1 mo. CPAPer/mild apneac with doubts & detailed PSG resu

From all the posts I have read in here, it seems that sleeping on your side causes less apneas. As for getting use to the mask, it took me a few months. I started wearing it only a few hrs, then removed it. But the length of time slowly but surely increased. I also found listening to music through lightweight head phones helped distract me from the mask.(I wear a full face ultra mirage, great mask). O f course make sure its soothing music. then you remove headphones after you you have slept for awhile. I go right back to sleep.

I was titrated during the 2nd test. However, I just read another post from littlebaddow about sleep position. So I looked at my detailed results and interestingly enough, I slept more on my back during the 2nd test

I'm in a similar situation: AHI of 4 in the first PSG, sleeping only on my side, and AHI of 18 during the titration study, where I spent most of the time on back (with very little sleep). I asked for the titration study because I know I wake up snoring and choking.... Haven't yet recieved a reasonable explanation for those results - meeting a technician on Wednesday.
O.

ozij, please keep me posted (either post or PM me). I'd be very curious to hear how the meeting with the tech goes. When you say you "know you wake up snoring and choking," are you referring to the titration study or your sleep in general? I'm also curious if your sleep test results show a timeline for arousal events as well as a timeline of body position to see if there is a significant correlation between the two. You don't happen to be a Kaiser member do you?

loonlvr, thanks for the music suggestion. I'll keep it in mind, though right now I wear ear plugs and falling asleep initially isn't difficult. It's staying asleep. If only I had an angel to lullaby me to sleep every time I woke up! CPAP makers out there, when's that lullaby model coming out?

Hi Noah
I asked the doctor for a sleep study because I found myself waking up from the sound of my snores, choking, with my heart pounding;

They reported my body position for the first study - though unreliably, I was, for instance, awake on my back for a long time (abt. 13 mins) and that postion, on the time line, wasn't reported at all.
During that study the apneas and hypoapneas were almost the same, 18/20 of them in REM sleep, of which there was a lot of proportionately. (no stage 3 or 4 though)

The second study (titration) didn't report body position. I hardly slept (bits and pieces that together came to about 02:10 hours of sleep. During this study I apparently had mostly apneas, all in NREM, and hypos were negligibel (36 ap's 2 hy's). 10% REM sleep, and 11.5 % stage 3-4.

Maybe I should add that I am 52 years old, a female.

I know I am not a Kaiser member - but I don't really know what Kaiser is - a DME or insurance company? And apropos of ignorance - I haven't figured out yet what LOL stands for.... do you mind telling me?

O. - who lives in Jerusalem, Israel.

noahmckinnon wrote:
I was originally told over the phone that on the first test, I had a *TOTAL* number of 39 arousals. Divided by a Total Sleep Time of 7 hours, I had an AHI score of 5.6. However, when I actually got a hard copy of that first test, the "39" was written over a crossed out "24"...which would mean an AHI of 3.4

In some cases most of teh apneas occur in REM- my mom's was like that. She has an AHI of 9 but since they only happen in REM her apnea is more severe then what the AHI indicates. Position can also make a difference in AHI for some people so it could have been a combination of things that caused the discrepency in the number of events.

noahmckinnon wrote: My second sleep test ... suggests an increase in the number of centrals and apneas but a lowering of hypopneas, as the pressure was increased.
At 4cm (49.5 mins) I had 1 central/0 obstructives/29 hypopneas = AHI 33.9;
at 5cm (142 mins) I had 2 centrals/2 obstructives/20 hypopneas = AHI 10.1;
at 6cm (200.5 mins) I had 4 centrals/11 obstructives/28 hypopneas = AHI 12.3.
Is it possible that PAP treatment is causing more centrals and obstructives?

