Need Help On What To Try Next

[forgetcolor]

I need some help deciding what to try next.

Diagnosed with OSA last Feb. Study rate was 15 AHI (but almost all during REM sleep). Titration set pressure at 5. Started CPAP (ResMed S9 Autoset) w/ a Swift/FX mask. I've used it all night, every night since (except for a couple fully-congested sick days). Leak data is very good.

First month was terrible. Awful sleep quality, possibly worse than pre-CPAP. Data said my average was down but still lots of apnea spikes, again, in REM. But trendlines were in the right direction.

Second month was also bad but third I started to feel better. Data bore this out, with an average down to 5/hr. I didn't feel great, but had less daytime drowsyness and a few actual OK days.

Ever since it's been bad again. Saw my specialist a few weeks ago and showed him the data. My averages are up (overall to an 8 AHI, but some days as bad as 16), although the trendlines haven't turned up yet. We decided to increase the pressure to 6. Since then it's been at least as bad if not worse. A typical night for me looks like this (http://i.imgur.com/qg9eL.png):



To me it looks like my apnea rate increases from 0, levels off for a while, and then eventually gets bad enough to fully wake me up, at which time it goes back to zero and starts the cycle over again. 5-7 of these peaks each night is typical.

I'm not sure what to try next. My sleep is awful. I feel completely unrested after 8 hours of it. I usually only notice/recall 1-2 awakenings each night, often right at the 5 hour mark.

I know how to make changes on the machine so am happy to experiment w/ pressure. But I feel a bit blind. Should I try a significant increase? Switch to auto? My specialist is nice but seems a bit perplexed that I'm not feeling better already.

Thanks for any advice!

[avi123]

When I started CPAPing about two years ago I had AHIs above 10 on a CPAP. It took me a year to fine tune the treatment. Including finding an optimal mask, and switching from CPAP to APAP. You can see here my present Stats indicating good results on my machine. No wonder that I agree with the report near my signature line that AHIs below 15 are acceptable for new CPAPers.




Full month results:



It takes time and patience! According to a 2009 survey 12% of those who were using XPAPs for more than a year, had residual excessive sleepiness during the daytime. Excluding depression and restless legs, the prevalence dropped to 6%.

Add: assuming that you don't suffer from COPD, Central Sleep Apnea Syndrome, or Heart problems, I would switch to APAP mode, set max pressure at 10 cm, min pressure at 6 cm, EPR = 3, no ramp, and try it for a few days. This may not solve your sleep fragmentation right away.

[The Choker]

Study rate was 15 AHI (but almost all during REM sleep)

Get a copy of your sleep study and check what position you were sleeping in during REM.

If you were sleeping on your back you might get significant relief by sleeping on your sides or stomach. This would be something good to look into and it might mean you could avoid CPAP altogether by avoiding backsleeping.

Just a thought, but worth considering.

[The Choker]

BTW, were you involved in the civil rights movement in the sixties?

[Sir NoddinOff]

It's not too unusual for our sleeping brains, which are used to coping with a long history of destructive nite-to-nite apnea, to take awhile to get on board with this newfangled CPAP device. Your AHI numbers, while not great, are within the okay range in spite of the spikes. Upping the pressure ranges as suggested by someone else is a possible place to start (consult your doctor) and will likely help your problems... just go in increments and see how you fare during each experimental stage. This sleep deficit 'lagging' phenomena has happened to many of us, including me, and takes some time to adjust to. It could be days, a few weeks or a few months - hang in there and things will get better!

[forgetcolor]

Add: assuming that you don't suffer from COPD, Central Sleep Apnea Syndrome, or Heart problems, I would switch to APAP mode, set max pressure at 10 cm, min pressure at 6 cm, EPR = 3, no ramp, and try it for a few days. This may not solve your sleep fragmentation right away.

thx for the suggestion. i do have some central apneas, but my diagnosis was OSA. can i still try the auto?

one thing on auto: my doc said that auto will always result in some apneas, while a set pressure, when set correctly, could remove them all. true?

[forgetcolor]

Study rate was 15 AHI (but almost all during REM sleep)

Get a copy of your sleep study and check what position you were sleeping in during REM.

If you were sleeping on your back you might get significant relief by sleeping on your sides or stomach. This would be something good to look into and it might mean you could avoid CPAP altogether by avoiding backsleeping.

Just a thought, but worth considering.

thx for the suggestion. i do know from my wife and from experience that it happens more on my back but also on my side. i try to stay on my back but suffer from hip bursitis. i'll try and get a copy of the study.

and no, wasn't alive in the 60s.

[greg-g]

Can you please post your detailed graphs over 1 night showing
Leak, Flow Limitation, Pressure, and Events.
The behavior of the Flow Limitation graph in relation to the others will give a good indication about your pressure settings.
A pressure of 6 is fairly low.

[Pugsy]

my doc said that auto will always result in some apneas, while a set pressure, when set correctly, could remove them all. true?

