Waking up every 15 minutes ASV

[jamadu]

Here are the full snaps of my night with BPM off as well as last night's data. I'm wondering why last night showed no OA? My starting epap was 7 with 4 PS.

BPM off page one


BPM off page two


Last night May 5 page one


Last night May 5 page two

[Pugsy]

I am short on time at the moment...just going out the door to go pick up hubby. Then we will likely stop for a bite to eat then come home.

Interesting that BPM being off may be the trigger for the absent data points on the prior night.

Last night's report actually looks quite decent. I am not surprised that no OAs were flagged because your main problem isn't OAs...it's centrals.
I will comment more when I return home later this evening...for now plan on keeping same settings tonight.
I don't know what to make of the hyponeas but I suspect that they are more central in nature than obstructive...just suspecting... given your sleep study was primarily centrals..with only 3 hyponeas all night and no OAs.

I am going to let RobySue delve into the insomnia issue because she has much better working ideas about that than I do. She may have some questions for you. I don't know for sure that the insomnia issue is related to the sleep apnea issue. Since there is a chance that it is then I would think that it's worth continuing with therapy to see if it helps but this is something that is going to take some time...this whole ASV adjustment thing. It sure won't hurt to try.

[Pugsy]

Okay...I have done some thinking about that May 4th report that looks like Cheyne Stokes pattern but wasn't flagged. It's possible it was flagged but SH being messed up could explain the lack of flagging. We could use Encore Pro and maybe be able to retrieve the wave form for that night but at this point I don't know that it is all that critical that we know for sure. Instead I am inclined just to move forward with what we have now and not have you go to all the trouble to install Encore at this time now that SleepyHead seems to be working once your turned BPM back on.

We need more nights at this current setting anyway. Let's just see what happens as time goes by.

Even though the central index barely met criteria for the diagnosis...and we don't know if the lack of OAs on the sleep study was because of hold over effect or not and we don't know if the bad sleep is related to the sleep apnea or the RDI which is elevated just a little bit. Could all this be responsible for your insomnia?....yes, it could. It could also be something unrelated to sleep apnea and the machine won't be able to fix things unrelated to sleep apnea but we might as well give it a try since you have it.

For sure do at some time talk to your doctor about what we said earlier but in the meantime I would proceed with the ASV adjustment. We do know with ASV use that it is common for people to find that it takes some time before they see much change in sleep habits. So thus you get the "give it time" speech. It is worth trying.
While giving it time I think I would try to investigate other potential culprits that might be a factor in the insomnia.
If the only medication that you take is thyroid medication....I don't know that it is very much of a likely culprit. It certainly isn't known to affect sleep architecture all that much.

Also take your time and poke around in that flow rate graph to see if you see anymore of the respiration like you zoomed in on. Or if you actually do get some PB flags...see what those look like.

[robysue]

jamadu,

Pugsy has suggested that I comment on the insomnia end of what you're dealing with. And as she hinted at, I have more questions than answers at this point.

Background: Comments and questions about your history and the titration study
I've read through this thread and the other one at viewtopic/t111812/Respironics-sv-advanc ... -Help.html. But I haven't looked up any other threads you may have started. So please excuse me if I ask you a bunch of questions that you've answered somewhere else.

First I want to make sure I have some of the background information correct: It seems that you were diagnosed with OSA about 10 ago and that you have been using a CPAP at 16cm for most of that time and feeling lousy. So you recently had a sleep study done that showed some problems with CAs and have been recently been switched to a PR BiPAP autoSV advanced. So it seems reasonable to assume that your doctor suspected that you might have CompSA---in other words the CPAP therapy prevented your obstructive events effectively, but triggered enough CAs to cause clinically significant problems.

It looks like the sleep study that you posted was an ASV titration study and that the overall treated AHI was right at 5.0, but 22 of the 26 the residual events were CAs. It's kind of hard to read the images of your sleep study report since it is fuzzy. But if I am reading the event chart correct, it looks like all the CAs were scored during a 15-20 minute period when you were sleeping on your back between (roughly) 5:35 and 5:50. It also looks like the tech made one or more adjustments to the therapy settings and it looks like there were no more CAs scored during the last 20 minutes or so of the test.

There's also a lot of RERAs on the test, including a pretty significant bunch of them that occurs right after the end of the nasty cluster of CAs. And it looks like the tech bumped the EPAP up a notch in response to this cluster of RERAs right around 6:00 and after that adjustment there don't seem to be any more RERAs.