If you look at the number of centrals there are not that many- 7 for the whole would be an average of 1.07 per hour. Even at a pressure of 6 you only had 1.2 per hour. SOme people do experience a slight increase in centrals during titrations because the body needs to adjust to dealing with the pressure- there was a study that showed the centrals usually go away after a couple weeks when the body has adjusted to CPAP. Occasional centrals like you had can also be just from turning over in our sleep. Most doctors wouldn't be concerned about centrals in a person with OSA unless there are over 5 hour- sometimes not until there are over 10 per hour becasue they can be a symptom of the OSA. I have the reverse situation- I have 65 centrals per hour and 1-2 obstructive apneas per hour which isn't enough to change for a diagnosis of OSA or even mixed apnea.

I would focus on the hypopneas more as it looks like that is your main problem- I know some people have reported that certain models of autoPAPs are better for hypopneas then others. If the results from the autoPAP aren't conclusive then another sleep study will be needed. If you are concerned about the centrals you may want the study done at teh sleep center instead of home since home studies tend to focus more on obstructive apneas.

ozij, Kaiser Permanente is a Health Maintenence Organization in the United States. In addition to providing insurance coverage, they also operate their own facilities. LOL stands for Laughing Out Loud. I constantly have to look up what seem like an ever-growing number of internet-born acronyms. Fortunately, there are many sites that define them. e.g. http://www.netlingo.com/

christine, thanks for your insights. You may be right about focusing more on the hypopneas. Looking at the way the Resmed Autoscan software graphically displays the events, I have given more weight to the apneas. Hypopneas are displayed as a blue dot, but apneas are displayed as a red dot atop a vertical red line with the number of seconds shown within the dot; the longer the duration of apnea, the taller the red line. Unfortunately, the duration of the hypopneas is not indicated, leaving the blue dot stemless and less significant looking.

I'm not sure whether there's any way to tell from the Resmed read-outs whether I'm experiencing centrals. And at the rate I experienced them during my PSG's, I'm not sure yet whether I should be concerned. I'll have to add that to my list of things to ask the doc.

Occasional centrals like you had can also be just from turning over in our sleep.

Does that mean that turning over in one's sleep can cause an actual central apnea or that the motion of turning over somehow gives a false reading of one?

My concern about the centrals stems from a suspicion I have when looking at my readouts, which I admit I'm not well versed in doing. It seems that most of my apneas (and some hypopneas) are preceded by both a brief spike in the pressure (+2-3cm) and leakage. Zooming in as much as I can on the graph, it appears that the brief leak slighty precedes the spike in the pressure (compensation for the leak?) but both go down very quickly and then a few seconds later, an apnea is recorded, during which the pressure does not seem to go up. It's only after the apnea is recorded that the pressure goes up. I need to ask my RT, Resmed or my doc about the finer details of graph, though if I don't get a satisfactory response, I may post the readout here to see what people here think.

noahmckinnon wrote:
Does that mean that turning over in one's sleep can cause an actual central apnea or that the motion of turning over somehow gives a false reading of one?

THink about when you exercise or concentrate hard- if your not aware you can hold your breath which is essentionally central apnea. Turning over in your sleep is basically like an exercise- you go from doing nothing to moving. If you were to have your breathing monitored while you are awake you would see a lot of 'central' events. During a sleep study the bands can misread yoru breathing effort- especially when you move & scorers can misinterpret so there is also a possibility that some of your events could be incorrectly labeled too.

Oveall it seems like to me a lot of people panic when they hear they a central event. It probably has to do with the whole 'forgeting to breath'- O-My-Gosh- how could I forget to do something that basic! In reality is it any more scarey then having your airway blocked during an obstructive event? Both obstructive & central apneas result in not getting O2 in and disruption of sleep. You might want to check this older thread out on CSA- http://cpaptalk.com/viewtopic.php?t=105 ... hlight=csa

I have more events on my back than side. My AHI at sleep test (but I was waking up every hour) was only 3.5 but my first two weeks of APAP showed a higher AHI, even on therapy. I have also had several centrals since I got my 420E, so suspect my apnea is worse than the sleep test indicated. I had desat rates down to 86%. Another reason I was put on CPAP. And I slept during all 4 naps on the Sleep Latency test which they said was extremely unusual.
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_Plan to do a Home Sleep Test with my APAP set at 4 for top and bottom pressures to see what the results are.

