APNEA -v- HYPOPNEA

GoofyUT · Post by **GoofyUT** » Wed Jun 28, 2006 6:56 pm

I need all of your wisdom to help me to understand my journey through the adventure of xPAP treatment.

I was diagnosed about three months ago in a split-night study when I got a total of about three hours of sleep, during my last night of a four day hospital stay following a pretty dramatic heart-attack. My AHI during the study was 23 and I prescribed a pressure of 10 cmH20. Two days later, I was given a CPAP, a Fisher&Paykel HC608 and an Activa. I switched from the Activa to a Swift about one week later. I switched from the F&P CPAP about three weeks after that to a ResMed S8 AutoSet VAntage/H3i APAP. Since then (about 2 months) I've been hugely compliant (8.75hrs/night) and I've been keeping good records of my stats.

Like many ResMed users, my numbers have been mostly hypops, and my AHI stayed well above 5.0 until about 10 days ago when I figured out that my S8 was scoring hypops while I was awake since I had settling turned off (on the advice of my DME). When I turned Settling on for a decent interval, my AHI fell to below 5 and has stayed there.

I examined a months data from my SmartCard using AutoScan this past week, and I looked closely at the Excel spreadsheet I've contsructed with graphs I created. here's what I found out: The MOST my AI has been over the past 6 weeks is 0.2. The total time I spent in apnea was less than 0.5%. MY AHI IS VIRTUALLY EQUAL TO MY HI ON A DAY, WEEK AND MONTH BASIS. MY AI CONTRIBUTED VIRTUALLY NOTHING TO MY AHI, ITS ALL HYPOPS.

Now, my sleep quality is DEFINITELY worse since I started xPAP, with awakenings, some lengthy, occuring every night. I DO FEEL BETTER DURING THE DAY, with less daytime drowsiness and more energy. And, my "numbers" look pretty good since I set SETTLING to on. But, I'm sleeping worse than before starting xPAP. I'm starting to get used to waking up several times a night, and I never used to.

I respect the need for treatment given all of the serious consequences that can occur with untreated OSA, especially after my heart attack.. But , it looks like I have treated OSH (obstructive sleep hypopnea), and I have NO IDEA whther these hypops are causing ANY desaturations. I learned from Bill (NightHawk) the usefulness of measuring Sats,and I've been trying to get a pulse-ox. But in the meantime, I'm going through all of this rigamarole EVERY NIGHT with apparently no apneas and a bunch of hypopneas which may be S8 artifacts anyway, and which might not be causing any desaturations. And, I'm having more awakenings (and maybe arousals) now than BEFORE I started xPAP.

Does any of this make any sense to any of you???

PLEASE HELP ME TO UNDERSTAND THIS.

Chuck

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CPAPopedia Keywords Contained In This Post (Click For Definition): resmed, activa, swift, CPAP, DME, AHI, Hypopnea, APAP

TerryB · Post by **TerryB** » Wed Jun 28, 2006 7:13 pm

Remember the job of the machine is to STOP Obstructions and it is working perfectly. A Hypop is just an obstruction which didn't develop because of the machine working its magic. If you stop using the machine you will go right back to having full obstructions. Yes it is more bother to get used to the machine. I too felt much worse for a while on the machine than I had felt before, but I've hit 4 1/2 months of use now and although I still awake several times a night to tweak the Swift, I never spend any time awake and have very few days when a nap seems like a need. Remember the OSA causes hundreds of sleep disturbances AND large drops in OSAT. Waking 3 or 4 times a night because of the treatment is more noticable because you come more fully awake to deal with it but the damage done is much smaller.

Stay with it.

TerryB

Wulfman · Post by **Wulfman** » Wed Jun 28, 2006 7:23 pm

Chuck,

Are you running your machine as an APAP with a range?......or with a single pressure setting.
The reason I ask that is if you're running it in a range, I'm wondering if the changing pressure is waking you up.
I'm glad to hear your numbers have come down with the different setting for "settling".
Do you know that if your doctor writes you a prescription, you can get a pulse oximeter from a local DME to do an overnight test. And, the DME won't charge you for it. If you're worried about desats, you should explore that option.