Which brings me to my first set of questions:

1) Have you had a chance to discuss the data on the sleep study report with the sleep doc?

2) Did s/he have anything to say about why the CAs didn't show up until after 5 am? Did s/he seem to think that there was enough time after that cluster of CAs to determine whether the final ASV settings are effective in dealing with the CAs?

3) Did s/he have anything to say about the large number of RERAs that follows the cluster of CAs? The RERAs likely indicate that you do have an obstructive problem as well as the problem with CAs.

4) Do you have a follow-up scheduled with your sleep doc scheduled in the not too distant future?


Insomnia related questions and comments
You said that you have felt terrible for the last 10 years while using the CPAP at 16cm. When you say you felt terrible, do you mean that it felt like you were sleeping through the night ok, but you were waking up in the morning feeling awful and that you were dealing with a lot of the standard symptoms of sleep apnea: brain fog, daytime sleepiness, daytime exhaustion, falling asleep at odd points during the day, etc?

Or do you mean that you had a lot of insomnia problems during the 10 years on CPAP?

In other words, I need to understand when the insomnia started:

Did the insomnia start right after you were switched from CPAP to ASV? Or did it predate the switch in machine?

Next when you say that you're waking up every 15 minutes, how sure are you of the frequency of the wakes?

A lot of times when we are dealing with severe sleep maintenance insomnia it's easy to overestimate the number of wakes and the amount of time we're awake and at the same time underestimate the total time we are asleep. The data you've posted on this thread do show some extended wakes where the machine was turned off and back on. And given the spikiness in the Flow Rate curve on both nights, there is some evidence that you may have been very restless for some extended periods of times during both nights. But both nights also show that it looks like you got some real sleep between the time you went to bed and the first time you turned the machine off and back on.

On May 4, the restlessness seems to increase quite a bit as the night goes on. And given the fact that there are no timed breaths this night, I wonder if you really were awake most of this night.

It looks like you used the same settings on May 5 except for a minor change in max IPAP from 15 (on May 4) to 16 (on May 5). So why is the data so much uglier on May 5? Is it just that SH is correctly reading all the data for May 5 and there are some obvious SH issues on May 4? Or is it that you slept more on May 5 and the ASV algorithm had to do its job of treating your central sleep apnea? Which brings me to the next bunch of important questions:

1) When you woke up in the morning did you have more or less the same impression of how well you slept on May 4 vs. May 5? In other words, did you wake up feeling about the same on both days? Or did you feel much worse on one day? If so, which day did you feel worse?

2) What do you think happened during the last two hours on the night of May 5? Were you asleep or awake during this time frame?

3) Do you remember a wake around 5:20 or 5:30 on May 5? There's a large leak right around that time. And the cluster of events starts after that leak is fixed. So I'm wondering if you woke up, fixed the leak, and never got back to sleep.


Suggestions on where to go from here
I agree with Pugsy that we're going to need more data to sort out the ASV settings. But to sort out the insomnia stuff, I think we're going to need some data that is not recorded by the ASV machine. In particular we need you to keep a sleep log to document the insomnia stuff. A simple EXCEL spread sheet based sleep log can be found at http://www.sleepmedicinecenters.com/Pat ... s/SleepLog.

Fill out one line each morning when you wake up. Do NOT look at the clock when you are in bed for establishing how long it took you to fall asleep or how many wakes you remember. It's not important to accurately document when the wakes occurred or how long each wake lasted. Just a overall estimate of how many times you woke up and how much sleep you got is what we need.

When you have your follow-up appointment with your sleep doc, bring the sleep log with you. The data will be useful for your sleep doc to have when you're talking about the fact that it feels like you're waking up every 15 minutes on the ASV machine.

As for what to do about the wakes: That may depend on what your sleep doc wants you to do. If prescription sleeping medicine is not contraindicated, the doc may suggest that. It may or may not help much, but it can be worth trying if you don't have any objection to it. Cognitive behavior therapy might also be suggested. That may be very useful either by itself or in conjunction with prescription sleeping pills. The point of the CBT would be to learn things you can do to try to teach your body to consolidate the sleep cycles and minimize (but probably not eliminate) the number of wakes that you experience every night.

Good luck. And do keep us posted on whether the insomnia is getting better or worse.

[Pugsy]

jamadu....please clarify for me...I thought the sleep study you linked to above with without cpap or any pap.

If that AHI of 5 that is primarily central is with ASV/Pap or whatever then that means I totally have to rethink my ideas.

