How Am I Doing?

[wacomme]

Thank you Pugsy for a super informative reply. I think you're spot on. I felt like I slept well last night and I dreamed a lot. I probably was supine most of the night. It's interesting to note that OSA increases during REM sleep. I had no idea. Why is that?

My only sleep study was the home kit, so the data is limited. Despite the OSAs, it's nice to know that I have a strong REM inclination. Having read Why We Sleep by Matthew Walker, REM sleep is very important.

I will try to minimize the constantly changing variables. Currently, my machine is set for 7-17 pressure and no EPR. I'm using the F20 mask.

Michael

[Pugsy]

https://www.verywellhealth.com/what-mak ... se-3014749

during REM the airway muscles are paralyzed (like our other muscles) which makes the already saggy, floppy muscles even more saggy and floppy which in turn can cause a need for more pressure to hold them open.

[wacomme]

https://www.verywellhealth.com/what-mak ... se-3014749

during REM the airway muscles are paralyzed (like our other muscles) which makes the already saggy, floppy muscles even more saggy and floppy which in turn can cause a need for more pressure to hold them open.

Yes. Of course. I should have ascertained that reasoning from reading the book. Thank you. That makes a lot of sense.

Michael

[wacomme]

I think I've settled on the ResMed AirFit F30i mask (small frame, medium cushion). The F20 mask may stay in place a bit better and leak a bit less (maybe), but the F30i feels better, has the hose above the head, and doesn't irritate the bridge of my nose. Overall, the F30i is more comfortable than the F20 - for me.

I still get a fair number of OA's throughout the night despite a pressure range of 7-20. This is likely during REM sleep. I'm not sure if this can be avoided; I just may need to live with it. Here's a graph from last night - typical of what I've been getting for the past week.

screenshot-20200513-092028.png (270.63 KiB) Viewed 799 times

Michael

[Pugsy]

I have REM worse OSA. Like 5 times worse in REM and I had reports very similar to yours when I first started therapy.
The trick is to increase the minimum pressure up to a point where the clusters during probable REM simply aren't so pronounced.
Might not ever totally eliminate them but they can be broken up so they are less dense in terms of OAs or hyponeas.

The minimum pressure is the key. It has to do a better job holding the airway open and preventing what happens during REM.

[wacomme]

I have REM worse OSA. Like 5 times worse in REM and I had reports very similar to yours when I first started therapy.
The trick is to increase the minimum pressure up to a point where the clusters during probable REM simply aren't so pronounced.
Might not ever totally eliminate them but they can be broken up so they are less dense in terms of OAs or hyponeas.

The minimum pressure is the key. It has to do a better job holding the airway open and preventing what happens during REM.

So maybe raise the minimum pressure to 9 instead of 7?

[Pugsy]

Yes...increase the minimum.
I don't know how much more you will need but probably at least 2 cm.
We just don't ever know for sure how much of an impact any increase might make in the end results.
What I did some 11 years ago was gradually increase the minimum by 0.5 cm a week (the machine only offered 0.5 as the smallest increments). It was an easier adjustment for one thing to go up slowly...and sometimes a little change in pressure makes a much bigger change in results than we might initially expect.

It's your choice what to try if you want to try more minimum. It will help break up those clusters and you get to decide at what point you are happy with the density of any remaining clusters. I still occasionally will see one..maybe two clusters that are a bit dense...but it's a rarity so I don't worry so much about them. I go for overall average results and how I sleep and feel more than just a single AHI number night to night. Night to night results can change markedly so I always look at overall averages as primary marker.
Meaning....for me to totally eradicate all REM clusters means I would have to use a lot more minimum all night long...I don't want to do that so I made a compromise and accept the fact that I do occasionally get a couple of ugly clusters for some reason or other.
Those ugly clusters don't seem to cause me to sleep or feel any different...so I shrug my shoulders and move on.

Right now you are where I was at about 2 weeks into therapy (it took me that long to get what I needed to use available software back then) and it didn't take long to clean up the reports to the point where my AHI ran between 2 to 3...then I slowed down the adjustments and gave more time to each setting to see how things trended.

If a 2 cm increase is comfortable for you to try...won't hurt to try it.
If it isn't comfortable...go up slowly so it's more comfortable for you...won't hurt to do that either.

[wacomme]

Thanks Pugsy! I'll give it a try, likely 1cm increments.

