Confused with APAP results!

[grumpygirl]

Hi Everyone- I have been using my ResMed Auto in Apap mode for a few days and wondered about some of the morning readings I have gotten. I set the pressure at 9.0-10.6 trying to avoid aerophagia and to maybe help with the constant sluggishness I feel. Anyway I have noticed that on nights when the pressure is higher-like 10.4 or 10.6 my AHI is higher (along of course with my AI and HI). Why is this? I may sound dumb but I thought that the purpose of the auto was to raise the pressure to meet any AI or HI needs-so I thought that the higher the pressure the lower the AI and HI. BTW- on nights when the pressure only goes up to 9.8 or 10.0 my results are lower. What am I missing here??
I was titrated at 12cm but cannot tolerate anything much higher than 10.2 on straight cpap and 10.6 on auto- the aerophagia just kills me. On straight cpap at 10.2 I have been getting excellent daily readings as far as my AHI and AI and HI but I have been feeling sooo tired and depressed. That is why I switched to auto hoping maybe I might get better results as far as feeling more rested. I have been on cpap now for over 2 years and except for a very short time about 5 months after starting I have not experienced much improvement in my feelings of fatique and grogginess.
There have been many days where I feel like just giving up and putting the machine in the closet but I know I can't do that. I am desperate to feel human again and I think that if I could just get a good nights sleep that might just happen. I resorted to taking Prozac again (very low dose) about 3 weeks ago hoping that it would solve the depression problem and it has helped only minimally. I worry about taking it too long because the last time I took it (around the time I was titrated)after a few months it began to keep me awake at night and I just had to stop using it. When I use antidepressants I walk around feeling like I am covered in a fog all day-almost like I am not feeling anything. It's a trade off I know.
I know I sound like a basket case-believe me I feel like one-but I am so tired of going around and around with all of this and still not feeling any better. Doctors just look at me and say that it is just because I am getting older(57 in March) but other people don't feel this way. What's a gal to do? Sorry to have subjected you guys to this " pitty party"!! Thanks-GG

[roster]

From what you say about Prozac, I can't understand why you continue to take it.

There are some basic things that should be partners to CPAP:

- Regular exercise program - doing something you enjoy.

- Disciplined diet - Lots of veggies and berries, lean meats, good fats (olive oil, tree nuts), a few fruits, very limited grains. Portion control.

- Good sleep hygiene (Mayo Clinic website is one good source).

- Fostering of good personal relationships.

You don't mention your AHI. What is it?

[nosenabook]

First, I offer sympathy. You are not having fun.
You may have answered a question for me - I have often wondered if people could more easily get used to the pressure if they started lower than the recommended level. Sounds like a no. The level found by the sleep study is the lowest one that keeps your airway open.

Next, I sense a pattern in your post - you are doing several things part way, but expect total results. I would suggest you take a walk on the wild side and try the APAP as prescribed. A few good nights of sleep will clear your head, which will help you make decisions.

[scrapper]

Despite the many drawbacks to antidepressant therapy, there are people who truly have a chemical imbalance and require chemical intervention. That being said, AD drugs are not the cure all or candy to move people out of their medical offices, as many prescriber's tend to believe based upon their writing prescription habits.

Taking AD drugs should always be a last resort...........after trying all of the things that Rooster suggests........exercise, appropriate diet, good sleep hygiene, and most importantly healthy, personal relationships, AND professionally certifying that depression is the cause and not treatable by these other methods. There's other factors like menopause or other hormonal imbalances that also play into this situation potentially.

You just began the drug therapy....and it takes 14-21 days to reach effect, and longer for the fog to lift, if it is going to.............

I understand your frustration..........and two years is way beyond my patience level, but I think if you share specifics on your ai/ahi etc, we may be able to help you optimize your cpap therapy, and work allow you to work on the other issues Rooster suggests. Whatever you do, don't just quit the AD cold turkey---that needs to be weaned off when the time is right. (and those drugs also DO contribute to higher ai/ahi...........)

This comes from personal and professional experience...............

[Jay K]

Let me try to give this a shot. The amount of pressure you need to keep your airways open is not constant, not from hour to hour, or from day to day (a number of factors can contribute to this, ranging from stage of sleep, position you are sleeping in, use of alcohol or medications, etc.). Moreover, if at a given time you need a pressure of 13, but are only getting 12, it is not as though you are keeping your airways open 12/13 of what they should be. Your airways may simply be closing at 12, and would stay open at 13.

