Not such a goodknight

[Guest]

well it doesn't look all that better in my opinion.

I'd try it at 10cm in CPAP mode.

Acoustical Vibrations which may be driving up pressure don't improve with increased pressure, FL's don't improve with increased pressure.

Setting it to CPAP mode it will ignore those Acoustical Vibrations and FL's triggering a response from the machine. Set it at 10cm and see what happens,

If you have problems falling asleep at higher pressure you can setup a 30-minute Ramp if needed at about 8cm or what ever is comfortable if you have problems dealing with the pressure.

If your snores or Acoustical vibrations are caused from a flabby soft palate, they most likely won't improve with pressure. This can drive an autopap nutso. If the snores are caused by the tongue in the back of the throat then they should reduce with increased pressure.

At this point high pressure or low pressure doesn't seem to make much difference towards your AHI. Those increased CA's seen at higher pressure should not be ignored because they WILL wake you up, if you have 3 per night they will wake you 3 times per night, that is why you want to avoid them unless you just like feeling tired.

The characteristics of your sleep disordered breathing is causing the machine to go nuts, you may be better off in CPAP mode where that doesn't play a part.

[MrPaul]

OK Once again thanks.

So it seems like the snoring is my big problem? Is this something I can control either by mouth taping or a full face mask?

As far as pressure I actually found 12 more comfortable then 10, 10 almost feel claustrophobic, go figure.

I don't think over the last few days my nose is very stuffed up, it has been in the past and I do have sinus issues. Around 7-8 years back I had a nasal turbinectomy and surgery for deviated septum (before I was diagnosed with Apnea). After that my ENT said something like you can drive a semi through my nose.

[rested gal]

Those increased CA's seen at higher pressure should not be ignored because they WILL wake you up, if you have 3 per night they will wake you 3 times per night, that is why you want to avoid them unless you just like feeling tired.

Why do you say centrals "WILL wake you up"? Why would a person's brain have to necessarily arouse him/her any further up from a central apnea (to resume breathing) than from an obstructive apnea (to resume breathing)?

As far as how a person feels the next day, are you saying 5 centrals during, say, an 8 hour sleep session would leave them more tired the next morning than 5 obstructive apneas would? Assuming the amount of time spent in each "not-breathing" scenario was the same, I don't see any difference in the consequences.

I've never read that a central will necessarily wake you up, more so than an obstructive would. I'm always open to learning, however, so would very much like to see where you've read that centrals WILL wake a person up.

The characteristics of your sleep disordered breathing is causing the machine to go nuts, you may be better off in CPAP mode where that doesn't play a part.

That may very well be so. I'd like to see how a REMstar Auto set at 10 - 20 would treat MrPaul. Might be more suitable for him.

[Snoredog]

Those increased CA's seen at higher pressure should not be ignored because they WILL wake you up, if you have 3 per night they will wake you 3 times per night, that is why you want to avoid them unless you just like feeling tired.

Why do you say centrals "WILL wake you up"? Why would a person's brain have to necessarily arouse him/her any further up from a central apnea (to resume breathing) than from an obstructive apnea (to resume breathing)?

As far as how a person feels the next day, are you saying 5 centrals during, say, an 8 hour sleep session would leave them more tired the next morning than 5 obstructive apneas would? Assuming the amount of time spent in each "not-breathing" scenario was the same, I don't see any difference in the consequences.

I've never read that a central will necessarily wake you up, more so than an obstructive would. I'm always open to learning, however, so would very much like to see where you've read that centrals WILL wake a person up.

The characteristics of your sleep disordered breathing is causing the machine to go nuts, you may be better off in CPAP mode where that doesn't play a part.

That may very well be so. I'd like to see how a REMstar Auto set at 10 - 20 would treat MrPaul. Might be more suitable for him.

look at any PSG you want that correlates the event with sleep state, nearly every CA seen will show it takes the person back to the wake state. and that is the only thing I see bad about them, is they destroy your sleep architecture. Think it was Pam's PSG which gave a good example of that.

When I see CA's increasing in frequency it tells me the mask being used or therapy being applied is exhausting too much of the patients CO2, reason the CA's increase in frequency. Are CA's a bad thing? I don't think so, I see them as our bodies natural way of controlling your CO2 levels and breathing. Sure that control can get out of control sometimes as we see with patients that have CSR or other CSA disorders, but there is usually some other underlying disorder like CHF or impaired lung function etc.

