No any improvement after 7 days of APAP therapy

[deyneko]

Hi,
At the first, I would like to say thanks to Ms Pugsy for her help. I successfully bought ResMed S10 AirSense AutoSet + Nasal pillows ResMed AirFit P10. In spite of "warnings and threats" from local Canadian representatives who sell CPAP machines here, my machine and mask were delivered from the USA to Canada without any problems.

I set my machine according to prescription (auto, 5-18 H2O) and already have 7 days of therapy.
Unfortunately, I don't see any improvement in my condition. As previously, I feel sleepiness and drowsiness all day and only in the evening I feel myself normally. So, I don't feel refreshed after sleep.
But according to results of my machine statistic is good.

May be I missed something? Maybe I have to adjust my settings?

Here my statistic:
CPAP settings:
APAP with min 5 and max 18 (cm H2O)
EPR: full time 1 cm H2O
Humidity level 4
Mask Pillows
Temperature 27 C
Temperature enable 2

CPAP usage
Average Hours per Night 07:07
Compliance 100%

Therapy Efficacy
AHI 1.30
Obstructive Index 0.10
Hypopnea Index 0.32
Clear Airway Index 0.84
RERA Index 0.12

Leak Statistics
Average Leak Rate 7.27
90% Leak Rate 0.00
% of time above Leak Rate threshold 4.28%

Pressure Statistics
Average Pressure 6.42
Min Pressure 4.14
Max Pressure 11.20
90% Pressure 0.00
Average EPAP 5.47
Min EPAP 4.02
Max EPAP 10.20

This is an example of last night:


Surprisely, I found a lot of "clear airway events", some of them kind of false:


But there are also CAs which resemble really central apnea compexes:

[MaxINTJ]

Everyone here started xPAP with the hopes of a miracle.

Some people get that miracle after one night, some people a week, some people a month, and some people multiple months. There are also others that are still waiting...

All you can do is keep trying. Maybe up your minimum a bit and see if that helps, a lot of people can't even breathe properly at min 4, but your numbers look pretty good.

[Cpapian]

Just for future information there is a Canadian supplier with good prices.

http://Www.cpapmachines.ca

Another member Arlene recommended them to me. They are run by a cpap user, offices in Ontario, I believe and will match prices in Canada.

[Julie]

Hi - your min. pressure setting - the one that 'counts' - is very low and most complain they can't even breathe at that level, so I suggest you bump yours by at least a couple to 6 or 7 cms for a few nights and let us know how it goes. You can/should leave the upper setting high, 15 to 20 for now... no potential problems doing it and it will leave room for pressure to rise if needed.

I also suggest that unless you know for a fact (experience) that you need such a high humidifier setting, turn it back down to 1 and see how it goes... many people experience congestion or cold symptoms at that high setting unless they're e.g. in Arizona (and you're not). I don't even use the thing at all. You may want it in e.g. Jan/Feb. if central heat's on and the cold is 'dry'... but play with it and see how it goes.

[Btoeps74]

I wouldn't say that it 100% works for me but I definitely can tell the last few days having not used my cpap due to issues that it at least helps. I can say that with cpap I 100% don't snore at all.

[Pugsy]

Can you get me a detailed image of one night without all the zooming in?

Are you sleeping soundly for the most part or is your sleep fragment with multiple wake ups and some time spent on the machine but awake?

Do you take any medications of any kind? If so, what?

Are you totally comfortable with the starting pressure? Do you feel like you are air starved or suffocating at all?

In terms of humidity... is your nose comfortable....having any congestion, drainage, sneezing or dry mucosa feelings? Your nose will let you know if it isn't happy with the humidity settings.

[coconur]

I set my machine according to prescription (auto, 5-18 H2O) and already have 7 days of therapy.
Unfortunately, I don't see any improvement in my condition. As previously, I feel sleepiness and drowsiness all day and only in the evening I feel myself normally. So, I don't feel refreshed after sleep.
But according to results of my machine statistic is good.

Getting the settings right for you can take months and a lot of perseverance. When I first started PAP, the apap numbers suggested that 8cm was enough pressure for me. My Dr had my machine set to cpap mode at 8cm. My AHI was good (don't remember the exact #'s anymore), but my blood pressure was high. Having previously used a dental appliance, I knew my blood pressure could be well controlled with the right apnea therapy, so I inched (cm'ed?) my pressure up to 10. AHI was now zero, but BP was still high. Then my husband reported that my breathing was shallow while on the machine. My Dr instantly bumped my pressure to 12, and the next time I went in my BP had dropped back to normal. Don't give up!

[deyneko]

Hi,

Are you sleeping soundly for the most part or is your sleep fragment with multiple wake ups and some time spent on the machine but awake?

During 7 days of CPAP therapy, my wife noticed only couple times of snoring. But I awake a lot of times.

Do you take any medications of any kind? If so, what?

I don't take any medication. My health, in general, is good except feeling bad after sleep. Actually, I have this long, long time approximately after teenage age.

Are you totally comfortable with the starting pressure? Do you feel like you are air starved or suffocating at all?