Den

GoofyUT · Post by **GoofyUT** » Wed Jun 28, 2006 8:01 pm

Den-

I am using my S8 AutoSet in AutoSet mode with a range of 7-14 cmH2O. I've read the thread over the last day or so from folks who are swearing that they are having a better response to CPAP rather than APAP, and I've been curious about that. But I've sort of trained myself not to go fiddling with my S8 based on any post I read here, or I'd drive myself nuts changing things all the time, or worrying about whether I'm missing out. So, I'll keep it in mind, and maybe in a week or two, if I'm still looking for an improvement in my sleep quality, I'll try a course of CPAP for a couple of weeks.

Your suggestion re: asking my DME for a pulse-ox is wonderful! I did an over-night pulse-ox the night before my last visit with my pulmonologist. I did have desats down to 89% in that study. But, what I'm really curious about is the impact of my supposedly frequent hypops on my sat. I'd actually LOVE to have a shot at using ResMed RESLINK so I can actually look at events-v-pressure-v-sats. Maybe I'll call my pulmonologist and discuss this with him.

I'm also mighty curious about my sleep architecture. In my recollection, I've dreamt ONE night since I started xPAP tx. Of course, I may be dreaming more, and simply not remembering them. But, I'd love to feel like I was getting more REM and maybe even Stages III and IV sleep. I know that I had ZERO stage III and IV during my sleep study, during the THREE hours I was actually asleep that night. However, clinically I am feeling more refreshed and alert during the day, and I'm MUCH less cranky. However, I've also started an aggresive exercise program since my MI and its starting to pay off. I'm excited about getting fit again, and I'm certainly getting an endorphin boost.

Terry-THANKS SO MUCH FOR YOUR POINT OF VIEW!!! Very thought provoking and reassuring. I simply never thought of it that way!!!!!!!!!

BTW, I did try Ambien CR this week, a couple of times and found on both occasions that I still awoke BRIEFLY about two hours after falling asleep, and again BRIEFLY at 4 in the morning (my usual times since starting xPAP). I've NEVER had a problem with sleep latency so it didn't affect that, but I DEFINITELY experienced some retrograde amnesia when I awakened in the morning, and felt slightly hung-over. I'll take a pass on the rest of my samples.

Thanks guys!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Chuck

Guest · Post by **Guest** » Wed Jun 28, 2006 8:10 pm

Hey there - woozle here - couldnt' log on - I too have the s8 vantage and use cpap only - and MY ai's are .1 to .7 per night with hi's at 2 to 4 every night - so I know the ai's are almost gone - I was not aware this is common with the new s8 - curious - may be the time spent before I fall asleep - or as noted - apnea's that were 'fixed' adn changed to hypopnea's

I am doing this for 2 months and still REALLY tired during the day - but averaging about 7 to 8 hrs per night and waking up alot - due to leaks I am trying to fix - so realize this is not much help to you~ but thought I would add that I am experiencing similarities with regards to nightly results - am stickin' with it though!

ufo13 · Post by **ufo13** » Wed Jun 28, 2006 8:31 pm

Chuck:

I know you said you don't like fooling with the numbers but I had some of the same problems you are having. The advice I would give you (at your discretion of course) is if your titrated pressure was 10cm H2O and your range of 7 to 14 seems to cover but you are not sleeping as well as you should and the hypos are still higher than you think they should be I would take a ONE NIGHT SHOT and set the range a little tighter say 9 to 12 and see your numbers in the morning! This may well not only help you sleep better due to less pressure changes but may also lower your HI's. Hope this helps,

Steve,
ufo13

GoofyUT · Post by **GoofyUT** » Wed Jun 28, 2006 8:38 pm

Thanks for the advice Steve!