Problem is with apnea is it will get worse with time if untreated, so test results from 2 years ago are likely lower than what you would test now.

christine, thanks for the link. That was helpful. Makes me curious what the average "normal" person's PSG would/should look like.

Janelle, doing a test at a constant pressure of 4 is an interesting idea. I may do that. One warning though, according to the Auto Spirit manual, "At low pressures, the flow through the exhalation ports of your mask may not clear all exhaled gas from the tubing. Some rebreathing may occur." I have an pulse-oximeter so I'll get an idea of what kind of desaturation I can expect from being at the lowest pressure (I breathe about 5-6 litres of air per minute).

I met the sleep/cpap technician today, and she was very inofrmative.
According to her, since I was awake and tossing about in bed for most of the titration study, most of the apneas reported are an artifact and some could have been the result of the titration attempts. Likewise the desats, which could have been caused by the oximeter moving. The only informative time period to look at is those 2 hours during which I slept at a constant pressure of 7 where I had few apneas, and normal saturation. During the discussion, when I mentioned that sometimes I wake up feeling dreadful, and sometimes less, she did suggest that my apneas could be positional, so I said: "That's why I want an automatic machine, I want it to accomodate itself to my position just the way my multifocals accomodate to the position of my eye". I think I saw a penny drop. She said that the titration with an automatic machine was in no way exhausted (I had just a week of auto), was surprised I was switched on to a stable 7 pressure with a new mask on the second week, and thought the pressure was too high.
She suggested we attempt to look for threapeutic pressure without paying too much attention to the mask (!) so I said: "But I have to sleep also" which she agreed to.
I left the place with a GoodKnight 420E set at 4-9cm and a Breeze (I didn't ask for it) (small nasal pillows) and the sales person's promise to bring me : a humidifier, software and bigger pillows next week. Had to argue about the pillows. He was going through "You know, not everything you read on the internet..." And I said firmly that a. I want to try, and b. I know how to filter the things I read on the net... And this, by the way, is a nice guy (really). Last time when the male technician insisted on raising the pressure to 7.5, this guy tried to convince him to give me the machine (GoodKnight 420E) on auto; he gave me the software and even suggested I set the machine on auto after trying the prescribed pressure for a few nights...Today he had neither software nor cable, which is why I have to wait for his next visit.
After one night at 7.5 (with a Swift) I had such a terrible headache that I informed the lab I'm stopping till I meet a doctor. The doctor suggested I speak to the technician as well, ("she understands CPAP better than me")and I'm glad I did.
Kind of disappointed not to be able to follow the results this week, but at least I was listened to: The auto is no longer so open at the top (I was actuall frightened into shallow sleep because I woke up choking when the pressure was 12), and we're going to change variables one by one.

Tonight will be my first with the 4-9 pressure and the Breeze.

Thats the one reason I like the auto with c-flex. It reduces pressure on exhalation. Its really wonderful change.

ozij, do use the long side straps with the Breeze. If moving the straps down to the bottom "slot" of the clip track in front doesn't hold the head gear steady, just take the straps off the clip, bring the straps over the entire front of the hose as low as you can put them, and just stick them to themselves in front. Hang that hose high!

Even if the "small" were, by chance, to work ok ("small" didn't for me - I have small nares, but I wear "Large") do hang onto the Breeze until you can get medium or large pillows to try. Breeze is one of my favorites - great for side sleeping.

You're well on your way ozij! Good luck!!

I've just discovered something:
Standard Diagnostic Test For Sleep Apnea Does Not Detect Condition In Many Patients

"Writing in the peer-reviewed journal of the American College of Chest Physicians, Olivier Le Bon, M.D., from the Brugmann Hospital Sleep Unit, Brussels, Belgium, along with six associates, studied 243 patients admitted to the unit between 1992 and 1998 to determine whether they had sleep apnea-hypopnea syndrome....

...In the study, 101 patients had an AHI of more than 20 events per hour. Of these individuals, 74 tried nasal continuous positive airway pressure (CPAP) on night two.
These persons were not part of the night two comparative data to determine the value of a second test. A subgroup of 169 patients who did not use an CPAP device constituted the comparison group of night one versus night two.
During night two, 62 patients shifted up to a plus 20 AHI score, almost twice the 32 whose scores dropped on the second night. The scientists said this finding "underscores the larger proportion of subjects having more severe sleep events in night two."


