Weird graphs

[Suenyo]

I'm so tired I can hardly think, but I have to ask about this sleepyhead chart. I got up a bit after seven and left the room. I am sure I turned off the machine before I took off the mask, but this looks like it was still running, but don't they shut off after a little while? And I didn't hear any warning beeps. And what about those apneas around 9 am? Thats impossible isn't it?

This is the second one of these I have seen this week.

here is the link: http://imgur.com/a/zwXLz

I went back and broke it up into 2 images so they display larger. The top one allows magnification and is quite clear now.

Pugsy, if you see this it is not a bad example of my events that you asked about under the AirSense 10 Wifi post from 2 days ago, except that I had pretty bad leakage last night which is not the norm these days.I sure have been tired today tho…

[LSAT]

You should really be worried about the amount of events...17 events per hour stinks. Your pressures are set too low. Your minimum should be about 12 and the max set at 16-20. If you stop breathing 17 times an hour there is no way you can have a restful night. No wonder you are so tired.

[Suenyo]

My new sleep study calls for CPAP only at 11.

The reason I got a new one is because my AHI shot up from around 6-8 to 30-40 in September. I changed my machine to APAP 8-12 to see what would happen and it has come down to what you see there. The leaks are unusual. I don't know what happened last night.

I don't have much confidence in a steady 11 prescription. Maybe I should try to go higher, but my experience is higher means more leakage.

[LSAT]

My new sleep study calls for CPAP only at 11.

The reason I got a new one is because my AHI shot up from around 6-8 to 30-40 in September. I changed my machine to APAP 8-12 to see what would happen and it has come down to what you see there. The leaks are unusual. I don't know what happened last night.

I don't have much confidence in a steady 11 prescription. Maybe I should try to go higher, but my experience is higher means more leakage.

You are saying that your AHI came down to 17 and you think that's OK? If you think you have too much leakage you may need a mask liner. The leaks on your chart don't look that bad.

[robysue]

My new sleep study calls for CPAP only at 11.

Did your titration study say anything about centrals? I bring this up because a significant portion of the events scored during the time you know you had the mask on are scored as CAs. And more pressure can make the number of CAs increase.

In other words, there's a lot more I would need to know before I would be comfortable saying you obviously need more pressure.

The reason I got a new one is because my AHI shot up from around 6-8 to 30-40 in September. I changed my machine to APAP 8-12 to see what would happen and it has come down to what you see there. The leaks are unusual. I don't know what happened last night.

When your AHI shot up in September, was it the number of CAs, Hs, or OAs that shot up???

I don't have much confidence in a steady 11 prescription. Maybe I should try to go higher, but my experience is higher means more leakage.

Rather than increasing the max pressure on your APAP, you might try increasing the min pressure to 10 or 11 cm while leaving the max pressure at 14. It could be that you are spending way too much time below 11cm and that's what is letting the long clusters of events get started.

I'm so tired I can hardly think, but I have to ask about this sleepyhead chart. I got up a bit after seven and left the room. I am sure I turned off the machine before I took off the mask, but this looks like it was still running, but don't they shut off after a little while?

A PR machine will only turn itself OFF if you have Auto OFF set to ON. If Auto OFF is set to OFF, the machine will keep running until you turn it off.

And I didn't hear any warning beeps. And what about those apneas around 9 am? Thats impossible isn't it?

The Large Leak and Mask Off warning beeps on a System One are pretty quiet. And I haven't the foggiest idea of what happened around 9 am and what those "scored" events are since there is no flow rate.

This is the second one of these I have seen this week.

How old is the machine? If you double check the settings and find that Auto OFF is set to ON and you have this kind of thing happen again, I'd suggest calling the DME and telling them that you are worried that your machine is on the fritz. Have them look at the data. (If they insist on using Encore, like they probably will, remind them that they can get the last night's wave flow data in Encore if they download all the detailed data and then click on the little wave flow icon next to your name.)

[avi123]

Suenyo, your graphs show lots of Central Apneas (CA) and Obstructive Apneas (OA). You should seek a Sleep Physician who knows how to deal with these situations. Posters on this site are laymen. In the meantime you should avoid being on APAP mode.

[Suenyo]

RobySue,

Thanks, I'll look into it. I have been getting lots more centrals, sometimes as high as 50% or more. I don't know how to account for the change in September. I had some leakage with my old mask, the Airfit 10 and didn't notice that the cushion had actually pulled loose on one side for a week or so, and that seems to be when it started, but I don't know for sure because I lost weeks of data because of computer troubles. I really only have data from late Sept. And when I went off CPAP at 12 it did seem to help. I think I'll try your advice raising the min tonight.

Avi,

Thanks, but Why should I avoid APAP. I had an echo. My heart is fine, but I appreciate your concern.

[avi123]

Avi,

Thanks, but Why should I avoid APAP. I had an echo. My heart is fine, but I appreciate your concern.

Reply:

Until you know what is causing those lousy CAs,

Who should not use an Auto CPAP.

from SLEEP 2008.

A task force of the Standards of Practice Committee of the American Academy of Sleep Medicine has reviewed the literature published since the 2002 practice parameter on the use of APAP.

