Thoughts on doc's change in therapy (SleepyHead data)

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
Sibbs
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Thoughts on doc's change in therapy (SleepyHead data)

Post by Sibbs » Mon Nov 17, 2014 9:44 am

Hi folks,

I'd recently posted about having trouble adjusting to therapy in part due wakings that seemed to happen when my machine increased pressure quickly to 15 (my past post is here).

Folks here suggested switching to AFLEX, which helped. Also thought upping my APAP's min pressure might help (it was min=5, max=15 and I was often hitting that max). I called my doc and he suggested using constant pressure of 8. It wasn't a confidence inspiring conversation and I was very, very thankful for the insights you folks had given me. If I hadn't deliberately pushed your suggestions it would have been a dead end call.

I've tried the new setting for 2 nights and seem to be doing a bit better, but would love your continued input. I've captured 3 nights in the pics below-- the first in APAP mode and the latter two in CPAP mode with pressure set at 8. I'm still aware of waking up multiple times a night, but am able to get back to sleep now, though I don't feel rested in the am.

Based on these data, anything else that strikes you, or that you'd suggest?

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Image

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palerider
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Re: Thoughts on doc's change in therapy (SleepyHead data)

Post by palerider » Mon Nov 17, 2014 9:54 am

try nine, watch the CA's

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Re: Thoughts on doc's change in therapy (SleepyHead data)

Post by Sibbs » Mon Nov 17, 2014 10:27 am

palerider wrote:try nine, watch the CA's
I assume the idea w 9 is to try to knock out the remaining structural apenas, but can you say more about what you'd watch with respect to the Centrals? I don't really know what to make of them.
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LSAT
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Re: Thoughts on doc's change in therapy (SleepyHead data)

Post by LSAT » Mon Nov 17, 2014 10:50 am

Sibbs wrote:
palerider wrote:try nine, watch the CA's
I assume the idea w 9 is to try to knock out the remaining structural apenas, but can you say more about what you'd watch with respect to the Centrals? I don't really know what to make of them.
CAs are in most cases Clear Airway apneas. There was no blockage, but you stopped breathing for at least 10 seconds. Most of us do this when we turn over in bed or when we get restless before we get up. Unless we get large amounts in bunches, they are usually not a concern.

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Re: Thoughts on doc's change in therapy (SleepyHead data)

Post by Sibbs » Mon Nov 17, 2014 2:27 pm

LSAT wrote:
Sibbs wrote:
palerider wrote:try nine, watch the CA's
I assume the idea w 9 is to try to knock out the remaining structural apenas, but can you say more about what you'd watch with respect to the Centrals? I don't really know what to make of them.
Unless we get large amounts in bunches, they are usually not a concern.
I do see them to some degree every night and they do tend to be bunch. I don't have the experience to say whether what I have is a lot or a little-- curious what folks think from my pics.

CA's aside, other thoughts on how my doc's current constant pressure setting is working?
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Jay Aitchsee
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Re: Thoughts on doc's change in therapy (SleepyHead data)

Post by Jay Aitchsee » Mon Nov 17, 2014 2:49 pm

Sibbs, I'm going to guess the CA's are really wakes that are caused by the disturbance of the Auto pressure changes. It appears that with a fixed pressure, the CA's have diminished and you're overall AHI has come down, meaning possibly fewer wakes and more restful sleep.
To me then, it looks like a constant pressure is resulting in better treatment. If I were you, I would run at this pressure for at least a week to "settle in". After that, If there is still a significant number of Fl limitations, and/or hypopneas and apneas. I would raise the pressure, as PR suggested, but maybe to 8.5, and let it settle for another week, and so on. If CA's increase with pressure, you may want to consult your Doctor again.
J

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Re: Thoughts on doc's change in therapy (SleepyHead data)

Post by Pugsy » Mon Nov 17, 2014 2:50 pm

Sibbs wrote:CA's aside, other thoughts on how my doc's current constant pressure setting is working?
Technically it's probably working "okay". Remove the CA index from the AHI and the AHI is even more "acceptable"..
There's still a little more RERAs, FLs and snores than I would want to see if it were my report and I agree with Paleride...maybe 9 min and 9 max.

There's still enough stuff going on that could impact sleep quality and might be a factor in those wake ups.
Now if you were reporting..."hey I am sleeping soundly all night and feel like a million bucks"...then I probably wouldn't give those RERAs, FLs and snores much more than a second glance.

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Re: Thoughts on doc's change in therapy (SleepyHead data)

Post by palerider » Mon Nov 17, 2014 3:26 pm

Sibbs wrote:
palerider wrote:try nine, watch the CA's
I assume the idea w 9 is to try to knock out the remaining structural apenas, but can you say more about what you'd watch with respect to the Centrals? I don't really know what to make of them.
yes, more pressure should help the hypops and the obstructives, as long as that extra pressure doesn't start causing discomfort, or cause the centrals to shoot up, you're good.

around 15% of people have complex sleep apnea, which is basically obsturctive apnea, but then when you use the pressure to open the airway, central apnea starts to show up, it's more often a issue over 10cm, but that's not a given, but it's good to watch for when you're twiddling with things

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Re: Thoughts on doc's change in therapy (SleepyHead data)

Post by TyroneShoes » Tue Nov 18, 2014 3:02 pm

That is really interesting.

