to think it is. You want the log to be easy to keep. All you need to do is design a spreadsheet or even a paper form to fill in. Ideally it should take you less than 10 minutes to fill in the log.
I guess its time to take my sleep journal log back out
Yep. It's time. Just try to keep the journal logging relatively simple and quick to fill in.

_________________
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robysue
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Re: HELP AGAIN! ASV or APAP?

Post by robysue » Wed Apr 16, 2014 5:18 pm

sleepinow wrote:
robysue wrote:Out of curiosity, does your AHI go up or stay the same on the night after exercising? Or is it just that the sleep deteriorates because the number of wakes goes up and the restlessness goes up?
Truthfully, I haven't checked, but I do wake up much more often which increases my restlessness. Sometimes I wake up so much times that it is hard for me to go back to sleep.
So increased exercise appears to be correlated with increased wakes and increased restlessness. Use the sleep journal to establish the correlation (if it's really there) or to show to yourself that they're not actually strongly correlated.

Back to sleep hygiene questions:
  • 1) When you wake up in the middle of the night, what's the very first thing you do?
    2) When you have trouble getting back to sleep after a middle of the night wake, what do you do?

You write:
When you say you "breathe harder" during the days after an exercise day, do you mean that you are panting and short of breath?
No, it feels like I breathe better and like my airway is more opened.
and
I am not sure I am breathing more rapidly but definitely more deeply. It feels actually good vs having shorter breaths
So it's not that you are breathing harder. You're breathing better and more easily on the day or two after you exercise. If the breathing is so much easier, why is the fatigue worse? Usually easy, better breathing means more energy, not less: Bad breathing takes a lot of effort and the effort to breath when the breathing is bad is usually exhausting.

You add:
I think my breathing is better after exercise.
and
Yes, [the breathing stays good for] about two days after and then it [the breathing] gets weaker and shorter.
Do you sometimes feel short of breath? Or out of breath? Is it ever actually hard to breathe? I do think you should mention your breathing problems to your PCP. It may just be that you need to figure out a way of being more active without adversely affecting the sleep. But it could be that something weird is going on that needs to be investigated. You might want to add a "rate the quality of my breathing" to the day part of your journal. Keep the rating really simple:
  • 0 = breathing feels awful;
    1 =breathing feels bad;
    2 = breathing feels ok;
    3 = breathing feels good;
    4 =breathing feels awesome
would be sufficient. Again you need to establish whether there really is a correlation between exercise on Monday and how the breathing feels Tuesday, Wednesday, and Thursday.




You also write:
Okay so basically what I am trying to say is that my breathing feels more stronger and the resistance of the EPAP pressure feels weakened.
If you are breathing more normally, then exhaling against the EPAP pressure will be easier. And that's NOT a bad thing. The EPAP doesn't need to keep your throat open when you're awake; it's for when the muscles controlling the upper airway relax. And chances are when you feel that your daytime breathing is better, your night time breathing may be better too, and that might mean that on those best nights you need less EPAP than on a night where the breathing doesn't feel so good.

And by the way, a lot of people feel overwhelmed by the effort to exhale against the positive pressure when they are newbies, but after using the machine for a few weeks, they start to notice it now feels perfectly normal to exhale against the pressure. And then there are those of us, who even after several years of PAPing, find the exhaling against the pressure bothersome at the beginning of the night, but once we wake up (either in the middle of the night or in the morning) we're sticking our hand in front of the exhaust vents because there's now no apparent extra effort needed to exhale against the pressure and we want to make sure the dang machine is still on. In other words, with time you get used to exhaling against your EPAP and it naturally becomes "easier" to do. That doesn't mean that you somehow need to increase the EPAP; it just means you've become acclimated to the extra work needed to exhale against the positive air pressure.

_________________
Machine: DreamStation BiPAP® Auto Machine
Mask: Swift™ FX Nasal Pillow CPAP Mask with Headgear
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robysue
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Re: HELP AGAIN! ASV or APAP?

Post by robysue » Wed Apr 16, 2014 5:34 pm

sleepinow wrote:
You still haven't answered my question. What time of day do you exercise?
Umm, I used to do it early in the morning, upon waking up, then I pushed it to the noon because I needed to sleep longer, and then noon/afternoon/evenings. The reason I kept pushing it is because my tiredness was increasing to the point. I hardly ever exercised before four hours of bedtime and never, at least to what I can remember 2-3 hours before bed.
My guess is that you are going to need to do the exercise in the morning if you want to minimize its affect on your sleep.

As for the need to sleep longer---part of good sleep hygiene is picking a wake up time and a bed time and keeping them consistent every single day---even if you are exhausted when it's time to get up (as long as you're not actually ill with a virus). Going ahead and getting up will insure that you'll get sleepy at the right time the next evening. Sleeping longer in the mornings on selected days will mess up the "get sleepy at the right time in the evening" (This is one of MY biggest sleep issues---the failure to get sleepy at the right time in the evening; and inconsistent wake times can really play havoc on my sleep. I've learned that lesson the hard way way too many times to count.)

