Need advice to a solution to increasing CA/AHI * Follow-Up*

[zack243]

Months ago with the generous advice of veteran members, I was able to achieve success with the Dream Station settings and my sleep environment. For approximately 9 months my AHI averaged 0.6. Starting approximately 1 month ago, my AHI slowly increased and now it has tripled. I realize that my present AHI average of 1.8 is relatively good, but the sleepyhead statistics concern me because: (1.) I never had CA's until 1 month ago; (2.) FL incidence has been slowly rising; (3.) sleep efficiency is worsening and I am waking 3 to 4 times a night; (4.) the incidence of various events is now increasing as the night progresses. In other words, events get more numerous the longer I sleep. This is converse to the way it used to be.

Some background......My PS range is narrow and my IPAP and EPAP are set according to the ability of my re-constructed lacrimal duct's ability to handle the pressure. A lot of trial-and-error went into these settings and the current: FLEX off, RISE TIME 1, RAMP off, TUBE unheated, HUMID. adaptive, cervical collar, buckwheat pillows.

Medically, I am current with exams and labs, and have no significant issues at this time. Mentally, I have no apparent stress. Chemically, I take a minimal dose of Lexapro.

I have attached two screen shots from last night. These are representative of the last month, and show a lot more events than previous month's data.

I welcome any comments and/or suggestions. I hope the Korean hacker will hold off long enough for me to get some advice.

Thank you
Zack

[Pugsy]

The CA you zoomed in on looks more like SWJ than a real CA...see that big spike right in front of the flat line...that's a big gulp of air and that usually is associated with an arousal of some sort...you may or may not remember it.

Since you are reporting more awakenings then it wouldn't be unusual to have a few more CAs flagged that weren't real centrals.
You can't fix centrals/CAs with your machine and even if they were all the real deal you don't have nearly enough of them happening to warranting the different machine that does fix centrals.

Now as to what is the cause for the poorer sleep quality....the Flow limitations might be a factor there but more pressure is usually the fix for FLs and with your lacrimal duct issues I don't know how much more pressure you would be able to tolerate.

So I suspect the CAs are nothing more than SWJ or post arousal and really the only fix for that would be better quality sleep to lessen the number of potential arousals.
Would reducing the FLs give you better quality sleep...that's an unknown. It might but it might be that the poor sleep is caused by something else entirely. You might take a step back and look at any other sleep disturbing potential culprits that might be going on.

[Julie]

Believe it or not the smallest (even 5) weight gain can cause things to be off, to start creeping up again, so if there's a chance that applies, it might answer your question. If not, please ignore.

[zack243]

The CA you zoomed in on looks more like SWJ than a real CA...see that big spike right in front of the flat line...that's a big gulp of air and that usually is associated with an arousal of some sort...you may or may not remember it.

Since you are reporting more awakenings then it wouldn't be unusual to have a few more CAs flagged that weren't real centrals.
You can't fix centrals/CAs with your machine and even if they were all the real deal you don't have nearly enough of them happening to warranting the different machine that does fix centrals.

Now as to what is the cause for the poorer sleep quality....the Flow limitations might be a factor there but more pressure is usually the fix for FLs and with your lacrimal duct issues I don't know how much more pressure you would be able to tolerate.

So I suspect the CAs are nothing more than SWJ or post arousal and really the only fix for that would be better quality sleep to lessen the number of potential arousals.
Would reducing the FLs give you better quality sleep...that's an unknown. It might but it might be that the poor sleep is caused by something else entirely. You might take a step back and look at any other sleep disturbing potential culprits that might be going on.

Thank you Pugsy for the comments. Nine months ago, you were very instrumental in helping me with my machine settings. Your present information about the CA's is appreciated. I went back over the last few weeks and looked at these CA wave forms.... 90+ percent are the variety with the large pressure spike preceding the flat line.

I will try your suggestion about increasing the pressure to decrease the FL's. I will experiment with 1/2 to 1 because I don't think my lacrimal duct can handle much more. Should I increase the IPAP or the EPAP or both? Should I let the PS min. and max. where they are now set?

Thanks again for your help

Zack

[zack243]

Believe it or not the smallest (even 5) weight gain can cause things to be off, to start creeping up again, so if there's a chance that applies, it might answer your question. If not, please ignore.

Thank you Julie for the comments. I had no idea that a small weight gain can have that effect. Your advice does apply because I have gained about 8 pounds over the last few months. My body mass index is still OK , but that extra 8 pounds on my usual 185 might be an issue. This is a good reason to lose that extra weight, and I will report back on the results.