Pillows are not very comfortable of course, but I can sleep with it. I feel pressure by my ears. It is difficult to explain my feelings. I wouldn't say I feel suffocating, but without mask I can really that my breathing is "free". Additionally, I use chin strap and sometimes air out from my mouth. In the morning I really feel that pillows pressure on my nostrils...

Can you get me a detailed image of one night without all the zooming in?

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... so I suggest you bump yours by at least a couple to 6 or 7 cms for a few nights and let us know how it goes. ...
I also suggest that unless you know for a fact (experience) that you need such a high humidifier setting, turn it back down to 1 and see how it goes...

Thanks Julie, I will try increase low level up to 6 or 7 and decrease humidity (it is on automatic right now).

Just for future information there is a Canadian supplier with good prices.
http://Www.cpapmachines.ca

Thank you for site, there are good prices at least lower ~30-50% than here in Québec.

[Pugsy]

You won't have much chance to feel the nice low numbers until you can actually sleep soundly for the bulk of the night.

Frequent awakenings that we remember...usually means there are more that we don't remember...added together really messes with the normal sleep architecture that the body needs for the restorative powers of sleep to work.

So even if everything else is perfect...the awakenings/arousals themselves are problematic. Now figuring out why they are happening isn't always so easy...in fact is rarely easy unless you know for sure what is causing them....and fixing even if known isn't always so easy either.

Now it might be that you just need some more time and experience...heck at one week into therapy I was still waking a gazillion times a night just to feel the mask on my nose or check to see if the machine was on...it took quite a while for the brain to come to realize that all this new stuff on my face was really a good thing and for the brain to quit waking me up just to tell me that there was something weird going on in my face.

But while giving it time there are some things you can do to try to improve things and see if it helps or not.

The ear thing...that's a pressure related thing and common...try to relieve the ear thing by doing whatever works for you when you might be experiencing altitude change and the ears act up. For me yawning helps equalize the pressure...for others it's swallowing...for some it is chewing gum which probably isn't the best idea when trying to sleep .
I still have it happen on occasion but it is quickly resolved by the yawning trick.
If you can't get it resolved...see a doctor. There may be something else going on in the ears making it more difficult to equalize the pressure.
Sometimes decongestants will help...so something to consider if you can safely take a decongestant of some sort.

The problem is...my next idea is likely to make the ear thing worse.....more pressure to help with the initial comfort thing. You should be able to feel like your breathing is as "free" with the nasal pillows as without any cpap mask.
Couple of options to try though.
First...simply try a large size nasal pillow if you can go up in a size. For some people that extra room in the larger sized pillow will help the breathing to feel more natural and less constrained.
Second...more pressure...like Julie says...increase that 5 cm starting minimum to 6 or 7...play with it while awake just to see what feels good.
If you do this...change EPR to 2 or 3 even...again play with both and see what feels the best. Using more EPR will stand a greater chance of helping the ear situation not worsen.

If you make a change....don't make multiple changes at one time. Limit your changes to one so that you can better evaluate the results.
Remember Science 101...keep your variables to a minimum.
Unless you are having specific nasal issues...don't go playing with the humidity at the same time you are playing with pressures or EPR exhale relief.
Keep the experiments simple and separate when at all possible.

So...
1....try to isolate the cause of the arousals/awakenings if at all possible. It might just be that the brain needs time to accept it's new best friend the alien on your face...but try rule out other potential culprits if you can because we can't fix a problem if we don't know what the problem is.
2....try the next larger size nasal pillow if possible
3....try increasing the minimum starting pressure a bit and adding a bit more EPR to help with comfort and maybe the ear thing....if you aren't comfortable you can't sleep so great. Comfort is really important in that regard.
4....play with humidity if you wish and if you feel your nose isn't happy with how things are right now...but do it as a separate experiment.

I know you read about people having quick fast overnight miracles with cpap but those people are actually in a very small (and very lucky) minority.
Most of us it took some time and work and adjustment to get there.....myself included. I didn't have my first "energy miracle" until 4 months into therapy...and then not another one for probably 6 months. Now I knew cpap was working because of other improvements in other symptoms but the energy thing has always been a thorn in my side. I know the reason though and I do the best I can. For me it was directly tied to sleep quality more than sleep quantity. I had to work really hard on what was causing multiple arousals during the night.
Now it's normal to have 2 or 3 remembered awakenings...it's normal to awake after a REM cycle but most of us will go back to sleep so quickly we don't remember it. That's normal...it's when we start having a lot more arousals that we remember that we know that the normal sleep cycle is being messed with.

Your actual report looks pretty good. The first cluster of centrals sort of happens in conjunction with a couple of OAs...so it wouldn't be impossible for those centrals to be post arousal centrals with the arousal being secondary to the OA happening and that's sort of what they look like to me... I don't think they look like you were asleep.
You might have been but it doesn't scream out at me asleep breathing. It's not regular or smooth enough IMHO.
The fact that you say you were awake often....sort of makes me really think that they are arousal related.
If you had said...no, I went to sleep and don't remember waking at all...then I would rethink things.

