Hi from new member (tried taping my mask)

[leptic]

Sometimes SH exaggerates things.

Ok I will confess that I'm just proud of myself that I figured out how to make words red in bbcode...

However, I do feel better today after my record-breaking AHI of 10 so thank you again Pugsy!

Having Pugsy and this forum is just as good as having a fleet of French doctors in little Peugots coming to my house to titrate my machine

[leptic]

Hi -

Just an update on my cpap therapy. I went into the clinic to buy a cpap pillow (Best in Rest Memory Foam CPAP Pillow) and discuss my progress with the tech. I got a gentle scolding for changing the pressure settings myself - I was told that increasing my minimum pressure from 5-7 could be done by a tech but that the doctor is supposed to approve higher changes via an update to my prescription. Nonetheless he said that 7 cmH2O was a good setting at this point and also recommended turning off 'Flex' mode, in which the DreamStation tries to modulate the pressure applied during inspiration and expiration. I had noticed a weird pressure oscillation before, as if the machine was trying to 'guess' which way I was breathing. I have to confess I found this a bit disconcerting, and found it a lot more comfortable after turning Flex off.

Here is last night's trace - the first night I turned Flex off, the percentage of central apneas went way down.



Here is a table with some basic data going back to day 1.



I noticed that the centrals have been diminishing, and should mention that I got the green light from my doctor to start titrating off of cipralex (an SSRI). I'm experiencing mild SSRI withdrawal now, which might be skewing the results. Overall, from some combination of cpap and efforts to reduced refined carbs in my diet (and maybe just a little placebo effect), I'm feeling somewhat better in the mornings. I started cycling again yesterday, and hope I can resume that on a daily basis as I suspect it really helps my sleep.

Thanks in advance for any comments and advice!

[Pugsy]

What's the chance that you are maybe awake during those clusters of OAs? Or maybe partially awake?

The centrals/CAs we ignore for now anyway because we can't do anything with them with this machine.
The OAs are still elevated but appearing in dense clusters...awake maybe?...on your back maybe? ...REM stage sleep maybe? Middle of the night clusters could be REM but the initial clusters when you first turned the machine on is not normally when a person hits REM...first REM is usually around 90 minutes after first sleep onset.

If we can't explain away the OA clustering as awake/semi awake breathing getting flagged by mistake then you are going to need even more minimum pressure to deal with them because there's still too many OAs happening.

[leptic]

What's the chance that you are maybe awake during those clusters of OAs? Or maybe partially awake?

The centrals/CAs we ignore for now anyway because we can't do anything with them with this machine.
The OAs are still elevated but appearing in dense clusters...awake maybe?...on your back maybe? ...REM stage sleep maybe? Middle of the night clusters could be REM but the initial clusters when you first turned the machine on is not normally when a person hits REM...first REM is usually around 90 minutes after first sleep onset.

If we can't explain away the OA clustering as awake/semi awake breathing getting flagged by mistake then you are going to need even more minimum pressure to deal with them because there's still too many OAs happening.

Thanks - some of the centrals might be associated with SSRI usage/withdrawal?

Regarding wakefulness, remember that there is some evidence that I might be Type 1 narcoleptic (immediate REM onset at night, daytime REM, wakeful dreaming, sleep paralysis, automatic behaviours and cataplexy; all since adolescence). My sleep has been really fragmented for as long as I can remember, and the line between awake and asleep has often been quite blurry (at night).

My working plan is to optimize the OSA therapy, wean off the SSRI and Concerta, and have a proper clinical sleep test to see if anything is going on in addition to the OSA.

Thanks again for your helpful input!

[Pugsy]

SSRIs are known to depress REM...so getting off them could potentially increase REM time which of course potentially increases the chance of more OSA or higher pressure needs in REM.

I don't know that SSRI withdrawal necessarily increases centrals unless the withdrawal causes crappy sleep and increases the chances of arousal centrals (awake/semi awake breathing getting flagged by mistake).
Meaning the withdrawal just increases arousals and the increase in centrals is secondary to the arousals and not necessarily the brain forgetting to tell the body to breathe.

You have a lot of variables going on and unfortunately the data from the machine can't give us exact answers as to "why" .

You know rule number one in experiments....limit your variables as much as possible and in your situation it's kinda hard to follow that rule.
I think you are going to need more minimum pressure but given all that is going on ....I would work through some of those other variables and get them out of the experiment and then see what's left in terms of OSA therapy.
I wouldn't go dial a wingin while going off the meds especially if your doc gets his panties all in a wad if you go changing the pressures. The DME getting upset ...I don't care if they get upset.

[leptic]

Thanks Pugsy!

SSRIs are known to depress REM...so getting off them could potentially increase REM time which of course potentially increases the chance of more OSA or higher pressure needs in REM.

Will try to figure out a way to monitor this...

I don't know that SSRI withdrawal necessarily increases centrals unless the withdrawal causes crappy sleep and increases the chances of arousal centrals (awake/semi awake breathing getting flagged by mistake).

