Auto SV, Headaches

[uriahsky]

I am still getting these painful headaches in the morning when I wake up. Last night I was able to use the Auto SV for most of the night and I thought I was OK but a smaller headache started to creep up on me after waking. I am wondering what I might try to improve my numbers or are they really not that bad and maybe there is another reason for the headaches? Do you think these numbers are bad enough to generate headaches and what might I do to bring the numbers down.
Thanks again,
Russ

'

[Pugsy]

I will let the ASV experts advise on what you might do to further reduce the Hyponeas. There might be enough of them to still cause a bit of oxygen level desats. I don't remember if you have a recording pulse oximeter to check for desats.

Normally headaches that are a result of low oxygen are present immediately there upon awakening or even wake us up with pain. At least that was what I had happen when I had the low O2 pre cpap. I would wake up with a killer headache but it would fade away withing an hour or two.

That said...I also have a bad cervical spine and so I still get some headaches and some of them are pretty bad but they come on during the day (usually have neck pain with them but not always) or I might wake up with one if I slept weird on my pillow (or away from home especially where I don't have my own pillow). I know it isn't my oxygen levels because I don't have any desats. I tested it a few times to make sure.

Since your headaches aren't always present upon awakening and come on and get worse during the day then perhaps you should also investigate other possible causes. There are a lot of them.
And at the same time work on the Hyponea reduction. At least break up the clusters and cut them in half.

[jweeks]

Do you think these numbers are bad enough to generate headaches and what might I do to bring the numbers down.

Russ,

An AHI of 9 isn't optimal. It would be nice to see that under 5, and perhaps in the 2 to 3 range. I see that it is almost all hypos, which generally are not as serious as CA and OA events. There is a lot of snores. It would be nice if something could be done to knock them down--some sleep doctors are saying that any level of snoring can disrupt your sleep.

The only real suggestion that I have is to follow up on Pugsy's comment about oxygen desaturations. You could have had some due to the hypos, and if you slept for any amount of time without the machine, you almost certainly had some. It would be nice to get some data on that. You can buy inexpensive oximeters that are fairly accurate such as the CMS-50 line of oximeters. Another option would be to check with your sleep clinic to see if they will loan you one for an overnight run.

If you are not having desats but are still having headaches, then maybe something else is going on.

-john-

[-SWS]

I am still getting these painful headaches in the morning when I wake up. Last night I was able to use the Auto SV for most of the night and I thought I was OK but a smaller headache started to creep up on me after waking. I am wondering what I might try to improve my numbers or are they really not that bad and maybe there is another reason for the headaches? Do you think these numbers are bad enough to generate headaches and what might I do to bring the numbers down.
Thanks again,
Russ

http://www.healthcare.philips.com/asset ... otocol.pdf

Respironics calls for residual obstructive events to be addressed first with Min EPAP increases. So I think if it were me---based on that residual snore----I'd try raising Min EPAP all the way up to that 90% value of 9cm. I'd try 8cm if 9cm felt uncomfortably high or if central events increased at 9cm.

I'd evaluate those results before deciding what to do with the Min PS value. I see your hypopneas tend to correlate more with machine-triggered breaths than obstructive snore---suggesting residual central events. Residual central hypopneas can be tackled with Min PS increases, after residual obstruction has been addressed with Min EPAP increases.

Keep us in the loop and good luck with this.

[old64mb]

Russ,

A few things.

First, your numbers are still not good at all. That's not in question.

Second, presuming that night looks like your other nights in terms of scoring, titration protocol - meh, never mind SWS posted the link! - would suggest the following:

1. You're still running the ASV on what looks to be 6-20 mode, but your 90% EPAP scores at 9. That would indicate it's probably reasonable to set your EPAP at 9 as a base minimum so it's not constantly chasing down the right pressure to keep your airway open. It will also probably help with the snoring.

2. PS Min is probably ok for now at 2-3 over, since you're not having a ton of non responsive centrals, and you can probably get away with letting PS max get you to 16 or 17 cm - which would calculate to be 7 or 8 PS Max from a 9 EPAP - as you're not hitting anywhere close to max at 20. As -SWS points out, it's not worth messing with PS Min any more than that until you have a better idea of what's going on with your centrals and once the EPAP gets taken care of.

3. Backup rate could probably go to 2 under your normal breathing rate, or 11, although auto might still be safer for now.

4. For a Respironics ASV that's not a good leak line. You're definitely leaking quite a bit, which would explain the snoring and probably some of the hypopneas. Clean your mask, and try getting a new one, although I know money is very very tight for you.

Now all that said, the problem is that you've really reaching the limits of what anyone on this board can do for you. While we can help you get your machine to operate as efficiently as it can, we can't dispense what you really need, which is medical advice.

I can think of several things off the top of my head that would cause you to have headaches in the morning even after you treat the known stuff that's going on completely - which you haven't yet - and a few of them start rising to very serious medical situations. It may very well be (and I hope for your sake) that it's just you need some more tweaking of your ASV.