SWS made a similar finding in a post some time ago, as I recall, this was way before the Harvard study ever confirmed CSDB and manipulation of CO2 levels had any impact.

Those CA's may very well NOT be pressure induced, they could be from how the machine/mask combo is manipulating CO2 levels. We know if too much CO2 gets washed out you are going to see Centrals. When you are using a machine to manipulate other aspects of SDB and you see those CA's increase you should not ignore them and hope they go away. Will they do any harm? probably not, but if you see on every PSG they are associated with taking a person back to a "wake" state, I would avoid doing that because all you are doing is destroying sleep architecture.

Have SAG put up a few of his graphs, I've yet to see one that didn't take a patient back to a Wake state, if there is one I'd like to see it.

[tangents]

Very interesting, RG and Snoredog. I'm learning a lot.

So it seems like the snoring is my big problem? Is this something I can control either by mouth taping or a full face mask?

MrPaul, I don't think so. As Snoredog explained, the higher constant pressure might help, but it might not. Depends on the cause of the vibration.

I'll be watching for tomorrow's graph! Sweet Dreams, MrPaul!

[MrPaul]

MrPaul, I don't think so. As Snoredog explained, the higher constant pressure might help, but it might not. Depends on the cause of the vibration.

I'll be watching for tomorrow's graph! Sweet Dreams, MrPaul!

Glad I can be of use.

So is the consensus that the next thing to try is CPAP mode at 10?

[Snoredog]

So is the consensus that the next thing to try is CPAP mode at 10?

I would, the reason behind this would be to:

1. See if the constant steady pressure of CPAP helps stabilize your SDB over autopap mode.
2. Avoids triggering CA's (rapid moving pressure from autopaps can sometimes be the cause of CA's being seen).
3. Offers just as low AHI as seen with higher pressure already attempted in auto modes.

I would try CPAP mode over setting Min/Max pressures to the same value as long as the machine continues to record sleep details as it does now. I have never used my 420e is straight CPAP mode so I don't know for sure if it continues to record all sleep details, but you want something to compare to.

Using CPAP mode should ignore the current triggers now seen to drive up your pressure (e.g. snores, FL's etc.) and hopefully avoid the conditions which lead to increased CA's, avoid the CA's for better sleep quality.

Pressure may still need to be adjusted up/down until lowest AHI is obtained.

Lastly, what ever mode or pressure you use, you should be gaging the success of that therapy based upon how you feel the next day even if that means a higher AHI or more snoring seen etc.

[rested gal]

look at any PSG you want that correlates the event with sleep state, nearly every CA seen will show it takes the person back to the wake state.

---

Think it was Pam's PSG which gave a good example of that.but if you see on every PSG they are associated with taking a person back to a "wake" state, I would avoid doing that because all you are doing is destroying sleep architecture.

---

Have SAG put up a few of his graphs, I've yet to see one that didn't take a patient back to a Wake state, if there is one I'd like to see it.

Snoredog, I don't think either you or I have seen enough PSG hypnograms to say "they usually do" or "they usually don't" ("they" being centrals, and "do/don't" usually result in a person being fully awakened...in "Wake".) Don't know about you, but it would take a SAG pointing out what was happening here and there in the squiggles to me. I wouldn't recognize anything except REM on a sleep study graph.

I looked back at the Pam's (WearyOne) thread and SAG's comments in it.

viewtopic.php?t=18588
Mar 28, 2007 subject: Centrals Now?

Sounded to me more like SAG was zero'ing in on the possibility of insomnia (as in maintaining sleep) and what might be causing it, rather than being concerned about the few centrals Pam had. I didn't see where he said anything implying what you wrote, Snoredog: "Those increased CA's seen at higher pressure should not be ignored because they WILL wake you up"

Using CPAP mode should ignore the current triggers now seen to drive up your pressure (e.g. snores, FL's etc.)

Using APAP mode with min/max and start pressures all set to the same number ( like 10 ) will also achieve the same goal...preventing the pressure from changing up or down. Then there won't be any wondering if the machine's mode is still looking at the same thing when we're looking for a comparison of what events, including flow limitations, get marked on the data using what is, in effect, a single pressure.