A couple of weeks ago I went on a 3-day trip and forgot my Cipralex (SSRI). This was when I was monitoring myself using equipment borrowed from my university lab - I deliberately didn't take the Cipralex the night I got home, and the monitoring showed a dramatic reduction in centrals (which might have been other things, but it seemed quite dramatic).

Meaning the withdrawal just increases arousals and the increase in centrals is secondary to the arousals and not necessarily the brain forgetting to tell the body to breathe.

I think the withdrawal just generally makes you feel crappy and tired, and it's hard to know if the effect on centrals is directly associated with the SSRI withdrawal or indirectly from one of the withdrawal symptoms. Given that this will be temporary, I'm not going to worry about it too much but focus on the sleep data once I'm fully off.

You have a lot of variables going on and unfortunately the data from the machine can't give us exact answers as to "why" .

You know rule number one in experiments....limit your variables as much as possible and in your situation it's kinda hard to follow that rule.
I think you are going to need more minimum pressure but given all that is going on ....I would work through some of those other variables and get them out of the experiment and then see what's left in terms of OSA therapy.

Thanks for understanding - while it would be great to change one thing at a time, I think it will be better to focus on getting to a new 'clean' baseline where I'm not taking Cipralex (or Concerta), don't have such an awful diet, and then work from there.

I wouldn't go dial a wingin while going off the meds especially if your doc gets his panties all in a wad if you go changing the pressures. The DME getting upset ...I don't care if they get upset.

In fairness to my clinic, the tech was pretty jovial about it. He just related to me how it was 'supposed' to work. The sleep clinic is a one-stop shop for the doctor, tech, and cpap sales. I realize there is a potential conflict of interest here, but it is convenient and the tech is overall very engaged in figuring out what's going on. I think he's been very positive about our mutual interest in physiology, so I am happy with the care and education thus far. I'm not sure if the DME concept applies in Canada - I'm working with a private sleep clinic. Some of the doc consults are covered by government healthcare, and other stuff (cpap titration, pillow, cpap purchase if appropriate) are covered through additional private healthcare from my employer.

[Pugsy]

Thanks for understanding - while it would be great to change one thing at a time, I think it will be better to focus on getting to a new 'clean' baseline where I'm not taking Cipralex (or Concerta), don't have such an awful diet, and then work from there.

I think this would be the approach I would take if I were in your shoes. Since you already know that you want to get off those meds...do that first and eliminate that potential culprit period.
Then see what is left over in terms of OSA therapy that could stand improvement. While it may not be ideal at this point it is sure considerably better than without cpap and we can't fix the centrals with this machine (even if they needed fixing which at this point we just don't know) anyway.

Arousals, that you may or may not remember, might account for some of the AHI numbers you are seeing and the arousals could either be from the meds or from getting off the meds.
So maybe some of that AHI isn't really OSA at work. Makes it hard when the machine flags awake/semi awake stuff but it is what it is and we have to deal with the fact that the machine can't tell if we are awake or not.

I always say fix what is obviously needing fixing first and then see what's left over...in your case the desire to get off those meds is the first thing that needs fixing. Once that is accomplished you can see what is left in terms of OSA therapy that may need further attention.

[leptic]

Ugh - another night at 10+



And as SleepyHead would predict, I felt horrible in the morning.

[Pugsy]

That minimum of 7 isn't holding the airway open well enough...you are going to have nights like this as long as the minimum is too low. Your reports look just like mine did 7 years ago until I got my minimum up high enough to be a better starting point in the battle.
BTW....sure looks like those OA clusters go along with REM sleep stages..near textbook.

[leptic]

Increased minimum pressure to 8 - AHI went down to 7.26. Suppose I should probably keep it there for a few nights:



What is the typical range of 'final' pressures people arrive at? Not planning to go right there, just wondering how far I might have to go...

Thanks!

[HoseCrusher]

Every persons needs are individual. I use the 10 - 14 range because that is what works best for me.

[leptic]

Every persons needs are individual. I use the 10 - 14 range because that is what works best for me.

Thanks - just wanted a general idea of distribution. Does anyone ever get results with 7 cmH2O?

[Julie]

Yes, of course... everyone's different!

[leptic]

Yes, of course... everyone's different!

Thanks - I wondered if 7 might be a level that, while not expected to be therapeutic, could help identify people who will have significant difficulty enduring CPAP.

[Pugsy]

When I was using apap I ended up with minimum of 10 and max of 20 and would see it hit 18 cm quite often.
Some people do better with a large range and some do better with a tighter range.
Pretty much everything pertaining to cpap comes with a big YMMV sticker.

There's nothing magical about 7 cm...some people can get effective therapy at 4 or 5 cm and some might need the high teens. I do seem to remember a useless poll from a long time ago where it was asked what pressure do people use. Results were a typical bell curve with 10 cm being probably the apex of the bell curve.
In terms of overall comfort...nothing magical 7 cm there either. Some people feel like 7 is hurricane force winds and some feel like no air is moving at all. Again that YMMV sticker.

As to whether or not continue several nights with 8 minimum...maybe 2 or 3 more nights but that's all...I fully expect you to end up being more like me in terms of minimum requirements...I think 10 cm minimum is very likely where you are going to end up (or in that neighborhood).