In looking at the plots from AutoScan, I can see that my pressure NEVER goes above about 10.5. However, about a month ago, I did try titrating my floor pressure to deal with the hypops, and found that my 95% pressure was increasing every night, my AHI was increasing, and I was feeling TERRIBLE!!!! So, I lowered it back down to 7 and felt better IMMEDIATELY with lower numbers to boot!

Chuck

Sleepless on LI · Post by **Sleepless on LI** » Wed Jun 28, 2006 8:59 pm

Chuck,

Someone on this site once told me, whose advice I trusted with my life, that even though he'd been on therapy for a long time and felt so much better than he did prior to, he found he still awakened nightly, though only for a second or so, but multiple times to either adjust his mask or something else therapy-related and accepted this because of how much better he felt now and how his quality of life had improved so due to being on therapy, very similar to what Terry wrote.

I have tried to adopt that attitude throughout my therapy, which is now over a year's time. I rarely have a night that goes uninterrupted. And I accept that. Would I like to sleep through the night? Ah, yeah! But this is the first year in a long time that when spring rolled around, I was out in my gardens planting and transplanting, opening up the pool with my husband, and back out talking my walks because I felt alive for the first time in years. I could get teary eyed thinking about what a wonderful difference this has made.

Life is a long road of uphills and downhills and those arousals are some of the little uphills we just have to learn to hike over and not think about. Just count your blessings for the relief therapy is giving you and thank God for your improved health and well being. I know you and you are a trooper. That Energizer bunny's got nothing on you. So hang in there, continue to feel well and don't let the little things get to you. It's the big picture that really counts.

GoofyUT · Post by **GoofyUT** » Wed Jun 28, 2006 9:11 pm

Thanks Lori. The best benfit of this adventure has been the treasure of having the opportunity to make friends like you.

Chuck

Sleepless on LI · Post by **Sleepless on LI** » Wed Jun 28, 2006 9:15 pm

GoofyUT wrote:Thanks Lori. The best benfit of this adventure has been the treasure of having the opportunity to make friends like you.

Chuck

Ditto!

Rastaman · Post by **Rastaman** » Wed Jun 28, 2006 9:25 pm

This discussion sparks all kinds of thought. It makes one long for a manual of sorts, or a guideline. Say for example your AHI is 6 to 10. Then it could suggest that you try this or that, such as CPAP on a certain setting or changing your ranges on APAP. Sure we can experiment on our own but it would be nice to have something that says "Ok you're almost there, now time to tweak things a bit and find the exact perfect therapy for YOU."

-SWS · Post by **-SWS** » Wed Jun 28, 2006 9:31 pm

GoofyUT wrote:...about a month ago, I did try titrating my floor pressure to deal with the hypops, and found that my 95% pressure was increasing every night, my AHI was increasing, and I was feeling TERRIBLE!!!! So, I lowered it back down to 7 and felt better IMMEDIATELY with lower numbers to boot!

This is the exact opposite response of most people with unaddressed hypops, Chuck. That's because most people with unaddressed hypops actually need a little extra floor pressure to pre-empt the types of hypopneas that autopaps by design will not trigger on.

Contrary to most people you experienced more, not less, hypopneas with that extra floor pressure. That hints at the possibility of your hyponeas being pressure-induced, and thus a case of central hypopneas that are machine related versus primary. You might have noticed in several previous posts I mentioned that APAP algorithms are all preoccupied with avoiding the pressure induction of SDB sleep events. This pressure induction is presumably somewhat rare, yet must be statistically significant, none the less, for every APAP algorithm I have scrutinized to be preoccupied with this pressure-induction of SDB events.

You might also recall my having mentioned Complex Sleep Disordered Breathing (CSDB) as being a new condition recently brought to light by Harvard researchers. In their medical study they very specifically attribute our CO2 respiratory trigger as the likely culprit for the central apnea component in many cases of mixed apnea. They also state the likelihood of lesser SDB events being associated with that CO2-based respiratory trigger. These patients with unstable CO2 respiratory triggers tend not to fare as well on APAP's changing pressures as do most other patients. Very specifically it seems the changing ratio of CO2-to-O2 induced by APAP (or perhaps even an altered change of rate of that O2/CO2 blood gas exchange) may be attributable to these two observations: 1) these patients faring suboptimally on APAP, and 2) APAP algorithm designers having been preoccupied with this phenomena for years now (likely not knowing they were dealing with what Harvard researchers would some day label "CSDB").