If you do go the APAP 10/10/10, I hope you haven't changed the Max Command on Apnea from 10 in the Advanced Settings, MrPaul. That particular setting should have remained on the default value of 10 all along, imho.

Whatever experiment you try, MrPaul, it really needs to be for at least 3 or 4 nights without changing other things at the same time. Like different mask, or taping, or anything different. After trying APAP mode 10/10/10 for several nights, then it would be interesting to see a few more nights in CPAP mode at 10.

I don't mean to be trying to make a lab rat out of you, though, so try whatever you want to.

When all's said and done, I've got a feeling that the sleep lab titration that came up with a straight pressure of 12 for you is probably what's going to turn out to be your most effective treatment... cpap at 12.

And yeah, at some point I'd experiment with chin strap or Full Face mask, or tape, just to see if that made a change in the snore problem. If the snores are just from loose lips letting air be breathed in, taking care of that might solve the problem right away, and allow you to use an APAP range without all the pressure zigzags.

[MrPaul]

Guine Pig Paul reporting for duty.

Last night I did CPAP at 10 and tightened up the mask just a little bit more. Seems like it does record the same info as before.

I did seem to wake up a 3-4 times during the night, but other then that nothing really to report. The pink line seems to be solid so are the leaks now under control?

[MrPaul]

I switched the settings to 12 CPAP (which was what was prescribed) and got the below.

Seems to slightly increase apneas (though its hard to tell since the numbers are still pretty close) but it does seem to really cut down on the Acoustical Vib/Runs. Actually looking at the detailed data seems like I had apnea events right as I started and ended, I think that was me talking to my wife with the mask on.

I'm planning to test around this 12 mark (+/- 2) to see what lowers numbers the most, giving it a few days at each pressure to see what happens. I think I'm pretty close now so any differences are likely to take a few days to show up.

[rested gal]

Paul, that looks MUCH better now...the straight pressure of 12.

Don't worry about some variation in AHI from night to night. The pressure of 10 report and the pressure of 12 report indicating a difference in the apnea index from 0.4 to 0.7 is absolutely insignificant. Don't worry about decimal point changes or even whole point changes of a few points. Those kinds of normal variations are going to happen even using the same pressure all along, night after night.

What's looking so good here on the pressure of 12 night is the way it cut back the "acoustical vibrations" (snores.)

Again, it looks like your sleep lab titration nailed the minimum pressure you need very well.

I'm planning to test around this 12 mark (+/- 2) to see what lowers numbers the most, giving it a few days at each pressure to see what happens. I think I'm pretty close now so any differences are likely to take a few days to show up.

That's a good idea to give each straight pressure you try several days or a week. If you are going to be looking for decimal points differences in AHI with each experimental pressure, I don't think that would be important to look for at all. There will be normal variations.

The most important thing for you to knock down as much as you can and still be comfortable with whatever pressure it is...are the snores. Those were what were driving the 420E into crazy pressure spikes for you.

An interesting future experiment (after you find out whether straight 13 or straight 14 knocks the snores practically out of the box and are pressures you can go to sleep with ok) would be to go back to APAP mode for a few nights...just to see what happens. APAP mode with the minimum pressure set at 12 or 13 or 14 and the top pressure set at 20. I'm betting the machine will behave itself with you if you have the minimum pressure set up where there's practically no snoring going on.

Of course, when you settle on a straight pressure (like 12, 13, or 14) that does fine for you (and 12 IS doing fine for you, just like the sleep lab said) there's no real need to try APAP mode again...other than curiosity. If I were you, if I did try APAP mode in the future, I'd never set the minimum pressure below 12, given the wild pressure swings your snores were making the machine deliver.

Good lab-ratting, Paul. Good guinea pig.

[MrPaul]

An interesting future experiment (after you find out whether straight 13 or straight 14 knocks the snores practically out of the box and are pressures you can go to sleep with ok) would be to go back to APAP mode for a few nights...just to see what happens. APAP mode with the minimum pressure set at 12 or 13 or 14 and the top pressure set at 20. I'm betting the machine will behave itself with you if you have the minimum pressure set up where there's practically no snoring going on.