If there's a universal need to "sleep longer" then you may need to compromise and see if you can get to bed a bit earlier.

And while we're talking about sleep schedules: How much time do you think you need to sleep each night? When is your desired WAKE UP time? And when is your bed time?

This raises a question that I have. What is the downside of having a slightly higher CPAP or ASV setting than is needed? Will it cause harm? If so, how and why?
If central apneas are a problem, then a higher than needed CPAP pressure can trigger additional CAs. On the ASV side if the settings are not correct it can aggravate the CSA problem rather than fix it.

For someone who doesn't have problems with pressure induced central apneas, the biggest problem with too much pressure is that too much pressure can lead to additional adjustment problems, such as more problems with leaks, dry mouth, aerophagia, and overall discomfort. And all of these additional problems can and do lead to more spontaneous arousals, which in turn can lead to additional sleep problems.
Considering my low pressure, while it may take time to adjust to a higher pressure, it would seem unlikely that a slightly higher pressure would cause much more problems. But if lets say I have a pressure of 13.0, then increasing the pressure would seem more likely to cause further problems because that pressure if pretty high.
And some people who have problems with centrals have the problems kick in at very low pressures. Others, it takes more pressure.

And the problem is: We don't know if you have a problem with central apneas or not. The home sleep test (which is very limited in accurately scoring central vs. obstructive apneas seems to indicate that CAs are not your issue. But the diagnostic part of the split study lists all but one of the apneas as central, which would indicate that you do have a problem with central apneas. And yet the diagnosis from the diagnostic part of the split sleep study is OSA, which raises the question of "where's the typo in the split study report?" Did someone put the wrong numbers in the "CA" and "OA" boxes? Or did someone type OSA instead of CSA?

Hence there is some reason to be cautious and not increase the pressure if your AHI < 5 when you use the ASV or APAP.

Have you got any data from your machine that you could post that shows us what the typical number and distribution of events recorded by your machine(s) actually is?

_________________
Machine: DreamStation BiPAP® Auto Machine
Mask: Swift™ FX Nasal Pillow CPAP Mask with Headgear
Additional Comments: PR System DreamStation and Humidifier. Max IPAP = 9, Min EPAP=4, Rise time setting = 3, minPS = 3, maxPS=5

sleepinow
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Re: HELP AGAIN! ASV or APAP?

Post by sleepinow » Wed Apr 16, 2014 8:08 pm

Do you get up at (roughly) the same time every day---all seven days each week?
Yes I usually do. That would be 12:30 every day. Sometimes I wake up an hour or two later or earlier but it is unlikely that I do that.


My point is that on the ASV test when you were NOT on your back, you had the machine, and your upper back and head were elevated, the percentage of REM sleep was just about the same. And recall you know that you exercised before the ASV study.

REM on home sleep study: 13.6% of the total sleep time (TST)
REM on ASV titration study: 13.7% of the total sleep time (TST)

The ASV, the different body position, and elevating your back and head did NOT increase the percentage of REM you got.



That's why you need a log. You show the log and you say, "I didn't think it mattered, but look at how much worse my sleep is on the nights following exercise." That way what you're saying is not a crazy sounding hypothesis with no data to back it up---it's a reasonable observation about data you've actually gathered.
Makes total sense, I should have continued with my Sleep Log that I previously had
Can the spontaneous arousals be caused by a too low pressure along with the pressure spikes of the ASV?
Some people are mighty uncomfortable sleeping at relatively low pressures. And anything that causes discomfort can lead to spontaneous arousals or wakes. Spikes in the IPAP pressure on the ASV are decidedly noticeable physical sensory stimuli and they can also lead to discomfort (from pressure or leaks in the mask or noises from leaks in the mask) and all of those things can cause spontaneous arousals or wakes. But if you genuinely NEED an ASV or a PAP to manage SDB, then sleep with the machine long enough and your brain will eventually learn to tune out the sensory stuff coming from the machine (including the pressure spikes) and no longer arouse or awake every time the machine seems to do something or the mask springs a tiny leak. Likewise you eventually get to where you don't have to wake up just to turn over without tangling the hose up.
(And yes, I know you want to blame the wakes on the conditions in the lab test, but the very fact that you are such a light sleeper is indicative of a large number of arousals, and the data indicate that many of your arousals are NOT respiratory related.)
Oh okay so if my arousals have nothing to do with my breathing, then please disregard the above question that I proposed.
There's more going on with PAP and ASV therapy than just fixing your breathing. The machine sends out a lot of sensory stimuli in the form of pressure, pressure changes, blower noise, the sound of your own breathing, the exhaust flow, the feel of the mask on your face, mask leaks, mouth leaks, and hose tangling. It takes a while for the brain to quit noticing all that stuff. And until it does, the PAP/ASV machine itself can trigger a fair number of spontaneous arousals and wakes.
The fact that you had no spontaneous arousals and so few wakes during the CPAP titration as compared to the ASV titration may indicate that you might just do better at a fixed pressure setting---i.e. straight CPAP rather than something with varying pressures (like APAP or ASV). Did you ever try straight CPAP or did you jump immediately to APAP when you first started out?
I went straight to APAP when I first started off.