Thank you

Zack

[Arlene1963]

Hi Zack,

I'm wondering why two of those "clear airway" events are under 10 seconds long? Are those two included in the total AHI?

I thought that events had to be 10 seconds or longer. Just curious.

[Pugsy]

I'm wondering why two of those "clear airway" events are under 10 seconds long? Are those two included in the total AHI?

I thought that events had to be 10 seconds or longer. Just curious.

Those numbers in parentheses don't reflect event duration when the person is using a Respironics machine because Respironics machines don't report event duration like your ResMed machine does. Instead Respironics machines uses some sort of marker and that is what SH is reflecting and while it is close to event duration it isn't 100% totally accurate. The developer of SleepyHead didn't know what to do with the markers because we never knew exactly what it was.
I have a Respironics machine and I used to get those single digit numbers in parentheses also but when I would go zoom in on those flagged events and manually count the seconds those 7 or 8 or 9 flagged events were actually right at 10 seconds if I manually counted the duration.
Now on the other end of the spectrum when I might see an unusually prolonged event and I manually counted the seconds it might or might not be what was actually reported in parentheses. It might be 1 to 3 seconds different but always very close.
I probably manually counted over 100 such events both single digit and prolonged and they were always really close. The single digit flags were almost always right at 10 seconds and sometimes 11.

So yes...events do have to be 10 seconds to earn a flag but with Respironics machines that don't flag event duration SleepyHead is making an educated guess as to event duration based on markers..and while not 100% spot on...it's close enough for government work.

[Pugsy]

I will experiment with 1/2 to 1 because I don't think my lacrimal duct can handle much more. Should I increase the IPAP or the EPAP or both? Should I let the PS min. and max. where they are now set?

If it were me with your special problem with the duct....I would just start with EPAP and increase ever so slightly.
And keep PS where it is...which by default will push up IPAP by the same increase.
If that causes a problem then reduce PS ever so slightly.
My ever so slightly would be 0.5 cm. FL are air flow reductions that don't make criteria for OA or hyponea flag...so they are minor in terms of either duration or amount of air flow reduction and there's a good chance that a very small change could make significant impact.

[Arlene1963]

Thanks for explaining that Pugsy, much appreciated!

[zack243]

I will experiment with 1/2 to 1 because I don't think my lacrimal duct can handle much more. Should I increase the IPAP or the EPAP or both? Should I let the PS min. and max. where they are now set?

If it were me with your special problem with the duct....I would just start with EPAP and increase ever so slightly.
And keep PS where it is...which by default will push up IPAP by the same increase.
If that causes a problem then reduce PS ever so slightly.
My ever so slightly would be 0.5 cm. FL are air flow reductions that don't make criteria for OA or hyponea flag...so they are minor in terms of either duration or amount of air flow reduction and there's a good chance that a very small change could make significant impact.

I will follow your advice, and thanks for explaining it so clearly. I hope you realize how much I appreciate all of your help.

Regards,

Zack

[zack243]

I wanted to report back.

Over the last week, I have followed Pugsy's advice and increased the EPAP to 9.0, from 8.5 cm. All other settings mentioned in the first part of this post were not changed. Over a 5 day period, I had an AHI low of 0.35, and a AHI high of 1.00, and a 5 day average of 0.7. that is quite an improvement from the recent average AHI of 1.8.

For two nights I experimented and also raised my IPAP to 11.5, from 11.0 cm. I felt this was not successful...that extra IPAP 0.5 cm caused some lacrimal duct issues, my FL increased to 18 events, my CA's increased, and AHI went back into the 1.5 range. It is amazing to me how slight tweaks can make a fairly significant difference.

I realize that one week of statistics doesn't prove very much, but I am encouraged by the results. Thank you Pugsy for your knowledge and help.

Attached is two screen shot from last night, with the EPAP setting change. I have several questions about this data, and would appreciate any comments:

1. why is the pressure chart EPAP flat-lined at 9.0 for the entire night? When the EPAP was set at 8.5, this pressure chart would show the increases/decreases similar to IPAP. Should I adjust the PS settings?

2. why are the FL's as numerous as before? Is 14 per night any reason for concern continued setting changes?

3. The CA's are still there, but wave form still looks like the SWJ or pre-arousal type...and I do experience several sleep arousal per night. Are these CA's simply part of the new normal for me?

I guess that compared to other members, my concerns are fairly insignificant. I just wanted to follow-up and show that very small pressure changes can have some important results.

Thanks

Zack