Yeah you must've read my mind because that's what I was planning to do. Get a baseline of 12 for a few days, then go up to either 13 or 14 to see if it improves or not for a few more days and then up/down by .5 depending on what's better. Once that's done I'll give APAP another try mostly for curiosity.

Of course, when you settle on a straight pressure (like 12, 13, or 14) that does fine for you (and 12 IS doing fine for you, just like the sleep lab said) there's no real need to try APAP mode again...other than curiosity. If I were you, if I did try APAP mode in the future, I'd never set the minimum pressure below 12, given the wild pressure swings your snores were making the machine deliver.

This kind of makes me wonder if I should've gone for one of the C-Flex/A-Flex machines instead, I'm starting to be convinced the APAP settings (on the 420E at least for me) are counter productive. Maybe if I see a good price on one of the straight CPAP C-FLex I'll pick one up to compare.

I'll post back in about a week with some more results.

I think we all learned a few interesting points that might be worth repeating.

• APAP is not always a good thing
  The 420E does record just as much data in CPAP as APAP mode
  Having access to detailed data is awesome, I've been using CPAP for 5 years now and I feel like I can actually see results from day to day changes (duh!)
  I sure do snore a lot

[rested gal]

To add another point -- each brand of autopap has a different way of treating things. You might have been able to set a REMstar Auto at a range of 8 or 9 - 20 and not had any extreme pressure responses to your snoring. Or it might have run up just as much as the 420E did. Only way to know is by trying different machines, but that gets to be an expensive undertaking.

[Snoredog]

Those increased CA's seen at higher pressure should not be ignored because they WILL wake you up, if you have 3 per night they will wake you 3 times per night, that is why you want to avoid them unless you just like feeling tired.

Why do you say centrals "WILL wake you up"? Why would a person's brain have to necessarily arouse him/her any further up from a central apnea (to resume breathing) than from an obstructive apnea (to resume breathing)?

As far as how a person feels the next day, are you saying 5 centrals during, say, an 8 hour sleep session would leave them more tired the next morning than 5 obstructive apneas would? Assuming the amount of time spent in each "not-breathing" scenario was the same, I don't see any difference in the consequences.

I've never read that a central will necessarily wake you up, more so than an obstructive would. I'm always open to learning, however, so would very much like to see where you've read that centrals WILL wake a person up.

The characteristics of your sleep disordered breathing is causing the machine to go nuts, you may be better off in CPAP mode where that doesn't play a part.

That may very well be so. I'd like to see how a REMstar Auto set at 10 - 20 would treat MrPaul. Might be more suitable for him.

hey don't take my word for it, go ask someone like SAG what "terminates" a titration study, they will tell you:

1. study goes fine, person sleeping great, time runs out and it is over or
2. they experience a central due to over titration and it wakes them up.

if the patient doesn't fall back asleep and reach REM again the study is over, you can't titrate a wake person.

[Snoredog]

Mr Paul:

Looking at your cpap results, if you SUM up your AHI index it is only AHI=1.6, well under the 5 we strive for.

Nothing personal, but you have a lot of junk in your breathing pattern that can cause most autopaps to go nuts, that is FL's and snoring.

A lot of what you are looking at while in CPAP mode is "masked". CPAP masks those events or eliminates them whichever way you want to look at it.

The question now is comfort. How are you dealing with a constant pressure? In order to improve the quality of your sleep any more you may need to increase pressure up to 12cm as suggested.

Comfort is a big issue, know it is for me, if I'm not comfortable using the machine, I won't use it, then that isn't any good for your therapy.

Based upon what I've seen in your reports, I would suggest for increasing the comfort aspect:

1. Remstar Auto Bipap. It will allow you to tolerate the higher pressure and hopefully address those events. Snores are a problem, they are taken care of by EPAP pressure, so you may not see any relief there even with a Bipap.

2. Remstar A-Flex machine. This one is supposed to offer relief in both directions, I doubt if as flexible as the Bipap but probably pretty close.

If you are going to have to use higher pressure, might as well use a machine that offers you the most comfortable relief.

Autopaps like the 420e are great and can offer some pressure relief if your disorder allows it to run low and only go high when needed, if you are asleep when it needs to go high you never know it. But if your condition drives up the pressure from the start you get no relief from the auto.