True...but with a big DEPENDS YMMV sticker.
Depends on how high that set pressure happens to be. Depends on if you have centrals being flagged...doesn't matter what pressure is being used...centrals won't responds to pressure to make them go away and some people actually have more centrals with increased pressure (not everyone will though). I imagine I could use 20 cm all night and pretty much prevent all my obstructive events...but who wants to do that when I can use around 10 cm for most of the night and let the machine do its job and using APAP mode go to 16 or so just for the few occasional stubborn events.
Depends on a lot of things. Mainly I think your doctor doesn't trust APAPs to work like they are supposed to.

I am using Bilevel machine right now but in auto adjusting pressure mode (like APAP) and I have an example of how the machine responds and deals with events in this thread where I was really discussing leak.
It is still a good example of pressure increases dealing with events and shows the pressure staying rather low for the bulk of the night. If I was going to do what your doctor suggested...use straight pressure then I would have to use a much higher pressure all night. Not what I want to do...increases chance of aerophagia and just not nearly as comfortable as using lower pressures for the bulk of the night.
viewtopic/t79729/Encore-Basic-leak-repo ... ption.html

If I used straight cpap at the lower pressure...guess what would NOT be prevented. Yep, those stubborn events needing more pressure.
By using auto adjusting pressure...set properly with the minimum being the most critical pressure setting...I have pretty much done a much better job of eliminating events.

A lot of doctors don't understand that the APAP machines need to have that minimum set high enough to give the machine a good head start. If the minimum is 4 cm then yes it is very likely that there will be more events happen because the machine can't get to where it needs to go fast enough. 4 cm works well if you only need maybe 8 or 9 cm pressure...won't work well at all if you need 15 cm.

[avi123]

Add: assuming that you don't suffer from COPD, Central Sleep Apnea Syndrome, or Heart problems, I would switch to APAP mode, set max pressure at 10 cm, min pressure at 6 cm, EPR = 3, no ramp, and try it for a few days. This may not solve your sleep fragmentation right away.

thx for the suggestion. i do have some central apneas, but my diagnosis was OSA. can i still try the auto?

one thing on auto: my doc said that auto will always result in some apneas, while a set pressure, when set correctly, could remove them all. true?

Reply,

I also have some central apneas during the night. But I don't have Central Sleep Apnea Syndrome (CSAS). Just plain OSA. A person with plain OSA could get EMERGENT central apneas if the pressure on CPAP is too high. This does not mean that the person suffers from CSAS. Usually, CSAS is detected and confirmed during the sleep study in the clinic.

Several posters asked to see your graphs. You could do it by using SleepyHead (down load from Pugsy's post) or in ResScan (I have a link near my signature line below. You would need to fill a form. You give any names. The Clinical Guide should be included in the download).

Here are graphs that I use to check my treatment:






I need to add the Flow Limitation graph. But these graphs together with the Stats table (see examples in my above post) should give a good picture of the treatment.

[The Choker]

one thing on auto: my doc said that auto will always result in some apneas, while a set pressure, when set correctly, could remove them all. true?

He is probably speaking in the context of setting an APAP at pressures min 4 cm and max 20 cm.

As a general rule this is a very poor setting and your doctor is likely poorly educated on how to set an APAP for appropriate treatment. Pugsy provides some good comments.

[forgetcolor]

Can you please post your detailed graphs over 1 night showing
Leak, Flow Limitation, Pressure, and Events.
The behavior of the Flow Limitation graph in relation to the others will give a good indication about your pressure settings.
A pressure of 6 is fairly low.

this time i took it from sleepytime. this is from the same day as the resmed graph above, so they do plot them quite differently. here's a a direct link to the image in case it's too big: http://i.imgur.com/yqgKn.png

and the image itself here:



thx!

[forgetcolor]

and a couple more days, just for comparison:

http://i.imgur.com/Pz9Xg.png

http://i.imgur.com/OuVKh.png

[Pugsy]

Do you normally go to sleep right away when you mask up or do you spend some time awake?
Do you remember waking up for any reason during the night? Once, twice, three times..etc? Any reason even if just turn over in bed?
When you get copies of your sleep study you need to look for evidence of centrals being reported in either the diagnostic portion of the sleep study or the titration portion where you used the mask and machine.
Need to figure out if those "centrals" are something new, something real or if we can discount them or explain them away before we start worrying about them.
On the face of it the 6 cm pressure may not quite sufficient to deal with your obstructive events but since you also have more "centrals" than we would like to see...we need to try to figure out if those are real centrals or awake artifacts or possibly sleep stage/onset centrals which would not be such a big deal.

Oops I see another report where the obstructive index isn't so bad...centrals are still more than I would like but I suspect that those centrals may be sleep onset or turn over in bed centrals.
So get those sleep studies and try to remember if you had some awakenings that might explain some of those centrals.

[Tino2You]

I am curious, on the days your AHI was 16 and 11, there were two large clusters (one day at the start and the other at the end). I get these clusters when I am getting ready to sleep and also when I am in the process of waking. I know (as I am awake during this time) that I did not have any hypopna (obstructed or otherwise).

When I have days like this I select the time range, excluding those clusters, to see what my AHI really is.

Then again, I am a newbie and I may be all wet

-tino