If not, you can get a pulse ox, but it's not going to help you that much in terms helping you figure out what you do next. Even if it shows desats, ASV and a pulse ox aren't going to be enough evidence to introduce supplemental oxygen, since for certain conditions it could actually hurt more than it helps.

Your hunch has been correct and you've done a good job with your health here - you do have something causing central apneas, since 90.8% patient triggered breaths are an issue. If you didn't have centrals that it was treating, you'd be over 99%.

But if you still don't feel right after you get the titration set, it's time to sit down with your doctor from the clinic, show them the data, start talking about appropriate medication and treatment for everything else you have (because you now have good evidence you're on something that's either causing or augmenting centrals, and maybe they could do something about that), and figure out how to proceed. You're at a point where advice from the internet isn't going to be enough going forward. Not trying to be harsh, just realistic about what the data suggest your next step is.

Let us know how things look in a week or two once you try the above suggestions, but just be aware of the limitations if that doesn't work.

[Pugsy]

I disagree with the comment about leaks being bad.

The leak line and rate is fine. Actually quite excellent leak line. This machine reports only total leak which is the mask intentional vent rate plus any excess leak.
This average nor image cannot be compared to machines and/or software that reports leaks that are only unintentional leaks.
35 L/min and pretty much a fairly level line points to probably the vent rate for the mask at the pressures used.
It won't ever go much below this number. This machine and this software as it is set now won't ever show a nice 0.0 leak number.
Impossible. Even if we change the reporting to unintentional leak I am not sure that this older machine would give it..but if it did...then we would likely see a leak line very close to 0.0

So I don't think leaks need fixing at all but SWS did suggest what I would suggest.
The snoring could very well be from the fact that the minimum pressure is not quite effective enough all the time.

[-SWS]

For a Respironics ASV that's not a good leak line. You're definitely leaking quite a bit, which would explain the snoring and probably some of the hypopneas.

He shows 0% time in large-leaks, an average leak of 35.5, and rarely dips above 50. I'll have to politely disagree.

I'd also like to remind uriahsky the titration protocol is a sequence of single-steps rather than many parallel steps. So one change at a time...

[old64mb]

This average nor image cannot be compared to machines and/or software that reports leaks that are only unintentional leaks.

That's actually why I'm pointing that out, since you'll note I'm using the non-Advanced version of the Auto SV.

In my experience - and it may just be mine - figuring out when it's time to change masks on the Auto SV is a lot more subtle in comparison to the Respironics Bipap or CPAP series. What would come across as a mountain pattern of mask leaks in the other machines comes across looking like his pattern. I can post an example graphically of what happens when it's time for me to switch pillows on a standard Bipap versus the Auto SV if anyone's really that interested.

In general, it'll be putting out a very flat line if the seal isn't starting to leak, subject to changes in pressure. I'm not talking the mask coming off for a large leak; I'm talking the seal being not optimal from average wear and tear to a pillow or mask seal from nightly use.

I'd respectfully point out that a poor seal would, not coincidentally, theoretically explain some of the events. I also note that in his case the increased leakage just from EPAP varying as much as it has doesn't fit with eyeballing his chart between hours 3 and 4.

Hence, my comment, even though I try not to disagree with -SWS much since that usually means I'm wrong.

I'd also agree you don't have to do everything at once, and the EPAP is the most important thing to switch for now. However, I also want to make sure by changing his EPAP he's not suddenly changing his IPAP to 15 or 17 if he's got his machine set up differently than we suspect.

Cheers.

[Blindrage]

I am trying to get a handle on leaks with the Advanced Auto SV right now.

Brief history: Finally got my new machine on Saturday. I am using the same mask I was using with my PR S1 Pro CPAP machine. The CPAP machine showed normal leaks, and almost never showed a large leak issue. Suddenly the ASV unit is showing 75%+ large leaks.

My CPAP pressure was 12.5. On the ASV my EPAP min is 9, EPAP max is 20, PS min is 0, PS Max is 18 (I think). 90% is EPAP 12 PS 1. So I am around the same pressures my CPAP was using. Flex type is Bi-Flex at 1. Tubing type is set correctly. System one resistance was 0 the first night, and X1 the second night, this did not seem to have any effect on reported leak rate or what was considered "large leak".

The good news is OA and CA are virtually 0. Hypopnea events are around 7, and snoring is 9-12. On CPAP I was showing OA/CA of about 12, hypopnea of 2, and snoring at 10-12. So overall this is an improvement, but I am concerned that the high leak rate may make the numbers shown virtually meaningless.

I am going to try a brand new seal tonight, and reset all my headgear fittings. Any other ideas on why the ASV shows such a high leak rate compared to straight CPAP? Or anything I can try to fix the issue beyond the normal?