Do you know what the actual mechanism of higher pressure causing centrals to go up might be?

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Re: Thoughts on doc's change in therapy (SleepyHead data)

Post by Pugsy » Tue Nov 18, 2014 3:29 pm

TyroneShoes wrote:Do you know what the actual mechanism of higher pressure causing centrals to go up might be?
While we often think about it happening with higher pressures it doesn't always have to be "high" pressures. It can come about with any pressure even as little as 5 cm. Higher pressures don't always cause problematic centrals. Lots of people use pressures in the upper teens and low 20s and don't have problems with centrals.
It's a breathing issue.
This video does a good job of explaining what happens.
https://www.youtube.com/watch?v=CU-XTcf ... e=youtu.be

We do keep one eye on them when we see centrals that are maybe borderline problematic frequency especially when suggesting more pressure to someone whose therapy seems to be not quite optimal.
Not all centrals are caused by pressure anyway. Most of them are normal...it's normal to have a few. Especially during sleep onset...it's normal and not usually a problem unless there are a large number of them.
In this situation with the OP here in this thread his obstructive sleep apnea therapy is not quite optimal and what we are seeing could very well be centrals related to arousals and thus sleep onset.
We have no way to be sure though so we just tell people to keep one eye on them. Often if the OSA is more optimal then the arousals reduce and any sleep onset centrals will reduce simply because the cause of the arousals are reduced.
Should centrals happen to be related to cpap pressure....it's usually pretty obvious because with pressure increases the centrals will usually increase in numbers.
A different machine is sometimes (but not always) needed should centrals be present in large enough numbers to cause a problem. I usually tell people we will cross that bridge if and when we need to. The odds are it won't be needed to crossed.

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Re: Thoughts on doc's change in therapy (SleepyHead data)

Post by TyroneShoes » Tue Nov 18, 2014 7:52 pm

I don't know if I am understanding this properly, but it seems that you need to find a minimum pressure that will keep the airway open (which changes depending upon what sleep stage you might be in) to minimize OSA, but if the pressure is too high that may actually increase CSA, and all of that is apparently the case for those with complex SA.

I'll have to check, but I think my home study only showed primarily high OSA events, and the CSA events seemed to only arise with APAP.

My sleep doc told me to go to straight 8 from 5-20 after a 2nd study (lab). I disobeyed and went from 5-20 to 8-12. My AHI is around 3 now (was over 5 before I changed pressure), and my centrals are less than 50%, but in light of this info maybe he knew exactly what he was doing and I should have followed his recommendation.

Any thoughts?

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Re: Thoughts on doc's change in therapy (SleepyHead data)

Post by Pugsy » Tue Nov 18, 2014 9:11 pm

TyroneShoes wrote:Any thoughts?
Thoughts on what? What you did or your doctor suggested?
There are arguments for and against either.
If you never hit your 12 maximum...it really doesn't matter that you use the 12 max and doctor was okay with 20 max.
Just because it can go there doesn't mean it will go there and if it never even goes to 12 cm it really becomes a moot point. The minimum pressure is the most critical setting anyway.

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Re: Thoughts on doc's change in therapy (SleepyHead data)

Post by Sibbs » Wed Nov 19, 2014 8:01 am

Thanks for all of the input everyone – I'll stick with 8 for a few more days and then try to gradually bump up towards 9. Note that last night was a little worse than the previous two nights at 8 in the pics above. AHI up near 7 (as opposed to 5) and I woke up feeling very groggy.

I do have a sizable cluster of CA's at approx when I fell asleep and a few scattered elsewhere along with the H/OA's in the second half of the night.

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Re: Thoughts on doc's change in therapy (SleepyHead data)

Post by Nick Danger » Wed Nov 19, 2014 8:14 am

Those centrals when you are falling asleep or waking up are really not the issue. They are probably your irregular breathing while half awake (that is normal). The machine can't tell when you are really asleep or awake. I'm guessing that if you were hooked up to an EEG, those events would be discounted and not included in the results of the study. It is hard to say whether you would be better off at the variable range (e.g. 8-12) or at a pressure a little higher than 8. Try each for a week or two and see which makes you feel better and produces better numbers (evaluating things in that order!).

Note that some of the nighttime waking may be habitual - that should fade away over time if you continue to use the machine. I know that I always used to wake around 1 am, 3 am, and 5 am (as well as other times - but those are times I used to wake enough to look at the clock) before I became religious about sticking to CPAP all night long. It took many weeks, but now I rarely remember waking during the night.

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Re: Thoughts on doc's change in therapy (SleepyHead data)

Post by Drowsy Dancer » Wed Nov 19, 2014 10:45 am

I believe your model of machine can be set for CPAP for the first part of the night (e.g. 2 hours) and then switch to APAP for the rest of the night.

So somewhere down the road in your experiments you could try CPAP 8 for two hours and then APAP 8-12 for the rest of the night. For example.

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