Thus, on those days when you are hitting the high limit of what you have set the pressure range for, it is quite possible that the amount of pressure you are receiving is less than what you require at that moment to keep your airways open. This may be the case even though the previous day a slightly lower peak pressure was on average sufficient to provide the therapy you need. Accordingly, on one day you may be getting adequate therapy with an adjusted air pressure of 10 or 11 (on average), but the next day, 12 is insufficient, and you might need 13. But if you have limited the range to a high of 12 (for example), on that day you may not get sufficient pressure, and your AHI may be higher than the previous day, when the pressure peaked around 10 or 11.

Even if on a particular day you do not hit the highest pressure you have set the APAP for, the fact the pressure is higher on some days may be that on those days you are having "bad days" where the machine had to "chase" the right pressure, thereby spending more time where the pressure was not sufficent to prevent AHI events.

If anyone out there disagrees, please chirp in, as I am no expert, just a semi-informed person on all of this.

[roster]

If anyone out there disagrees, please chirp in, as I am no expert, just a semi-informed person on all of this.

What we haven't discussed yet is positions. For many people, maybe the majority, the body position has a bigger effect on variations in pressure needs than all other factors combined.

GG, What positions do you sleep in?

BTW Jay, aren't all humans at the very most semi-informed on any topic?

[DreamDiver]

We need to know what your large leak line looks like.
When people continue feeling crummy, that's the first thing to look at.
If you are having large leaks, you are not getting therapy.
If the mask is too loose, more pressure can mean larger leaks.
Similarly if the mask is too tight.

You may even have the wrong mask for you.
You may be mouth leaking with a nasal mask and not even know it.
That can also cause loss of therapy.
You could try a full face mask. Using a fall face mask doesn't mean you'll have to breath out of your mouth. It merely means the air column between your mouth and nose maintain equal pressure, thus reducing or eliminating a possible source of large leak. You can still just breathe through your nose as normal.

Sometimes, aerophagia is worse when sleeping in different positions.
Find the positions that give you the least aerophagia and the lowest large leak.
Posting your AHI would be a good thing too.

I hope you will be able to figure out soon how best to alter your therapy to give you better sleep.

Doctors just look at me and say that it is just because I am getting older(57 in March) but other people don't feel this way.

Find another doctor. When start lining your coffin for you, they're not interested. Move on.

[grumpygirl]

Thanks to everyone who posted a reply. My leak rates are usually very low, only VERY rarely to they hit .28 or .34 mostly they range from .10 to .14 something like that. I am a mouth breather and tape my mouth very well. I have tried FFM but because I have what is called a recessed chin(which contributes to my sleep apnea) I have never found one that is comfortable or fits my face, and believe me I have tried quite a few. I cannot stand to have them rest on the bridge of my nose - it seems to cut off my ability to breathe through my nostrils and it gives me a horrible headache.
I sleep on my back on a wedge pillow because I have GERD and bursitis in my shoulders so I cannot sleep on my side. So, that sums up my sleep positions. As far as sleep hygiene- I am very consistent in my bedtime, sleep with white noise (a fan), wake up at the same time every day, etc. , etc. I am an avid walker and usually walk almost every day, I have a diet that most folks would say is very good-lots of veggies and fruit, very little(if any)red meat,whole grains and green tea, etc, etc.
I am in menopause and do have hormonal imbalance but cannot use any hormones-breast cancer is a family risk.
I am wondering if I should go back to the original prescrip. that the sleep doc gave me early on. The apap range was 8-12, but I found I could not breathe at that lower level so maybe I should pump it up a little and see what happens. I just DO NOT want to risk the awful aerophagia I have had in the past. Anything above about 10.2-10.4 is about all I can stand.
At straight cpap on my titrated 12cm I was in so much pain I thought I was going to have to go to the hospital. I can't go back to that.
My AHI usually runs less than 2 as does the AI and HI ,often the AI will be 0.0 and the HI will be under 2. So as I have read on this site those are very good numbers and should allow me to feel better. Thanks All for the posts. Any suggestions would be appreciated- GG

[grumpygirl]

Was wondering if you guys think my pressure range is too narrow? Since I had the apap set at 9.0-10.6 is that causing some problems?? I moved it up once to 9-11 but my data was much higher- like AHI-3.0 (very high for me) and AI-1.? with a high HI also, and I did have a lot of bloating the next morning. So, any suggestions on setting the pressure range??
Thanks-GG

[silver123]

Are you using the exhale relief? If so, I'd turn it down to the lowest setting to decrease the pressure drop.Or turn it off and see how you do.