[uriahsky]

Once again a very big thank you to all who have helped me with this. I upped the pressure to EPAP 9min and for the first time I awoke the next day without a headache, and I didn't even have to use any Imitrex! I had been meaning to post some data but that crappy Encore Pro program keeps loosing data if your not real careful. I lost a few nights of data but managed to pull some from last night. It has been three nights of sleep and I can't say I feel all that good when I wake up but there wasn't a headache on the first night. The second night wasn't as good but that was because I had to try and fit in three months of missed work in that first day I had without a headache. I got pretty dehydrated and that also triggers headaches the next day. This keeps confirming that sleep apnea is one of the causes, perhaps the main cause of these morning headaches??





Is that about as good as it is going to get?? The HI are at 5 but the total AHI is 6 on this night and that wasn't the best of the nights. Is the only thing to try is to go up even more? I still have a lot to learn and am not quite sure just yet. Should I move the PSmin up to 1 or 2?

I know that one of my problems is going to be to get back to a normal sleep schedule where I wake up in the morning instead of going to sleep in the morning. This came about from months of headaches where I felt so awful that all I could do is pray for sleep it has slowly moved my sleep time until I now don't get real sleepy until 8:00AM. That can't be good.

I plan on seeing if I can find a sleep doctor who will talk to me without a sleep study being done. I have this sinking feeling he he/she won't be up on this type of situation. This CSA probably came about from long term use of doctor prescribed pain medication. I have cut back to about 25% of what I was using a month ago and plan on working my way off of this but I know from experience you have to plan this out and go slow. This situation seems to be somewhat new, few studies have been done and I don't see much on a solid treatment plan.

Regarding the Pulse Oximeter. I do have one and have used it a number of times. It does record for the night and here is one of the graphs.



That is the overview for the night from a month ago. They all kind of look like that and I am not sure how to interpret the data. Most of the time it never goes under the red line which is set at 88% but is that all you look for?

I remember when I first used it without using a CPAP machine and the graph was dropping below the red line a lot of the time and with the CPAP it was never under the line. This was one of the first clues I had that pointed to apnea.

Once again, thanks very much to everyone. All of the advice has really made a big difference.
Russ

[JohnBFisher]

Sorry for coming into this fairly late. I would like to suggest a couple things.

First, a note about morning headaches. Yes. That is a classic symptom of sleep apnea. And it can be an indication that your body is struggling to compensate. I went years - as I was attempting to have my sleep doctors at the time - address my central apneas. I would awaken with HORRIBLE headaches in the morning. Unfortunately, it also resulted in unmanageable high blood pressure. That caused permanent kidney damage. Gee, thanks! I *REALLY* hate it when doctors don't listen.

Next, it appears (looking at the graphs) that your O2 desaturations are linked to drops in your patient triggered breathing. Do you have a BPM set? Or is it set to AUTO? If it is set to AUTO you might want to see what happens if you change it to 10 or 11. I actually don't think that will make much difference as BPM does not appear to be related to the Patient Triggered Breathing (PTB). (There does not appear to be a correlation between the two graphs). But it is something to explore.

Also, some of the hypopneas might be due to the BiFlex setting. So in addition to the suggestion from -SWS to increase Min EPAP, you might want to seperately try changing BiFlex from 3 to 2 to 1 and see if it has an impact. We've seen others that have seen an improvement in the hypopnea score by just making that change.

Are you using a a full face mask? This is one of those instances it would REALLY help if you registered your equipment. For more information on how to do that, see:

wiki/index.php/Registering_Equipment_in_User_Profile

But you definitely want to try to bring those headaches under control. Hope the suggestions help.

[old64mb]

I'm glad to see your headaches are better and that you've raised the EPAP. I wouldn't be surprised if that's correlated, and there's still room for improvement.

That is the overview for the night from a month ago. (emphasis added)

John, while I agree with you for the most part, think you may have missed what I highlighted, which is important since he didn't have an SV a month ago. Russ, can you post a night from the pulse ox since you've started using the SV?

Second, what I think we all missed before is that you've been running this with a PS min of 0 and a max of 8, which doesn't make a lot of sense as you've essentially been letting the machine switch back and forth multiple times per night between CPAP and BiPAP modes. That's probably not helping your treatment much, and you should choose one or the other. As your average PS is 2, I'd suggest that you switch PS Min to 2 and run this as a Bipap. Once you do so, I would concur with John on reducing Biflex. In fact, you may find you don't need Biflex whatsoever as many people find fixed inhalation and exhalation pressures perfectly comfortable as long as they're different by a couple of cm. Last but not least, it probably will also help your hypopneas.

Third, another request to really needing to know your mask. You're still able to snore, are doing so quite a bit, and that concerns me.

And finally, just be careful when withdrawing from meds - that's generally a question you want to pose to your doctor as to how to titrate down.

Edit: and Blindrage, since you're using a FFM, got me since mouth leaks would be the first place I'd look with your amount of snoring. As to why the differential between the two machines, I have a couple hunches, but nothing that will help.