How may I overcome OSA to get my UK driving licence back?

[Pugsy]

I do have very strong lungs after all the SCUBA and aerobic sports I have done so perhaps I do need to have a higher minimum APAP pressure to combat the hypopneas.

Lungs don't have anything to do with pressure need to hold the airway open.
It's the soft tissues in your airway behind and below your tongue where the obstructions occur with obstructive sleep apnea. The tissues get a bit saggy or floppy and need X amount of pressure to keep them from collapsing and blocking the airway.

When the minimum pressure is too low or not quite optimal the machine, when set to apap mode to auto adjust, can't do a good enough job of holding the airway open to prevent the collapse and it can't respond quickly enough to prevent the collapse and subsequent obstructive event.
These machines actually increase the pressure relatively slowly when compared to how quickly a collapse of the airway tissues can form/happen.
When this happens the machine will sense the need to increase the pressure but while it is going up in stages the collapse comes and goes. Then the machine senses that everything is okay and reduces its pressures until the next collapse tries to happen. Sometimes the next collapse happens while the machine is already up there (like 8 or 9 cm) and it can actually prevent any further collapse but once the pressure goes back down to 4 cm...it has a long way to go again to get to where it needs to get to.

The minimum pressure is the most critical pressure setting and often that 4 cm just doesn't do a good job.
Heck for me my 8 cm minimum didn't do a good job...still had AHI in 8 to 10 range and my max was 20. Once I changed the minimum pressure to 9 and then to 10...the apnea events became random and my AHI dropped to 1 to 2.

If you aren't comfortable making the change yourself then do get the provider to get it done. If they think that the machine should respond quickly enough with wide open settings...then they don't understand the equipment functions and limitations very well.

[welshmike]

Thanks for the reply

Yes I do have saggy soft tissues in my airway.

I think that the pressure increases after I have a Central or a Hypopnea and that tends to wake me up. The higher air pressure then continues for what seems a long time.

Looks like it is essential that my minimum pressure is increased.
I'm confident that I can increase the minimum air pressure myself.
However I do feel that I should refer to the consultant first.

I noticed that the S9 Autoair was brand new and the consultant unpacked and opened the sealed box in front of me.
Also I'm fortunate that my National Health Service, NHS, trust has the funds to give me the machine as it is expensive and the NHS National Institute for Health and Care Excellence, NICE, may have only recently approved use of the S9 Autoair as a cost effective machine for the treatment of sleep apneas.

I've become aware of the limitation of the S9 Autoair especially its delayed reaction in providing pressures appropriate to my apneas or lack of them.

[Pugsy]

Your S9 won't increase the pressure in response to a central apnea where the airway is open...it won't help and they just don't do it.
Now you might see an increase in pressure around the time of a central flag but it is pure coincidence as the machine will only respond to what it thinks is a potential collapse of the airway and it is entirely possible for someone to have both a central and some sort of obstructive (airway collapse) warning sign but it will be the obstructive warning sign it is responding to..not the central.

There are auto adjusting machines that will increase the pressure in a special way in an effort to prevent centrals but that is a very special machine and yours isn't one of them. That machine is a totally different type of machine and your machine won't do what it will for centrals.

[welshmike]

If a central apnea is when I stop breathing with an open airway, I'd have hoped that my APAP having sensed (by lack of back pressure?) and recorded the apnea, it would have increased the air pressure after a central had lasted say 10 seconds.

As far as my hypopneas (shallow breathing?) are concered I would have hoped an increase in air pressure too after a certain period.

So my APAP that "only" costs 574 UKP plus 120 UKP for the full face mask does not appear to very sophisticated and not a great deal of use to me.

[Pugsy]

If a central apnea is when I stop breathing with an open airway, I'd have hoped that my APAP having sensed (by lack of back pressure?) and recorded the apnea, it would have increased the air pressure after a central had lasted say 10 seconds.

It will flag it but it will not respond...won't do it. The airway is already open during an open airway cessation of breathing. APAPs do NOT respond to centrals at all. It won't act like a ventilator..apaps don't work that way.
The algorithm is specifically written to ignore open airway cessation of breathing.
Besides...not every central that gets a flag by your machine needs treating/fixing anyway.

Listen to RobySue...she knows what she is talking about. I don't have the time to download your files and go through them as I am trying to get ready for a little trip and can't take on anything else right now. When she responded I just said to myself...he's in good hands.

