Dreamstation 4-5 hours a night - Asking for Help

[hadley101]

Long time lurker and first time poster,

My story is PR BiPap user for 10 years and recently got a PR Dreamstation
1.5 years ago. Diagnosis OSA

Have severe overbite and have used SnoreRX mouthpiece along with my Bipap
for 2 years

Also suffer from COPD and was switched like many from Spiriva in January to
Incruse which has been a part of my problem, I feel anyways. Tachycardia,
Edema, Joint pain and lack of sleep. Got an echocardiogram and doppler
to rule out my heart, cleared and found out I have a bicuspid aortic valve
in the process. This left the Incruse as the most likely culprit.

My Pulmonologist/Sleep Specialist is not very helpful with either my
breathing or OSA, see him next week to set up a titration and discuss
preauthorization to get me back on Spiriva

Since starting Incruse and am pretty sure its why I'm only getting
4-5 hours of sleep each night I'd like the experts here to surmise
from my Sleepyhead data if there is anything that stands out
as a red flag.

Thanks for your time and help

[LSAT]

No Image

[palerider]

Looks like your pressure is too low for your current needs.

[SnoringInOregon]

I'm no expert, but ...

Your leak rate seems a bit high. Figure out how to make the mask fit better?

You're not in "large leak" territory, but your leak rate is quite high. In my personal experience my Dreamstation doesn't work as well when I have air leakage.

Maybe you'll sleep better once you get "dialed in" to you machine both in pressure and in leak rate.

[hadley101]

This was something that confused me about Sleepyhead and my
Dreamstation, the Dreamstation itself reports 100% mask fit and
no leaks. Don't experience any leaking either and mask fit is
generally excellent.

[USMCVet]

Looks like your pressure is too low for your current needs.

Care to elaborate? Wouldn't more pressure possibly increase his centrals which he seems to be having a good amount of?

[Pugsy]

There's nothing wrong or excessive about your reported leak rate unless the leaks are causing sleep disruptions.
In terms of the machine being able to effectively compensate for leaks....as long as the machine itself doesn't flag a large leak (you would see it on the events graph) then you are fine.

The total leak (that top leak line on the graph) does sometimes border what might be large leak territory but it doesn't seem to quite make it so again...if leaks aren't causing wake ups then I don't think leaks are the cause of your poor sleep.
Is the leak maybe enough to affect sleep quality and you not realize it....maybe.
That total leak line...not horribly high considering your pressures. Remember that total leak includes the mask's expected vent/intentional leak and it will go higher with higher pressures and your 15 cm IPAP is going to cause a higher vent rate anyway.

Obviously anything that disturbs our sleep in general is unwanted.

Insomnia has a long list of potential causes and sleep apnea is only one on that long list. If sleep apnea is the cause of the insomnia then cpap should help but if sleep apnea or some sort of sleep disordered breathing isn't the cause of the insomnia then the best cpap therapy in the world is unlikely to make much of a change in insomnia.

Medication side effects are always at the top of the list of suspects for causing insomnia.
Since you have noticed a direct correlation since starting the Incruse then I wouldn't be surprised to find that it is a factor.

About half your AHI is clear airway and they may or may not be more related to arousals or poor sleep quality than being real.
You can't fix ClearAirway apneas with pressure tweaking on your machine and I am not so sure that the remaining obstructive stuff needs treating.

[raisedfist]

About half your AHI is clear airway and they may or may not be more related to arousals or poor sleep quality than being real.
You can't fix ClearAirway apneas with pressure tweaking on your machine and I am not so sure that the remaining obstructive stuff needs treating.

Do you think he may benefit from trying a bit higher IPAP and EPAP, and also reduce the PS? Something like IPAP 16 / EPAP 12?

Also: Either your machine is showing up weird on SleepyHead, but you probably need to lower your rise time. Your inspiration time is very long - which is not good in the case of COPD.

[Pugsy]

Wouldn't more pressure possibly increase his centrals which he seems to be having a good amount of?

Only if pressure was the cause of the centrals and I doubt that the centrals are related to pressure at all.

People need to quit being so scared of "more pressure because it causes centrals"....yeah, sometimes it does but sometimes centrals will happen with as little as 5 cm pressure.

Higher pressures causing centrals is actually fairly uncommon....last I read about 10% and that included people who got centrals with any pressure (like 5 cm).

