TEN Years on CPAP and still groggy?

[rozenbob]

I started on CPAP in 2006 changed to APAP in 2011 and now have the Airsense 10 Auto.

I will attempt to send copies of my last two nights after changing APAPs two weeks ago.

I am a non smoker with no other health issues.

Any suggestions will be appreciated

Thanks Bob

[rozenbob]

I have been upping the lower pressure incrementally from a starting level of 7. I usually wait a few days to check results before adjusting more.

[kaiasgram]

In both of these screenshots the central events are the largest part of the AHI so increasing the pressure(s) may not be the right thing to do. Pressure does not treat central events. Bob, could you describe more about your therapy over the 10 years you've been on PAP? Are these two screenshots representative of most of your nights?

[rozenbob]

My AHI has varied from 20 to below 3 during past month. Average is about 7.

[Jay Aitchsee]

Bob, I agree with Kaiasgram that a significant portion of your AHI is composed of CA's and an increase in pressure will not help get rid of them. In fact, it could make them worse. IMO, many CA's are reflective of disturbances which tend to cause arousals or near arousals which result in disturbed breathing which the machine scores as CA's (though they would not be scored as Centrals during a PSG).
So, if the CA's are a result of disturbances, what is the cause of those? Possibilities include Flow Limitations, Leaks, Auto pressure increases due to flow limitations, pain, meds, caffeine, environmental conditions, etc., etc.
How about this? Set your mode to CPAP and select a pressure of 10cm with EPR on at 3. This would be similar to a fixed bilevel with an IPAP if 10, an EPAP of 7 and an PS of 3. You would be inhaling with a pressure of 10 and exhaling against a pressure of 7.This might eliminate disturbance caused by the Auto pressure variations. The goal here is to reduce the disturbances and the associated CA's.
However, these pressures might not be high enough to suppress hypopneas and Flow Limitations and they could go up. IMO, your Flow Limitations are a bit on the high side now and probably are what is driving your pressures up in your examples. Generally speaking, I think Hypopneas are treated by maintaining a sufficient EPAP while Flow Limitation are suppressed with IPAP.
The results of a few nights at these suggested settings might yield a clue as to how to better optimize your treatment.

[Pugsy]

Some questions.

1. On the nights with the high CA/central numbers are you sleeping soundly for the most part or do you experience multiple awakenings with prolonged times on the machine but awake or semi awake trying to go back to sleep.

2. Do you take any medications of any kind? If so, what are they?

3. How would you classify your sleep quality in general even on the low AHI nights? Sleep soundly for the most part or frequented by multiple awakenings?

4. Can you clarify the unwanted daytime symptoms...groggy meaning excessive sleepiness and strong desire to take a nap or groggy mentally or fatigue?

5. When was the last time you saw your sleep doctor?

[rozenbob]

Hello Pugsy,

Answers:
1)ALL nights sleep pattern the same. Multiple awakenings/semi awake going back to sleep. Occasional drowsy during day.
2)Zolpidem 1hour before bed and Venlafaxine ER 75 mg Twice Daily.
3)same as 1
4)Groggy mentally with fatigue....never want nor able to take nap. Active during day, gardening, dog walk etc.
5) Saw Sleep Dr early April

Any suggestions appreciated

[Pugsy]

Multiple awakenings during the night will mess with sleep architecture in that we can't progress normally through the various sleep cycles that are need for sleep to be restorative.
Look up the side effects for your medication...insomnia (which can be going to sleep or staying asleep) could be a factor.
Both meds...the Zolpidem and Venlafaxine ER 75 mg .
Both can also cause a "groggy" feeling the next day
Research the side effects...dig deep, look at multiple resources for each medication .

While your meds may not totally be responsible for the unwanted symptoms they could be playing a part in how you feel.
Something to discuss with your doctor for sure.

[chunkyfrog]

Time to see your doctor.

[rozenbob]

No recommended pressure adjustments??

[Pugsy]

You have reports with a lot of centrals/clear airway events...some nights a truck load of them and some nights not so many.

The bulk of the problem seems to be primarily central in nature and we can't fix centrals with pressure changes.
I can't see a direct relationship between the centrals flagged and pressure as in thinking maybe they are related to higher pressures because you have blocks of centrals at lower pressures.