Or...was the first part of the night without any pap and that's the AHI of 5...and the mention of EPAP settings part of a split night that failed due to time constraints?

[robysue]

jamadu,

Please do answer pugsy's question. The data you posted in your sleep study sure seems to indicate that they had you on a machine since there are IPAP and EPAP graphs along with a data table that is split by pressure setting. But in reexamining this data, the IPAP = EPAP throughout the night, so it looks like this was probably a CPAP titration study and not an ASV study. Is that correct?

Here's the data that seems to indicate the study was a straight CPAP titration study.

[Pugsy]

Oops...looks like my bad...I may have misread the first initial post you made.
Looks like this was on cpap (thus titration) report so please disregard prior thoughts about "where are the OAs" and "why are we even doing this".
Also disregard the thoughts about holdover effect. CPAP probably dealt with the OA but obviously couldn't deal with centrals.

Doesn't change the plan though....use current settings as they seem to be working well (leave IPAP open at max 25 so the machine can go there for the centrals if needed ) and let's "give it time" and do your insomnia homework with RobySue. The machine won't go up there if it doesn't think it needs to.
It may be that eventually as your body adjusts to the ASV way of doing things that the insomnia abates but it won't hurt to try to sort out the insomnia issues while we are "giving it time" because there's no guarantee that your insomnia is related either totally or in part to the sleep apnea.

[jamadu]

Hi Pugsy. yes, my overnight study was with Cpap with a starting pressure of 10cm per Doc's orders. I was diagnosed with severe apnea in 2006 via home study(that's all insurance would pay for). The original prescription was for CPAP set at 16 centimeter. Since my original diagnosis, I've been through four different doctors and have complained about how terrible I was feeling. I lost my job after 30 years and because of desperation I reached out to the VA for help. Three years ago, the first pulmonologist at the VA put me on auto cpap and I still felt terrible. I kept begging for an overnight study because I could see my stats on the machine was showing between 20 and 30 percent periodic breathing every night. I begged for an proper overnight sleep study and the doctor told me that I should just accept my situation. I again presented him with the fact that I had periodic breathing and he said that it may be due to my low thyroid which hadn't been addressed at this point. I was prescribed armour thyroid and have been normal for the last 4 months. I noticed that my periodic breathing was still at 20 to 30% so I ask the VA for a different pulmonologist. My wish was granted and the VA gave me another doctor to work with. My new Doctor read my SD card off my CPAP machine and decided to give me an overnight sleep study. The person who interpreted the overnight sleep study suggested that it was inconclusive and I should have another overnight sleep study using BiPAP. My pulmonologist decided to forgo another sleep study and instead put me on a BiPAP SV machine. I got my new machine on April 23rd and since then I'm feeling so much better.. I'm Dreaming often and am hopeful. I want to thank you for your input, and I believe that my frequent awakenings will subside with the wisdom and knowledge of people like you, helping me.

[Pugsy]

Thank you for the clarification.

Things are indeed better with the ASV machine and while not where a person might want to be (or quickly enough which I totally understand) it's going in the right direction.
It's progression that we strive for and not so much perfection because things are rarely ever perfect.

You definitely need this machine and with time and experience and maybe a wee bit of tweaking some settings things will continue to improve. While it would have been nice to have a real ASV titration in a sleep lab because they could dial in the settings more quickly, we can get there doing it at home.

[jamadu]

I agree! keep looking up. I wanted to let you know that I went over the last couple weeks of data and decided to go with the settings I had the best results with. I will use this as a baseline for awhile unless you see a reason for more adjustments. Last night was the lowest
ahi yet and I actually slept 6 hours with only one wakeup! I tried going back to sleep, but mouth leaks started(Swift fx nasal mask) and I laid there for about an hour so I changed my mask to a Mirage Quattro. Here is my result from last night including a zoom in of what was marked as PB.

[Pugsy]

Cheyne Stokes Respiration is one form of Periodic Breathing but it is not the only form of Periodic Breathing.
These machines flag PB in general which is nothing but a waxing and waning of the air flow.
Obviously this flagged breathing isn't indicative of Cheyne Stokes..it's just some gentle waxing and waning. This sort of breathing even though flagged as PB isn't something we worry about....especially when it is very random and short lived like this one is.
Not all PB means there is anything going on to worry about. I have seen this type of flagged PB on occasion myself and it really isn't something to give more than maybe a brief second glance.