Treat the obstructive stuff first and then worry about centrals once the obstructive stuff is well prevented. Fix what you can with the equipment you have and then worry about anything left over that needs treating.
Having centrals happen...not the end of the world and the chances are relatively low that more pressure will cause them when someone is already using 15 cm IPAP and not having a truckload of centrals.

I have my doubts as to whether more pressure would fix the insomnia issues here. Things were fine until a new medication was added...so that makes me really lean towards medication side effects and just because something isn't well known to cause a particular side effect doesn't mean it won't ever happen to a few unlucky people.

OP is using a fixed bilevel pressure mode. If it were me I would probably try auto mode and let the machine increase the pressure if it felt the need to and see if the obstructive stuff reduces and see if the insomnia issues improve or not. I doubt it will help but wouldn't hurt to try and would answer a question.
Worry about centrals only if/when they become something that needs to be worried about. Chances are it won't happen.

Also....those CAs/Centrals flagged now...they may not even be real. They might be post arousal centrals and more related to an obstructive event of some sort happening and if the obstructive event was better prevented then the maybe arousal might not happen.
I have seen it often....lots of centrals flagged along with a few obstructives and we reduce the obstructives with more pressure and the centrals reduce in number because they were related to arousals from the obstructive stuff.

Don't assume that all centrals are real and don't assume that they are all related to pressure.
Some are real and normal to have...and some won't be real and those don't count.

[Pugsy]

Do you think he may benefit from trying a bit higher IPAP and EPAP, and also reduce the PS? Something like IPAP 16 / EPAP 12?

Actually I think that if it were me I would just try auto mode and set max IPAP to 20 and just see what the machine wants to do and see if whatever it might want to do improves sleep quality or not.
I don't personally care for PS of 5 but I don't like making multiple changes at one time. I like to keep changes simple...science 101...keep your variables to a minimum so you can better evaluate the results.
So I would just do the one change...auto mode with IPAP max of 20...keep EPAP minimum at 10 and PS at 5 (at least for now).
In theory what little obstructive stuff we see should be fairly easily killed with just a little more EPAP and I would just do auto mode and let the machine sort it out.

All this is a big maybe....because my gut tells me that the insomnia is related more to medication side effects than sleep apnea or the therapy. I would maybe try the changes just to see if it helped or not but my first suspect....medication side effects and if that's the case then a discussion about options and risks vs rewards needs to be had.

If someone doesn't like auto mode...then I would try 0.5 cm more EPAP.
But again it would be mainly to see if there is the chance that the insomnia is related to the airway issues....rule out type of thing.

When someone has no problem for a long time and then they change meds or add a new med and they suddenly have a problem...sure makes me want to blame the new meds.

[USMCVet]

So how common is it to have centrals as apart of SWJ? I only ask because I don't get them and if it was a very common issue I would expect to see it more in people's charts here.

I'm not saying in this case all of them are real but I wouldn't just discount them without looking closer at the actual data for each one.

[JDS74]

+1 Pugsy

[Pugsy]

So how common is it to have centrals as apart of SWJ?

Extremely common and especially so when someone is reporting trouble sleeping. Usually means more awake/semi awake time wearing the mask with machine on. More awake time wearing the mask means more chance of the machine simply flagging awake breathing irregularities by mistake because the machine only measures air flow.

[hadley101]

Thanks everyone for your help,

I'm going to have to say that my sleep issues/insomnia pretty much coincided with
my switching from Spiriva to Incruse back in January. Wanted to have a better look
at some of my data from you guys here to help rule out other possibilities such
as my settings.

Currently my rise time is set at 0, have never used the flex settings either and
truth be told don't feel the need for relief at EPAP 10. Although I've never
actually tried using it. My breathing has suffered quite a bit recently and as Pugsy
stated Incruse has been a factor.

Think I'll sit tight and wait to pick up some samples of Spiriva and get my
doctor to authorize a script. Hopefully things will improve and if not
then I'll be back requesting some help again as I'm a bit green on adjusting
settings and really don't know how to go about setting the Dreamstation
on Auto. Would like to try this after my medication switch as things
were cruising along pretty good for me.

[hadley101]

Back in January when my issues first presented themselves my
doctor did attempt to set my Dreamstation on Auto and lasted
one night. Should have let it trial a bit longer and probably would
have if my breathing was better although might not have even requested
it if no side effects presented.

Just simply couldn't tolerate the bump in pressure but Pugsy has
put this into perspective for me.