I had some problems with this. Aerophagia at more increased pressure, as in around 11 or 12. With time, I decreased my range to 9-20. I want the top wide open so the pressure is there if needed. Normally my AHI is under 1.0 with an average of 9.2 and 90% of 10. There are very few incidents of needing more than a pressure of 12 and those are for a very small percentage of an hour.

Too much pressure and you get aerophagia and GERD acts up. Too little and OSA kicks in. Are you taking any meds for the GERD? Have you consulted with a GI specialist, had an endoscopy to check out that valve?

It may not be the quantity of sleep you are getting but the quality that is leaving you so fatigued. If you are having a lot of arousals, it can destroy a healthy sleep cycle. GERD and the aerophagia, pain from bursitis, etc can play a role in that. You might try a range of 7 - 10.5, check your data for 5 days and adjust as needed increasing the bottom by .5 at a time. Your AHI is pretty darn good at less than 2. Less pressure may relief the GI symptoms and you might have to settle for less pressure, slightly higher AHI and see if your sleep quality improves. It also might help to decrease your anxiety about the whole thing as well. Worrying about AHI in comparison to how rested you feel is not a winning battle.

Not sure I am helping but hope so....

[SleepyBobR]

I'm currently using an S8 AutoSet II on loan from my DME and I am having problems with it similar to yours. My doctor prescribed a range of 5 to 15 but this didn't work at all as my apneas require a much higher pressure to clear them and the machine doesn't move quickly enough when starting from 5. I only left it at 5 for one night. I was using a pressure of 10.8 on my CPAP and, although the AHI numbers were pretty good (under 2), I still wasn't feeling good in the morning. I assume that this means I am still suffering from RERAs that don't quite make the AI/HI cut but are still causing arousals or waking me up. I wanted the AutoPAP to keep me unobstructed. I can't seem to get to sleep with my CPAP at 11 or higher so I thought the APAP would solve the problem by letting me start below 11, then increasing the pressure as required once I'm asleep. What I'm finding, as I said before, is that the AutoPAP doesn't respond quickly enough to deal with events requiring a significant pressure increase from the current level so the event still causes an arousal before it is dealt with by the APAP. I was expecting the machine to respond more quickly in these situations but it doesn't seem to. It does seem to stay at the higher pressure level for a while after this happens but, once I'm awake, I can't go back to sleep at the higher pressure. All very confusing. Am I understanding this correctly? I now have the APAP range set at 10.8 to 15 to see how that works out.

[echo]

Hi grumpygirl, i'm really sorry to hear your story. It's difficult when you KNOW the therapy should work and is working and yet you still feel tired.

After nearly 3 years, I finally persuaded my doctor to treat me for hypothyroidism even though my thyroid numbers were in the "normal" range (but on the edge of the range). I feel so much better even on a low dose. It could be that your body just needs a kick start to get the metabolism going again (depression is yet another symptom).

So it's worth looking at other besides OSA: in addition to the thyroid, other problems can leave you tired even when the OSA is well treated: diabetes, low grade infection, iron levels, vitamin B levels, potential heart problems, ... Are you getting enough protein/fat in your diet?

FORGET the doctors that think you're just aging. I went through 4 doctors in 4 years until I finally found one that actually LISTENS to me, and that's the one that decided to treat me for the hypothyroid even though my numbers were "normal". You need a doctor that will listen to you and work with you, not just dismiss you. If you can, go shopping for a new doc! For what it's worth, my new doctor is very young and is very open-minded, compared to the other ones that were 50+ (and I'm not saying "old" people are closed-minded, my partner is nearly 50! But you know, sometimes people get set in their ways!).

Back the CPAP, have you tried 12cm at all in the last year? I wonder if your tolerance may have improved in the meantime? Also the question on sleeping position is very valid. You may very well need 12cm some/most nights.