I guess its time to take my sleep journal log back out
Yep. It's time. Just try to keep the journal logging relatively simple and quick to fill in.
Yes I will certainly do as suggested with the journal logging

_________________
Mask: Quattro™ FX Full Face CPAP Mask with Headgear
Additional Comments: Trying my best to get quality rest. PR System ONE REMstar BiPAP Auto SV Advanced
System One Respironics Bipap AutoSV Advanced Quattro Fx

Min EPAP: 13.0 CmH20
Min Pressure Support: 3.5
Max EPAP: 25.0
Max Pressure Support: 5.0
Max Pressure: 20.0
Flex Setting: Bi-Flex - 3
Backup Rate:Auto
Humidification Mode:off
Humidifier Setting:c5

sleepinow
Posts: 457
Joined: Thu Apr 25, 2013 9:40 am

Re: HELP AGAIN! ASV or APAP?

Post by sleepinow » Wed Apr 16, 2014 8:36 pm

Back to sleep hygiene questions:
  • 1) When you wake up in the middle of the night, what's the very first thing you do?
    2) When you have trouble getting back to sleep after a middle of the night wake, what do you do?
Umm I usually just turn to my other side or try going back to sleep on the same side. I usually fall back asleep fast. But if I continuously keep waking up like five times, which is usual then I go pee, I sometimes eat something small which is kept by my bed, clear out excess water near the nasal pillows

So it's not that you are breathing harder. You're breathing better and more easily on the day or two after you exercise.
Well a form a the definition of harder is "so as to be solid or firm." which is more of want I meant, but yes better and more easily are better words to use.
If the breathing is so much easier, why is the fatigue worse? Usually easy, better breathing means more energy, not less: Bad breathing takes a lot of effort and the effort to breath when the breathing is bad is usually exhausting.
That is what I am still trying to figure out. It seems that when I exercise I wake up more

Do you sometimes feel short of breath? Or out of breath? Is it ever actually hard to breathe? I do think you should mention your breathing problems to your PCP. It may just be that you need to figure out a way of being more active without adversely affecting the sleep. But it could be that something weird is going on that needs to be investigated. You might want to add a "rate the quality of my breathing" to the day part of your journal. Keep the rating really simple:
  • 0 = breathing feels awful;
    1 =breathing feels bad;
    2 = breathing feels ok;
    3 = breathing feels good;
    4 =breathing feels awesome
I honestly do not think my breathing is bad. It happens at such an unconscious level that I rarely notice myself breathing. But since I have not worked out in over a year, any form of exercise would make my breathing feel different because it is very different compared to when I sit for three weeks straight. Anyone would notice if they are very inactive and then suddenly exercise.
would be sufficient.
Again you need to establish whether there really is a correlation between exercise on Monday and how the breathing feels Tuesday, Wednesday, and Thursday.
Yes this too will be included in my journal.




If you are breathing more normally, then exhaling against the EPAP pressure will be easier. And that's NOT a bad thing. The EPAP doesn't need to keep your throat open when you're awake; it's for when the muscles controlling the upper airway relax. And chances are when you feel that your daytime breathing is better, your night time breathing may be better too, and that might mean that on those best nights you need less EPAP than on a night where the breathing doesn't feel so good.

And by the way, a lot of people feel overwhelmed by the effort to exhale against the positive pressure when they are newbies, but after using the machine for a few weeks, they start to notice it now feels perfectly normal to exhale against the pressure. And then there are those of us, who even after several years of PAPing, find the exhaling against the pressure bothersome at the beginning of the night, but once we wake up (either in the middle of the night or in the morning) we're sticking our hand in front of the exhaust vents because there's now no apparent extra effort needed to exhale against the pressure and we want to make sure the dang machine is still on. In other words, with time you get used to exhaling against your EPAP and it naturally becomes "easier" to do. That doesn't mean that you somehow need to increase the EPAP; it just means you've become acclimated to the extra work needed to exhale against the positive air pressure.
Hmm okay, thanks for your explanation too all of my questions, it must have been time consuming but it was definitely worth it. It gave me a different perspective on what may be wrong with me. I guess the next step to take is discussing with my doctor the results of my split test to see if it can get restored. I have saved most of the information that I thought was valuable in a word document and will use it for guidance. Wow, I have been glued to my computer all day, but it was worth it. Thanks. I will regularly check back to see if anyone else offers valuable help

_________________
Mask: Quattro™ FX Full Face CPAP Mask with Headgear
Additional Comments: Trying my best to get quality rest. PR System ONE REMstar BiPAP Auto SV Advanced
System One Respironics Bipap AutoSV Advanced Quattro Fx

Min EPAP: 13.0 CmH20
Min Pressure Support: 3.5
Max EPAP: 25.0
Max Pressure Support: 5.0
Max Pressure: 20.0
Flex Setting: Bi-Flex - 3
Backup Rate:Auto
Humidification Mode:off
Humidifier Setting:c5