I don't know if those centrals are related to the awakenings you experience or if they are real centrals.
If they are related to awake/semi awake pauses in breathing then they are of no real consequence. If they are real then they are a potential problem. There's no way for us to know here based on what we see here.
The fact that you have some nights when the AHI is nice and low and other nights where there's a truckload of ugly going on makes me wonder why so different from one night to the next or even part of the night to a different part.

The medications you take are known to be a disturbing factor in terms of messing with the sleep architecture.
I have no idea how much of an impact these might be having if (and that's a big IF) those are awake/semi awake centrals getting flagged. All this is something that probably should be discussed with your doctor.
Did you show your sleep doctor these reports with all the centrals?

I don't know that a pressure change will help...it sure won't help the centrals and the obstructive stuff isn't all that remarkable with the exception of a couple of little clusters of obstructive type of events/
Your flow limitations aren't terribly ugly but there is a little bit of activity that is sporadic later in the night which isn't that unusual and likely is partly the reason for the increase in pressure during those time frames.

Perhaps the variations in pressure during the night are also responsible for some sleep disruptions....some people sleep quite well through all sorts of pressure changes and some people find that the least little change can disrupt sleep quality.
It might be worth narrowing the range in pressure or going to cpap mode to see if the pressure changes are a factor.

In terms of fixing the centrals...real or not we don't treat centrals with the machine model you have and at this point we don't know that they need to be dealt with. This is something you need to discuss with your sleep doctor. He needs to see this and decide what to do about the centrals. So pressure changes are unlikely to do anything to the centrals unless these are post arousal centrals and perhaps limiting the range or using cpap mode helps reduce the arousals.

Could you pick about a 3 minute window sometime between 1:35 and 1:45 where there is a dense block of centrals? Go to the events tab...clear airway tab...see the long list of CAs...pick a time frame in with several before and after and click on it...the flow rate graph will change to a zoomed in view of that time frame.
Get us a screen shot of that zoomed in flow rate. It would be interesting to see what the breathing looks like at that level when the centrals are being flagged. Let's see if it looks like Periodic Breathing.

[rozenbob]

Pugsy,

Is this what you requested?



this is last night



Thanks Again

[Pugsy]

Sunday April 10...the one with the boat load of clear airway events.
Do it just like I said... by going to the events tab and then the CA section...that provides the optimal zoom in level for evaluation.

[rozenbob]

Pugsy

I edited my previous post with charts

[Pugsy]

Hmmm....not classic Periodic Breathing (at least to my eye) because not enough waxing and waning (up and down of the flow rate breaths).

How much time do you spend awake or semi awake with mask on each night? Is it possible that you were awake or semi awake during most or part of the times where the centrals are being flagged?

On the nights with the higher central index do you find that your sleep is more fragmented or do you have approx the same number of awakenings with the lower central count?

I am trying to figure out if you were asleep or not when those centrals are being flagged. If awake we ignore them.
I don't know if the centrals are the cause of the poor sleep or just a byproduct of the poor sleep. The CA at 1:50:45 could be an arousal central...see that peak in flow rate right after the CA flag? That's sort of a big gulp though not maybe as big as we normally see with a big arousal gulp.

Finally...I don't know that any of this is the cause of your unwanted symptoms. I know we hope that something as simple as a little pressure adjustment will be the miracle fix but the reality is that often there are multiple issues going on and it's often hard to figure out what they are and even harder to fix them.

I do know we can't fix those centrals with a simple pressure change unless we get lucky and those centrals are a byproduct of some sort of arousal caused by either maybe the general pressure changes that happen in apap mode.
That might be a setting change worth at least trying...it would hurt nothing to go with a fixed pressure or extremely tight apap range. I know your next question...what settings to try... maybe 9 or 10 minimum and 12 max or if using fixed pressure 10 or 11 maybe a starting point. I tend to lean towards the conservative side of things because often when the starting point is higher we see that the machine might not go as high as we are seeing here.

So...how many awakenings? Count on one hand or need multiple hands and even toes? How much time spent awake using the machine?
It's normal to have maybe a handful of awakenings and it usually isn't a big deal (normal to awaken briefly after REM stage) unless we have trouble going back to sleep.
I wake during the night but I normally roll over and go back to sleep.

Oh...one other question....do you have any pain issues that could be a contributing factor in the wake ups?