I don't think you fully understand your machine's capabilities or limitations and what to expect of it and I don't have the reference material in front of me right now to help you understand.

APAPs respond to obstructive airway event warning signs...snores, flow limitations.
The whole idea is to prevent the collapse in the first place and not try to fix it after it happens...that's not how it works.

[borgready]

You might want to try a bipap machine as they are easier to breath with. They always start you out on the cheap end with cpap. So then you have to buy another machine when you have problems dealing with cpap. It would make sense to me to start out on a bipap and as your body learns to adapt to the machine and mask then you can gradually set the pressure setting to act as a cpap if you so choose. But noooo. In an effort to save a few dollars or pounds, it ends up costing you more. How is you ability to breath through your nose? Not many talk about that. It don't take much to get a stuffy nose and then you cant breath very well and it renders the use of the machine almost useless. You mentioned you cheeks puffing up. Well your trying to breath through your mouth. Another thing you will learn is your doctor aint much help in getting you used to dealing with sleeping with a machine. It takes a while to adapt to using it. You have to learn to sleep with it. You also mentioned artial fib. Well that happens when your not breathing. You really don't want to lie there and sleep through it. Wake up and start breathing correctly. In and out. Your body gets caught in a cycle where your where you breath and stop. Each stop gets longer and longer untill you get in trouble and have long central or hypopneas. Yes your airway is open. Your blood gets out of wack from not breathing and high CO2. I have found taking calcium and or magnesium supplement help your blood recover to normal PH. I will also note that low vitamin D has an effect on the regulation of your breathing when your asleep. Low vitamin D and you get hypopneas and central real easy. Vitamin D won't cure your OSA but it sure helps the hypopneas and mixed centrals. While I am pushing certain supplements you might want to take your B vitamins as well. Take it easy with the B vitamins at first to see how you deal with them and the OSA and heart issues. I don't know how the heart meds influence everything but it probably as with most hard core med its not good for you long term.

[welshmike]

Pugsy,

I'm getting to understand how my APAP works thanks to you and this forum.

robysue's message was very helpful as was and is yours. Increasing the minimum pressure may well help reduce or stop the centrals and/or the hypopneas..

I hope you enjoy your little trip.

Mike

[welshmike]

bogready,

Yes I have been thinking that a bipap may be more affective than my APAP.
I don't have to buy my machine because my NHS trust provides it.
I have always had problems breathing through my nose and am a mouth breather due to having a large overbite, broken nose and deflected septum (drilled out 20 years ago). I have always slept on my back in the past.
But I am now forcing myself to sleep on my left hand side by wearing a towel stuffed backpack.

Thanks for your breathing advice.

I will “drop in” to my doctor's surgery this morning and grill him about all the meds I take, especially the beta blocker.

[borgready]

If you don't have a good pulse oximeter you might want to get one. Get one that records the data and that you can look at it on a pc. Also make sure it has alarms that sound off when your O2 drops below a certain level (about 90%). When you hear that alarm go off wake up and try to figure out what is happening cause something ain't working right. Why the pulse oximeter? It gives you feed back on how you are adapting to using the cpap machine. Just because you have the machine doesn't mean using it and adapting to it is going smoothly. If everything goes oK the O2 usually stays in the mid 90s. Dropping into the 80s and you probablly start getting that arterial fib thing going on. I notice after a non breathing event that I focus on breathing in and out and that the 02 pegs out at 99 for say a half hour or longer and then drops back to around 96 when the blood chemisty comes back to normal. Staying in the cycle of breathing and not breathing, it gets worse and worse. So I force my self awake and untill everything is working right and go back to sleep. I like the oximeter with the throw away/replaceable finger reader. You can get cheaper oximeters that have a fixed finger reader that clamps on your finger and they are ok. Forget the oximeters that the entire unit clamps on your finger. Its too bulky for sleeping.

[welshmike]

I have been planning for a while to buy a pulse oximer like this one:
http://www.clinicalguard.com/handheld-p ... p-171.html
Sheer laziness on my part to not have bought one yet.

I had a letter yesterday stating that I have an appointment on 16 Jan 2014 with the consultant who issued the APAP to me. So I want my apnea data to be good enough for me to apply for a driving licence. We shall see.

[robysue]

If a central apnea is when I stop breathing with an open airway, I'd have hoped that my APAP having sensed (by lack of back pressure?) and recorded the apnea, it would have increased the air pressure after a central had lasted say 10 seconds.

