Confusing regression

[loudman]

Hi,

I've been using CPAP since 2014. I started out with S9 Autoset, and a Mirage FX. Both have worked out great, until recently where I've regressed significantly. I'm waiting to see doctors, following my not-so-great PSG. But where I live, there's no specialized sleep doctors in the country. So I'm not too confident with what my doctor is doing. And I'm waiting for them to actually decide what to do, which is taking ages. Since this forum seems to be filled with nice people, that probably know more about CPAP treatment than the combined knowledge of the doctors in my country, I figured I'd see if anybody here had any ideas.




There's a bit of a timeline to it:
- October 15th, start 18mg Concerta in the morning for ADHD. Stopped modafinil
- November 7th, up to 36mg Concerta
- November 9th, first sign of increased AHI, peaking at AHI of 10 on the 9th of December
- December 10th, AHI back to normal
- December 16th, increased Concerta to 55mg
- January 2nd, AHI starts being above normal again
- February 4th, had full PSG. Showed AHI 25. Here is the result: http://i.imgur.com/uiE5GXW.jpg. http://i.imgur.com/6mtT3UJ.jpg
- February 5th, AHI back to normal again
- February 24th, start imterittently adding 18mg concerta at lunch(54 + 18)
- March 5th, AHI starts peaking again
- April 4th, change to an A10 AutoSet, as the doctor thought maybe my S9 was defective


As you can see, my AHI used to be EXTREMELY good. But at some point, something went wrong. Since February, I've lost 25 pounds, and started swimming daily since March 25th. So I'd imagine, if anything, that'd help. Anyway, here's an example of last night(Which is the worst I've had in a while):



Here's zoomed in on one of the major clusters:


One thing that's pretty typical of my apneas lately, is that they tend to be worst around 3AM, or 6AM. Here's another example of another night.




Zoomed in a bit for the 4:30-7:00 clusters:


And zoomed in for the 6:00 cluster:




As you can see, there's something totally weird going on. It seems like some sort of periodic breathing, but a little chaotic.

I'll give you one last example.



6am cluster:


3am cluster:



And here's me on a good night:



Anyway, that's a lot of pictures. Here's what my understanding is:
- There seems to be intermittent large batches of central apneas, somewhat resembling cheyne-stokes/periodic breathing. Often clustered around same time of night
- It may have started following start of treatment with Concerta. But with very heavy delay, and with breaks that I can't explain(I never took a break from Concerta)
- It doesn't seem to me like there's mask leaks. But I may be wrong
- I don't suffer from heart failure. I've been checked!


Here's what's been tried:
- Played with humidity. Doesn't change anything
- Turned off EPR, as I read that it can induce CAs
- Re-fitted mask, and gotten new mask in January(Still mirage fx). Tried super loose, and super tight


As I said, my doctors are not helpful, as there's not a single sleep specialist in my country, though I'm scheduled for several follow-ups the coming weeks, that I expect little to come from. So I was hoping you nice folks maybe would have some input. Here's my questions:

1. What are the chances Concerta could be causing this?
2. Can this be caused by too unstable/high pressure? Would a fixed pressure maybe help?
3. The doctor suggests that going to constant pressure may help, or switching to an ASV. What should I prefer as a patient?
4. My untrained eye suggests that there's no real leak. Is this right? Or could I be mouth-leaking?
5. Any other ideas for things that may help my specific scenario?
6. How soon following changing to constant pressure/ASV, would one expect to see an improvement? Is one night of constant pressure enough?

Thanks in advance!

[Julie]

Hi - don't ever look for results after one night of anything... too many variables to work with, no consensus you should count on.

Have you Googled Concerta side FX? First thing I'd do if I were you to see if any looked likely.

[loudman]

Hi Julie,

Yes, I've search Google, and pubmed for any suggestions that Concerta/Methylphenidate/Ritalin could either increase, or decrease AHI. I've seen nothing to suggest it could change the AHI in any way. In fact, it seems to be extensively used for sleepiness persistent, even after CPAP treatment. And I don't see it listed as

And it actually appears to have helped my PLMD quite a bit. On a poly I did last year, I had a PLMI of 39. On my last PSG, it was only 9.

So if it's related to the Concerta, it sounds to me like it'd be a one-in-a-trillion incident rate. Otherwise it'd be documented.

[palerider]

2. Can this be caused by too unstable/high pressure? Would a fixed pressure maybe help?
3. The doctor suggests that going to constant pressure may help, or switching to an ASV. What should I prefer as a patient?
4. My untrained eye suggests that there's no real leak. Is this right? Or could I be mouth-leaking?
6. How soon following changing to constant pressure/ASV, would one expect to see an improvement? Is one night of constant pressure enough?

2) well, first, your pressures are very low. a fixed pressure might help, I'd definitely raise the min pressure to 7 or 8.
3) a fixed pressure and an asv are on opposite sides of the spectrum.
4) you have periods of excessive leak. that's where the UAs are coming from, too much leak for the machine to tell what kind apnea you're having.
6) an asv will be a *dramatic* change.