It's hard to know for sure and we don't remember the times and should clock watch anyway.
What you can do to help isolate known awake time is if you find yourself awake just reach over and push the off button and then immediately push it again to turn it back on. This will show as a break in the therapy line and makes it real easy to spot known awake time and then if you spot events flagged right then or close to the break you will know they probably aren't real and are awake breathing getting a flag by mistake.
The machine has no way to know if you are asleep or not. All it measures is air flow and sometimes our awake breathing air flow can cause the machine to think something is going on when it isn't.

[deyneko]

Hi,
thanks all for your suggestions and especially thanks to Pugsy for her detailed explanation!

I followed your suggestions:
1. I used large pillows
2. The minimal pressure was increased up to 7
3. EPR also was increased for comfort
4. Additionally, I switched humidity to manual and decreased it (to 3)

Results:
One of the night I turn off and start button when I woke up (see graphs below). So, I woke up about 9 times.
I still have a lot of "clear airways apneas" as you can see from pictures (below). Nasal pillows + chin strap are not ideal for comfot, but I don't feel discomfort and can sleep very well with it. At the morning I don't feel pressure at all, even sometimes I am not sure that machine is working.

Negative things: unfortunately I still feel sleepness at the mornings.
Positive things: it is subjective, but in spite of feeling sleepness I feel that I more concentrated. And my cognitive functions at the mornings (at most of the days) are better.
Additionally, my wife, she is an accupuncture specialist, detected improvements in the lung meridian. The lung meridian is not connected to the lungs directly and nonspecific. But anyway this meridian reflects breathing conditions in general.

Well, I thinking what can I do next? Mays be it is needed to increase minimal pressure up to 8? May be it will supress all events of obstructive apnea. Actually, according graph (lets imagine it is not marked), for me sometimes it's difficult to distinguish clear aiway apneas from obstructive apneas. Any suggestions?

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[Pugsy]

Some of the Clear Airway events/Centrals are most likely awake breathing....especially when you see it flagged close to a known awake time like the first break in therapy shortly after 1 AM.

Don't try to kill all apnea events with more pressure because of 2 things.
1...some of them aren't real anyway and are likely awake breathing getting flagged by mistake
2...you can't kill any centrals with more pressure if they are real centrals. The airway is already open when it comes to centrals and more pressure won't make the air move any better when the airway is already open.

You don't stand much chance of not getting sleepy during the day when you have so much sleep fragmentation at night.
If you are awake enough to turn the machine off and back on again this much there's probably more arousals there that you aren't awake enough.

Right now the primary problem is fragmented sleep. Now figuring out why it is fragmented and doing something about it isn't necessarily going to be all that easy.
Do you have any idea why the wake ups during the night? Is there anything you can put your finger on in terms of comfort or something that might point to a known reason for the wake up?

[kteague]

Does your spouse report if you move around a lot during the night, particularly your legs? Any history of restless leg syndrome?
Are you and your spouse on the same sleep schedule, or is there activity in the room while you sleep?

[TedVPAP]

Hi,
At the first, I would like to say thanks to Ms Pugsy for her help. I successfully bought ResMed S10 AirSense AutoSet + Nasal pillows ResMed AirFit P10. In spite of "warnings and threats" from local Canadian representatives who sell CPAP machines here, my machine and mask were delivered from the USA to Canada without any problems.

I set my machine according to prescription (auto, 5-18 H2O) and already have 7 days of therapy.
Unfortunately, I don't see any improvement in my condition. As previously, I feel sleepiness and drowsiness all day and only in the evening I feel myself normally. So, I don't feel refreshed after sleep.
But according to results of my machine statistic is good.

May be I missed something? Maybe I have to adjust my settings?

Here my statistic:
CPAP settings:
APAP with min 5 and max 18 (cm H2O)
EPR: full time 1 cm H2O
Humidity level 4
Mask Pillows
Temperature 27 C
Temperature enable 2

CPAP usage
Average Hours per Night 07:07
Compliance 100%

Therapy Efficacy
AHI 1.30
Obstructive Index 0.10
Hypopnea Index 0.32
Clear Airway Index 0.84
RERA Index 0.12

Leak Statistics
Average Leak Rate 7.27
90% Leak Rate 0.00
% of time above Leak Rate threshold 4.28%

Pressure Statistics
Average Pressure 6.42
Min Pressure 4.14
Max Pressure 11.20
90% Pressure 0.00
Average EPAP 5.47
Min EPAP 4.02
Max EPAP 10.20

This is an example of last night:


Surprisely, I found a lot of "clear airway events", some of them kind of false:


But there are also CAs which resemble really central apnea compexes:

This data shows that your OSA is being treated well so no changes are warranted to address OSA. With time it is likely that you will become more comfortable and your CA's will decrease. Give it a month to see where the data is and how you feel.

[USMCVet]

I asked at my appointment today how long it would take to feel better. I was told its different for everyone and that how sleep deprived you are before starting all plays a role.

[TedVPAP]

I asked at my appointment today how long it would take to feel better. I was told its different for everyone and that how sleep deprived you are before starting all plays a role.

Exactly. I was worse for ~2 months until I conquered mask and mouth leaking. There is more than just A & H that disrupts sleep.