Current recommendations follow: (1) APAP devices are not recommended to diagnose OSA; (2))Patients with congestive heart failure, patients with significant lung disease such as chronic ob¬structive pulmonary disease; patients expected to have nocturnal arte¬rial oxyhemoglobin desaturation due to conditions other than OSA (e.g., obesity hypoventilation syndrome); patients who do not snore (either naturally or as a result of palate surgery); and patients who have central sleep apnea syndromes are not currently candidates for APAP titration or treatment; (3) APAP devices are not currently recommended for split-night titration; (4) certain APAP devices may be used during attended titration with polysomnography to identify a single pressure for use with standard CPAP for treatment of moderate to severe OSA; (5 certain APAP devices may be initiated and used in the self-adjusting mode for unattended treatment of patients with moderate to severe OSA without significant comorbidities (CHF, COPD, central sleep apnea syndromes, or hypoventilation syndromes); (6) certain APAP devices may be used in an unattended way to determine a fixed CPAP treatment pressure for patients with moderate to severe OSA without significant comorbidi¬ties (CHF, COPD, central sleep apnea syndromes, or hypoventilation syndromes); (7) patients being treated with fixed CPAP on the basis of APAP titration or being treated with APAP must have close clinical follow-up to determine treatment effectiveness and safety; and (8) a re¬evaluation and, if necessary, a standard attended CPAP titration should be performed if symptoms do not resolve or the APAP treatment other¬wise appears to lack efficacy.


Keywords: Obstructive sleep apnea; continuous positive airway pres¬sure; CPAP; sleep disordered breathing; autotitrating; APAP
Citation: Morgenthaler TI; Aurora RN; Brown T; Zak R; Alessi C; Boe¬hlecke B; Chesson AL; Friedman L; Kapur V; Maganti R; Owens J; Pancer J; Swick TJ;

Standards of Practice Committee of the AASM. Practice parameters for the use of autotitrating continuous positive air¬way pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: An update for 2007.

[palerider]

Avi,

Thanks, but Why should I avoid APAP. I had an echo. My heart is fine, but I appreciate your concern.

avi loves to dig up old, very outdated things, then twist them to scare people. nobody knows why he does this, but it really is best to ignore him.

[Suenyo]

Thanks Avi!

Very interesting. But where do you find out what causes Centrals? I looked back at my charts and all of October I was on CPAP at 12 and the everyday average purple section of the pie chart was over 50%. Here is an example:

http://imgur.com/a/Dwphx

So maybe I'm better off in APAP. Who knows? I don't get to talk with the neurologist until Dec. 12. I will post my sleep study here in a day or two. They are mailing it to me.

Thanks everyone! I'm going to bed.

[robysue]

Thanks Avi!

Very interesting. But where do you find out what causes Centrals?

Trying to figure out the cause of CAs is difficult when all you have is CPAP data. That is why it can be necessary to involve a sleep doctor if the CAs persist for a long time (i.e. weeks and months as opposed to a bad night here and there) and if the number of CAs is growing over time (i.e. the CAI goes up over the course of weeks or months as opposed to a bad night here or there).

At the "trouble shooting" level, which is all we can do for you, it's important to know if there are any other health problems and whether the CAs are largely confined to parts of the night where you think you were probably awake.

As for Avi's posting the standard list of contra-indicators for APAP therapy:

If you happen to have congestive heart failure or serious COPD, then doctors would rather have you on straight CPAP instead of APAP. So if you have either of those conditions, it is best to work with both the sleep doc and the doc treating the heart failure or COPD when using an APAP. But if you don't have congestive heart failure or COPD, then you don't need to worry about those contra-indicators.

The recommendation against using APAP when a patient shows signs of idiopathic central sleep apnea, mixed sleep apnea, or complex sleep anpea was developed back when APAPs could not distinguish between CAs and OAs. These older APAPs would increase the pressure for any "apnea" they scored under certain circumstances, and because of that, they had a tendency to increase pressure in an inappropriate way for people with central, mixed, or complex sleep apnea, which increased the number of CAs. But modern APAPs do distinguish between CAs and OAs and are programmed to NOT increase the pressure in response to clusters of CAs. How their auto algorithm handles a cluster composed of CAs and a mixturs of Hs and OAs varies from brand to brand; so the data recorded by the machine is critical in getting the max pressure setting "right" where "right" means high enough to manage the obstructive stuff and low enough to not trigger/aggravate the CAs.

I looked back at my charts and all of October I was on CPAP at 12 and the everyday average purple section of the pie chart was over 50%. Here is an example:

http://imgur.com/a/Dwphx

Things settle down dramatically after 0:45. They're still "not good" after 0:45, but they're nowhere near as bad as the stretch between 0:10 (when you turn the machine on) and 0:45. How long does it take you to get to sleep on average?

Also on this night you took the mask off for good at a bit after 2:05---in other words, you only used the machine for about 2 hours. So that begs the question: Did you ever actually get into a sound sleep on this night? Because if the answer is NO, then *all* of these CAs might be nothing more than sleep transition CAs.

So maybe I'm better off in APAP. Who knows?

If you don't have congestive heart failure or serious COPD AND if you can and use the mask for most or all of your sleep period in APAP, you probably ARE better off using APAP.

I don't get to talk with the neurologist until Dec. 12. I will post my sleep study here in a day or two. They are mailing it to me.

The sleep study reports will give us a lot more data and insight into what's going on in your sleep.

[avi123]

Thanks Avi!

Very interesting. But where do you find out what causes Centrals? I looked back at my charts and all of October I was on CPAP at 12 and the everyday average purple section of the pie chart was over 50%. Here is an example:

http://imgur.com/a/Dwphx

So maybe I'm better off in APAP. Who knows? I don't get to talk with the neurologist until Dec. 12. I will post my sleep study here in a day or two. They are mailing it to me.

Thanks everyone! I'm going to bed.

Question,

Beside the echocardiography were you also tested for Atrial Fibrillation?

[chunkyfrog]

I kind of guess that is standard, now, Avi.