[loudman]

2) well, first, your pressures are very low. a fixed pressure might help, I'd definitely raise the min pressure to 7 or 8.

That's the odd thing. My low pressure has served me super well so far. Hence my surprise that it suddenly doesn't work well anymore, despite improving all the things that should affect AHI.

3) a fixed pressure and an asv are on opposite sides of the spectrum.

Yeah, that I understand. But that's the two options my doctor seem to suggest. Which should I ask to try first?

4) you have periods of excessive leak. that's where the UAs are coming from, too much leak for the machine to tell what kind apnea you're having.

Right, the data does *seem* to suggest so. But from the graphs, it seems like apneas lead to "leak", rather than leaks leading to apneas. Am I reading that incorrectly by any chance? If so, can one tell the difference between mouth/mask leak?

[palerider]

2) well, first, your pressures are very low. a fixed pressure might help, I'd definitely raise the min pressure to 7 or 8.

That's the odd thing. My low pressure has served me super well so far. Hence my surprise that it suddenly doesn't work well anymore, despite improving all the things that should affect AHI.

the only time a pressure of 4 serves you super well is if the pressure hardly ever goes above four. yours is bouncing all around... which is making the machine less responsive to your needs, and allowing more obstructives, snores, hypos and flow restrictions to disturb your slep.

3) a fixed pressure and an asv are on opposite sides of the spectrum.

Yeah, that I understand. But that's the two options my doctor seem to suggest. Which should I ask to try first?

well, a fixed, or at least narrowed pressure, you can try now, without getting a different machine.

4) you have periods of excessive leak. that's where the UAs are coming from, too much leak for the machine to tell what kind apnea you're having.

Right, the data does *seem* to suggest so. But from the graphs, it seems like apneas lead to "leak", rather than leaks leading to apneas. Am I reading that incorrectly by any chance? If so, can one tell the difference between mouth/mask leak?

neither leads to the other... but they may be coincidental. I see a couple stretches of gray area (large leaks) in the middle of strings of apneas, indicating where your mask is out of place, or your mouth is open,... or something.

I've never been able to tell the difference in straight mask leak and mouth leaks just from a chart.

[robysue]

2) well, first, your pressures are very low. a fixed pressure might help, I'd definitely raise the min pressure to 7 or 8.

That's the odd thing. My low pressure has served me super well so far. Hence my surprise that it suddenly doesn't work well anymore, despite improving all the things that should affect AHI.

There is nothing in the data that indicates a pressure increase is needed. The problem is long chains of CAs being scored by the machine. And more pressure is not going to make those go away. In fact, more pressure could increase the problem with CAs.

3) a fixed pressure and an asv are on opposite sides of the spectrum.

Yeah, that I understand. But that's the two options my doctor seem to suggest. Which should I ask to try first?

You have a machine that can do fixed pressure right now. So you can run that experiment right now while you are waiting to be seen by the doc. There's no need to wait.

Strings of CAs can be caused by a number of things. If switching from APAP to CPAP happens to eliminate the CAs, then you've gotten lucky and you're done with trying to figure out what to do.

And ASV machine is a much more expensive machine. As in they're about 4-5 times as expensive as an APAP. In the US you would need a new script for an ASV machine. And that would most likely require a new sleep test to document that those strings of CAs being detected by your machine are real CAs and not just some form of "sleep-wake-junk" breathing. And then after documenting that CAs are a real problem, you'd need another sleep test to titrate the ASV.

Now, it is possible that you do indeed need an ASV. But it's not going to be as simple as "buy and ASV and plug it in and expect it to work." You most likely will need some kind of a titration study for getting an idea of what the initial settings on the machine should be.

4) you have periods of excessive leak. that's where the UAs are coming from, too much leak for the machine to tell what kind apnea you're having.

Right, the data does *seem* to suggest so. But from the graphs, it seems like apneas lead to "leak", rather than leaks leading to apneas. Am I reading that incorrectly by any chance? If so, can one tell the difference between mouth/mask leak?

Causation is not important here. And it's most like a coincidence that an apnea is occurring around the time of a large leak.

As for the difference between mouth leaks and mask leaks: It can be difficult to tease them apart.

First: What kind of a mask are you using? If you are already using a FFM, then mouth leaks won't be the direct problem. If you are using a nasal mask or a nasal pillows mask, mouth leaks must be considered. If you frequently wake up with a very dry mouth, chances are you are doing some mouth leaking. If the leaks look like plateaus in the leak graph, that's often a sign of mouth leaking. If the leaks are really spiky and very short lived, that's often a sign of mask movement. If you wake up with air blowing in your eyes, that's a sign of mask leaks.

[loudman]

You have a machine that can do fixed pressure right now. So you can run that experiment right now while you are waiting to be seen by the doc. There's no need to wait.