[wacomme]

It seems that I'm getting worse than better. My AHI is slowing increasing. My high pressures are often reaching my ceiling of 20. My low pressure is set at 10 - higher increases my aerophagia. And now I seem to have CSR. I'm not sure where to go from here.

screenshot-20200529-082253.png (152.12 KiB) Viewed 763 times

[Pugsy]

Zoom in on a segment of that CSR flagged time....about a 4 to 5 minute segment please.

I doubt it is real CSR but lets look to make sure.

If you need more pressure to deal with your OSA and more pressure causes aerophagia issues then you need to be getting with your doctor about the possibility of getting a different machine that might help out and/or deciding what your options are.

You can try increasing EPR to 3 but it might not be enough to help the aerophagia enough.

[wacomme]

Here is the segment with CSR.

I'll try an EPR of 3. What kind of machine would address my issues? I have a doc appt next Wednesday.

screenshot-20200529-092923.png (143.38 KiB) Viewed 757 times

[wacomme]

And here's another screenshot with several OAs during the 20' CSR episode.

screenshot-20200529-093359.png (143.18 KiB) Viewed 757 times

[Pugsy]

What you are showing is nothing more than periodic breathing which is a waxing and waning of the air flow.
CSR or Cheyne Stokes Respiration is a form of periodic breathing but it is NOT the only form of periodic breathing.
This is what real CSR looks like..



or this in the OSCAR software



As to what kind of machine might help the aerophagia...a bilevel machine that will allow a greater difference between inhale and exhale than you can get with the 3 cm difference that EPR can offer. A bilevel machine offers the ability to use 4 or 5 cm difference and sometimes that will allow the pressures to be increased to the point of dealing with the OAs more effectively without causing so much aerophagia issues. If it can't then you have to figure out a potential compromise between dealing with the aerophagia problems and the problems that using less pressure might cause in terms of the OA event clusters that will happen when less pressure is used.

I know people who have simply had to make a compromise in terms of AHI and pressures used so that belly issues don't end up being a bigger problem than the AHI is a problem.

[wacomme]

Thank you for your very informative feedback. The information will help me with my appointment with the doctor next Wednesday. It seems that a full sleep study is warranted. I only had an in-home sleep study to ascertain my apnea and current CPAP machine. Does that make sense? Or is there little to be gained from a full sleep study?

Michael

[Pugsy]

Oh man, how important or informative would an in lab sleep study end up being in your situation....in all honesty it depends on what they do and what parameters they set up and their goals.

We already know you need cpap and have OSA and you need x amount of pressure probably to deal with special needs OSA presumably REM stage sleep OSA. So I don't know what they would do any differently during the in lab sleep study and/or would they just start off with bilevel or whatever. There are certain protocols that each doctor and each lab and each insurance company requires to get all the various i's dotted and t's crossed as well as just the personal preferences of each doctor.

I am uncertain as to how effective a bilevel in lab titration might be in terms of simply the aerophagia issues alone.
Aerophagia issues tend to be cumulative and not easy to isolate in a single night on the machine. And that's assuming the in lab sleep study is using the bilevel machine....which it might not be. They might want to start from square one with cpap and go through what you have already gone through.

It's relatively easy to figure out what pressure will deal with the OSA events.....not so easy to figure out what pressures cause the belly problems.

If it were me in your shoes...with the compounding problem of obviously needing more baseline pressure to prevent the dense clustering of events which appears to be probably REM related...and that more pressure causing significantly worsening belly issues....I would start with making use of the available pressure support using EPR at it's maximum of 3. It might help enough to get you by...it might not.
If that didn't do the trick then I would ask the doctor for a bilevel machine where I could use a higher pressure support (the difference between inhale and exhale) in hopes that I could then use a higher baseline pressure without adding to the belly issues.
I don't know that I would be wanting an in lab sleep study at this point in time because I don't know that it would tell me anything that I didn't already know and the end result would likely mean a trial on a different machine would need to be done anyway.

My personal opinion is often doctors use sleep studies as a fishing expedition when they don't know the problem and they use the fishing expedition as an attempt to attempt to identify the problem so they can fix it. In your situation we already know the problem and we also know in theory anyway, what is needed to fix the problem. I wouldn't be gung ho on getting an in lab sleep study at this time unless you just really have to know if those clusters are REM related or supine related or what pressure is needed to break up the clusters.
Now your doctor may feel differently about it and that's certainly within his scope of powers and rights.

Try EPR at 3...see what happens if you add in a little more pressure support in terms of hopefully easing the belly issues when the pressure goes higher and if with it you could maybe increase that minimum pressure enough to break up the clusters.
You might have to just accept less dense clusters...I don't know what your belly can handle.