While this supposedly is the opposite of Dr. Phillips' presentation, it actually supports her. Two studies are even more expensive than one, and the proprtion of false negatives is staggering!

So here's my little bit more than a week on the GK420E, with the Breeze, exported from the Silverlining synthesis screen.

Start date : 30/03/2005
End date : 09/04/2005
Period : 11days

Compliance :
Compliance (h/d): 6h50min

Used pressures (Average) :
Average pressure : 4.5 cmH2O
Low pressure : 3.9 cmH2O (I used the machine to dry out the hose for one hour)
High pressure : 7.0 cmH2O

Events :
Number Apneas : 88
Index/h Apneas : 1.3
Number Apneas/CA : 105
Index/h Apneas/CA : 1.5
Number Hypopneas : 31
Index/h Hypopneas : 0.5
Number Acoustical Vib. : 2 (i.e. snores)
Index/h Acoustical Vib. : 0.0
Number Runs (FL): 2444
Index/h Runs (FL): 35.7

Cycle states :
Normal cycle : 65 %
Intermediate cycle : 1 %
Flow Limited cycle : 34 %
Invalid cycle : 0 %

Pressure efficient more than 90% of time : 6 cmH2O

Last settings of the period :
Min. pressure : 4.0 cmH2O
Initial pressure : 4.0 cmH2O
Max. pressure : 9.0 cmH2O
Max. press. for command on Apnea : 9.0 cmH2O

Pressure (cmH2O)
Time % - < 4 cmH2O : 0
Time % - 4 cmH2O : 65
Time % - 5 cmH2O : 18
Time % - 6 cmH2O : 11
Time % - 7 cmH2O : 5
Time % - 8 cmH2O : 1
Time % - 9 cmH2O : 0

I felt better (even good) on some of the days. The medium pillows, with KY jelly were better for me than the large – I gave those up after one night, because they 1. leaked more and 2. hurt more.

As you can see, the machine identified about an equal number of apneas and apneas with cardiac oscillations, (the average index for the first was 1.3 the second 1.5) and 0.5 hypo apneas – and weirdest of all – my flow limitation runs are 35.7
My nose is frequently stuffed –pre cpap as well as now - on one side, the side I lie on (changes as I turn form side to side). However, it seems to me that this kind of congestion was worse on the two nights of humidifier use. The H20 humidifier (on about no. 2) caused rainout within about 3-4 hours of use...
IFL1 and IFL2 (the instruction to raise pressure on flow limitations) were off – I turned IFL1 on today.
I would appreciate comments. I wonder at the number of "central apneas" could they be a result sleeplessness – or a slow breathing pattern?

I'm ambivalent about trying the humidifier on a slightly lower temp tonight … I know about the heated hose already – I think I prefer waiting with the ordering of one till next winter – we're entering summer soon, here and I don't have air conditioning….

After 5 + 6 + 11 days on different machines, masks and settings I can say the following for sure:
Wrong masks (leaky and uncomfotable), wrong pressure range (4-16 was not good for me) or too high constant pressure (one night of 7.5 straight) can make this therapy a real misery.
The right pressure range, a comfortable mask, practical tips given by fellow PAPers (for me it was "use KY jelly and hang the hose above your bed") plus other peoples ways of handling the problems - littlebaddows diary and "note to self" come to mind, make it much better - and give me hope.

O.

Hi ozij

To my untrained eye, those numbers seem pretty good. I use the remstar, so I'm not familiar with the output from your machine, but the indices look pretty low, except the last one but I'm not sure what that is

The acid test is you say you "I felt better (even good) on some of the days" so I guess it's beginning to work for you, which is good news

I too suffered regularly from a single blocked nostril, depending which side I slept, both pre- and post-PAP but I must say since using the heated humidifier that has largely gone away. Have you tried any of the nasal sprays to see if they help?

Do keep at it and stay hopeful