What I find curious is that when you bump up the APAP pressure, you get a higher AHI. The only way that makes sense to me is if you're getting leaks at the higher pressures (mouth or mask). If this was only a one-day test the results may not be that reliable.

Maybe at the higher pressure you start getting aerophagia so you switch sleeping positions which makes apnea more likely.. I dunno I'm just making wild guesses at this point!

I assume that this means I am still suffering from RERAs that don't quite make the AI/HI cut but are still causing arousals or waking me up.

Just from my own experience I find that to be true - I was titrated at 10cm but supposedly I had too many central's at that pressure so the doctor said to start with 7.5cm. My AHI is very similar at everything between 7.5 and 10.5cm, but I find that I sleep the best at 10.5cm. In the first year I did quite a few experiments, running from 7.5 to 10.5 in both APAP and CPAP mode. I recently did the same for a few weeks, running at 7.5-12cm in APAP mode as well as 7.5cm CPAP mode, and I just really felt lousy although the AHI was the same. I have also concluded that I just don't do very well in APAP mode.

[roster]

I just DO NOT want to risk the awful aerophagia I have had in the past. Anything above about 10.2-10.4 is about all I can stand.
At straight cpap on my titrated 12cm I was in so much pain I thought I was going to have to go to the hospital. I can't go back to that.
My AHI usually runs less than 2 as does the AI and HI ,often the AI will be 0.0 and the HI will be under 2. So as I have read on this site those are very good numbers and should allow me to feel better. Thanks All for the posts. Any suggestions would be appreciated- GG

Many of us have positional sleep apnea (PSA). According to ResMed 60% have PSA. PSA means your apnea is worse while backsleeping and the pressure requirements may also be higher. Of course the higher pressure requirements translate into more aerophagia.

I have learned to sleep on my tummy in the Falcon position, viewtopic.php?f=1&t=36738&st=0&sk=t&sd=a&start=15 . I found this to be the most comfortable position for my spine and maybe more importantly I was able to lower my pressure and avoid aerophagia. It did take some time to learn tummy-sleeping after so many years of ingrained backsleeping. The longer I sleep on my tummy, the more I like it. Have a look at Falcon's posts and think about trying it.

Regarding your wedge and GERD, sleeping on a wedge may actually make GERD worse because the wedge causes the body to bend at the stomach. The MedSlant wedge is long enough to reach the hips and the body bends at the hips rather than the stomach. However, I found it uncomfortable to sleep like this. The better alternative is to raise the head of the bed four to five inches by placing some risers under the legs of the bed.

Finally, consider the Hybrid mask. This is a full face mask and I am coming up on a four-year anniversary of using it. It does not leak for me and works well for tummy sleeping. Nothing touches the bridge of your nose and the mask can be used with or without the chin flap.

BTW, a very large percentage of us have recessed chins. That is one of the fundamental causes of OSA. It means a jaw that is narrow front-to-back and therefore a restricted airway is likely.

[Muse-Inc]

...I am in menopause and do have hormonal imbalance but cannot use any hormones-breast cancer is a family risk...

Do a search for progesterone, I've written several long posts about it. Originally used by Doc John Lee for his breast cancers patients who aged enough to go thru menopause and suffer symptoms. Makes a huge difference AND activates the gene that protects against breast cancer. There is some evidence that it is slightly protective against the oxygen deprivations that we experience until we get our treatment dialed in. BTW, every single cell in our body, both men and women, have progesterone receptors..including sperm! Any form you take must be labeled USP Progesterone and don't fall for that Mexican yam hype, our bodies can't convert to the bioidentical form, that has to be done in lab.

[grumpygirl]

Last night I changed the pressure on my Auto so that the range was not so tight. I set it for 8.6-10.4. I woke up a couple of times last night but did go right back to sleep. I slept about 7.5 hrs. My results look like this:
Pressure: 9.8
Leak: .18
AHI: 1.6
AI: 0.0
HI: 1.6

Not too bad huh? I do feel pretty good today. Not tired or groggy and less depressed. All in all-darn good. However, I have had days like this in the past and they didn't last-so I'm not going to celebrate just yet. After a few more days I may widen the range a little more and raise the upper number to 10.6 and see what happens.
Wish me luck!!! Any thoughts or suggestions??? Thanks for all the feedback-GG