Strings of CAs can be caused by a number of things. If switching from APAP to CPAP happens to eliminate the CAs, then you've gotten lucky and you're done with trying to figure out what to do.

Yeah, I've considered that. I just don't wanna piss off my doctor by changing the settings. But I may try it. What pressure would you suggest to try?

And ASV machine is a much more expensive machine. As in they're about 4-5 times as expensive as an APAP. In the US you would need a new script for an ASV machine. And that would most likely require a new sleep test to document that those strings of CAs being detected by your machine are real CAs and not just some form of "sleep-wake-junk" breathing. And then after documenting that CAs are a real problem, you'd need another sleep test to titrate the ASV.

Now, it is possible that you do indeed need an ASV. But it's not going to be as simple as "buy and ASV and plug it in and expect it to work." You most likely will need some kind of a titration study for getting an idea of what the initial settings on the machine should be.

That's no worries. Nationalized healthcare is great! My doctor has already brought up that we may need to go to an ASV.

First: What kind of a mask are you using? If you are already using a FFM, then mouth leaks won't be the direct problem. If you are using a nasal mask or a nasal pillows mask, mouth leaks must be considered. If you frequently wake up with a very dry mouth, chances are you are doing some mouth leaking. If the leaks look like plateaus in the leak graph, that's often a sign of mouth leaking. If the leaks are really spiky and very short lived, that's often a sign of mask movement. If you wake up with air blowing in your eyes, that's a sign of mask leaks.

Mirage FX. I don't really find that I wake up with that dry of a mouth. But I never have had issues with leaks from the Mirage FX. There's some plateaus in the data, lasting for anywhere from 2 to 30 minutes. But sometimes it's very big and short spikes.

I guess I should ask for a chin strap when I go to the clinic on Thursday?

[palerider]

2) well, first, your pressures are very low. a fixed pressure might help, I'd definitely raise the min pressure to 7 or 8.

That's the odd thing. My low pressure has served me super well so far. Hence my surprise that it suddenly doesn't work well anymore, despite improving all the things that should affect AHI.

There is nothing in the data that indicates a pressure increase is needed. The problem is long chains of CAs being scored by the machine. And more pressure is not going to make those go away. In fact, more pressure could increase the problem with CAs.

the thought of a little more min pressure was to cut down on the ups and downs that are happening... 4 is too low a min pressure for most people, for effective treatment.

[lilly747]

2) well, first, your pressures are very low. a fixed pressure might help, I'd definitely raise the min pressure to 7 or 8.

That's the odd thing. My low pressure has served me super well so far. Hence my surprise that it suddenly doesn't work well anymore, despite improving all the things that should affect AHI.

There is nothing in the data that indicates a pressure increase is needed. The problem is long chains of CAs being scored by the machine. And more pressure is not going to make those go away. In fact, more pressure could increase the problem with CAs.

the thought of a little more min pressure was to cut down on the ups and downs that are happening... 4 is too low a min pressure for most people, for effective treatment.

+1

It's worth a try: High pressure does not cause CAs for me BUT bouncing around does. I have real CAs without CPAP too.

[loudman]

I raised the minimum pressure up to 6, since the average pressure for the week was 6.1 anyway. According to the numbers, it was MUCH better. But in reality, I remember waking up every hour or so. I'll give this another night, as seeing a nurse tomorrow about this. It looks like there still could be some leaks. So I'll gun for a chin strap, and see if what is waking me up is me opening my mouth.

[Holden4th]

Concerta suppresses appetite so I wonder what your eating habits are. At what point/s in the day do you take your medication and when do you eat. Food does affect AHI and an increase/decrease in Concerta could affect your AHIs.

[loudman]

Concerta suppresses appetite so I wonder what your eating habits are. At what point/s in the day do you take your medication and when do you eat. Food does affect AHI and an increase/decrease in Concerta could affect your AHIs.

Interesting. What's the relation between food and AHI?

My food intake before concerta was higher, more carb-heavy. I'd often skip breakfast, do lunch, and then a heavy dinner at 17:00 or so.

With concerta, my food intake is definitely lower. I now eat at 7:45, 12:00, and 17:00. But it works out to 2000 calories, +/- 10% or so. And it's worth noting that my hydration levels are much better, and I've quit pepsi max since.. Actually, the dates where I stopped consuming caffeine of any type probably matches up with when my AHI started increasing!

[Julie]

Sounds like you have the food/diet thing under great control and I wouldn't be too concerned about any 'relationship' now between food and AHIs, which unless you're gaining weight and/or eating a lot just prior to bedtime, would normally be a non-issue.

[loudman]

Sounds like you have the food/diet thing under great control and I wouldn't be too concerned about any 'relationship' now between food and AHIs, which unless you're gaining weight and/or eating a lot just prior to bedtime, would normally be a non-issue.

Nope, definitely not an issue. I'm down 24 pounds in 2 months, and in some of the best physical shape of my life