You are correct, the PAP machine is using subtle differences in the back pressure to track your breathing. And if there's no airflow for 10 seconds or more and apnea of some type will be scored. But these machines are NOT ventilators and they will NOT try to force you to breath during an apnea.

As pugsy pointed out, the machine is programmed to NOT respond to CAs with an increase in pressure. CAs occur when the airway is already open and the problem is the brain forgot to send the signal to breath. A few CAs now and then are pretty common and on a sleep test CAs that happen during the transition to sleep are not usually even scored.

As far as my hypopneas (shallow breathing?) are concered I would have hoped an increase in air pressure too after a certain period.

With OAs and Hs, the machine is programmed to increase the pressure only if two or more OAs and Hs occur within about 5 minutes of each other. In other words, if there's an isolate OA or an isolated H, the machine is not likely to increase the pressure. If there's also snoring or flow limitations being detected, it may increase the pressure as much because of the snoring or flow limitations as the event itself. This actually follows AASM titration guidelines for a manual titration study. The idea is that a single isolate OA or a single isolated H does not necessarily mean the airway needs more pressure to prevent additional events from occuring, but if two or more OAs and Hs occur close together, then the current pressure setting is not sufficiently high to provide enough "splinting" to keep the airway open.


Remember: The PAP machine is NOT breathing for you. It is NOT a ventilator. It does NOT try to "end" an apnea or a hypopnea by forcing you to take an inhalation---that would turn the machine into a ventilator. Rather a PAP machine's job is to simply blow enough air down your airway to make it more difficult for the airway to collapse. An an APAP increases the pressure when it has data that says the current pressure is NOT sufficient to prevent future events.

[SleepyToo2]

Robysue, thank you for the explanation of how an auto machine works. Now I know that I would be wasting my money with an auto machine. My apneas, when they occur, are too far apart to trigger a pressure increase. I need to concentrate on finding that perfect mask, so thank you!

[Pugsy]

Now I know that I would be wasting my money with an auto machine. My apneas, when they occur, are too far apart to trigger a pressure increase. I need to concentrate on finding that perfect mask, so thank you!

An APAP mahine WILL respond to flow limitations and snores...so don't totally discount it because of the OA criteria.
There's more to it than just responding to OAs that snuck past the defenses.
Actually the main job is to respond to the event warning signs...not the actual event once it happens.
It tries to prevent the airway collapses from ever happening in the first place and the greatest response is to flow limitations and snores which are warning signs of an impending airway collapse.

[SleepyToo2]

Thanks, Pugsy, for complicating the decision! Seriously, I rarely see snores, and flow limitations are not showing up (AFAIK), so I am not going to know if an auto will provide any benefits?

[Pugsy]

Thanks, Pugsy, for complicating the decision! Seriously, I rarely see snores, and flow limitations are not showing up (AFAIK), so I am not going to know if an auto will provide any benefits?

Flow limitations are totally turned off on the Pro model...we have no idea if they are happening or not.
Flow limitation flagging is something that is only available in apap mode because flow limitations are something that the machine responds to.
I really wish that Respronics hadn't turned off the FL flag in the fixed cpap mode machines...even if it can't increase the pressure it would have been nice to know if they were occurring or not.

I figured that what I said would complicate things for you..so sorry but I didn't want people to think that the only thing that the APAPs do is respond after an event has occurred.
Robysue was addressing OPs particular questions about response to actual events and her response about how the machine responds to the other stuff was a bit hidden. I saw it but newbies might not catch it and that's why I did the clarification.

When I was using APAP machine...I saw lots of pressure changes and sometimes some big changes with no events even being flagged...the machine was in prevent mode instead of fix it mode. Even now on the bipap I see the same thing.

I don't know if having APAP mode available to you would make any difference at all. Wish you had the 460 (or you had the Auto IQ450) instead of the 450 as it has a short term APAP mode available.
The machine envy virus....quite strong sometimes but there's no guarantee that it will change anything.
Now if you ever see little clusters of OAs or snores...then apap mode with ability to increase the pressure to better prevent the clusters from ever forming...might be of benefit.
But then a little pressure in cpap mode would also prevent them.
Comes in handy to have the variable pressures when the little extra pressure needed to prevent the airway collapse ...isn't so little...like with me.
Sometimes I see upwards of 20 cm...and I sure wouldn't want to use that all night just to deal with a 30 minute need otherwise.