I will bet a shiny silver dollar that per the Harvard researchers' predictions central hypopneas will also come to light as being CSDB related as well. I would even go so far as to expect central flow limitations (or "central hypoventilation") to factor in as well. Bottom line is this CSDB etiology may or may not be you, Chuck. However, if you can replicate again and again that raising your floor pressure caused your HI to go up every time, consider that you may very well manifest APAP-induced signs of CSDB.

With that said, you would be a good candidate for straight pressure experiments---or at the very least a very narrow APAP range. In my own analysis, it is theoretically possible to be painted in corner, so to speak regarding the xPAP treatment of obstructive events and the machine induced introduction of CO2-trigger based central events. In other words I suspect it may be possible that xPAP therapy for some CSDB patients can be a highly unstable tight-rope balancing act without proper management of CO2.

Snoredog · Post by **Snoredog** » Wed Jun 28, 2006 9:36 pm

you will nearly always end up with a very low AI score and a higher HI score with a Resmed Autopap.

Keep in mind that all those HIs are CALCULATED. The Resmed autopaps do not address Hypoapneas, they address them in their infant state when they are Flow Limitations. The Resmed Autopaps respond to the 3 basic events with additional pressure for as long as the event exists:

Flow Limitations
Snores
Apnea

You can visit the Resmed website and get the exact definitions on how it responds, but who is splittin hairs.

Settling: I have NO answer for you WHY the Settling feature lowered your score other than one can only assume that allowed you to fall into a deeper stage of sleep before therapy kicked in.

I'm not positive, but I think it doesn't score any events during Settling periods. So at this point, I'm going to stick with theory that it allowed you to reach a deeper stage of sleep.

I used to use the Settling feature on my Spirit, thought that was a very good feature to have.

I haven't seen the reports on the new S8 Vantage models, but I know the AutoScan on the Spirits were very limited in giving you good details such as hypoapnea information.

I would continue to use the Settling feature, as mentioned before if you want to lower the HI score increase the low or bottom pressure and see what it does to your score.

We have seen here before in MyEncore reports where pressures 1cm too high can actually increase the number of events seen (think it was Jerry's reports on his Remstar Pro2). He would go from 8cm to 9cm and his AHI score would nearly double, he dropped it back and it went down.

I doubt there are that many changes between the S8 and the S7 Spirit, you should study your data carefully and maybe lower the high pressure limit down to your 95% pressure and see what happens. If you have UARS or snore that could be what is increasing the pressure and number of hypoapneas.

I would also try putting it in cpap mode maybe with EPR enabled and see what that does to your score. That machine does continue to record in cpap mode doesn't it?

What kind of data do you get off Excel spreadsheets? That is the way to go if you can read and manipulate the raw data.

Linda3032 · Post by **Linda3032** » Wed Jun 28, 2006 9:40 pm

Chuck,

Just a couple of weeks ago several of us were discussing a topic regarding "feeling better with a lower pressure". You might be a candidate for that too. I know I feel alot better with my max pressure at 8 instead of 10. Yes, I might be getting a few more AHIs, but I can tolerate that as long as I feel better overall.

And yes, it's great having a forum full of friends (can you say that fast 3 times?)

GoofyUT · Post by **GoofyUT** » Wed Jun 28, 2006 9:41 pm

As always, tremendously useful and evocative. I'll share it with my pulmonologist and discuss approaches. Thank you SO MUCH SWS.

Chuck

APNEA -v- HYPOPNEA

APNEA -v- HYPOPNEA

Range

Floor pressure

Thanks

Re: Thanks

Thanks