i am in trouble...need your help please

[bsc1280]

Hi guys....

I have this painful situation and need to do something of abotu this asap.

sorry for the long story but i need it to express myself.

I am 27, 6'2", 225 pounds and just came to HK from tokyo. I was diagonosed with sleep apnea after sever tiredness and day time sleepiness I had in office. my AHI was 33.4 (mostly hypo-apneas). in 2006 I had my surgery for my nose because of deviated septum. I seldom do excercise but generally do light walk or 10-15 mins.

I started using cpap in september 2007 and my situation improved. I did not improve my tiredness (just by 20%) but reduced my day time sleepiness significantly. I used resmed s8 vantage at 4-8 pressure (apap). After moving to HK, my doctor in tokyo asked me to buy goodknight 420E as resmed was not easily available there. I have been using the goodknight for a month now.

The problem is that my tiredness has become worsened after moving to HK and with the new job. when i wake up, i have head ache in the forehead and at the back of the head and neck. Also my eyes are tired and i feel stress and pain at the back of the eyes. Imagine wathcing the TV for 10 hours (the kind of stress you feel). at office, i can not concentrate on work. the moment i start to thingk or focus on something, the head ache multplies.!! i feel i am physcially and mentally exhausted. it becomes better if i just do something whcih does not require much thingking (like chatting wiht friends etc). If i place my hand on the forehead and press it , it relaxes me. I also feel pressure in my temples too. At night i only remember that i wake up avg 2~3 times and then sleep again. the software shows there are no apneas and ahi is only 3.3 .

I checked the result of my treatment on the software and i have placed the screen shots at

please review and tell me what do you think is the cause of my problems

http://www.flickr.com/photos/23068939@N ... 970480249/


A few things i have tried

1. my thyroid is working properly and t he test were normal
2. the head ache and pain in the eyes is not due to leask as the leak in the fostware is only 0.8 cm on avg and i have tried making the mask a bit tight so that it completely stops. But this does not help
3. I have tried using humidifier but no help
4. i have got my BP checked and that is also fine.
5. i taped my mouth to make sure i dont breathe from my mouth
6. the doctor asked me to keep pressure at 4-8. but i tried vrious ranmges liek 5-10, 8-11 but it did not help either.

i use goodnight 420E and activa masal (resmed)

my nose remains half closed (one nosril mostly blockeD) and the soiftware shows i do have runs and acoustical vibrations.

Its veeeeeeeeeery difficult for me to live like this. my work is gettin affected as i work in a bank and have work pressure too. my peronsal life is geting effected too. please help on what do you think can solve my problems.

The head ache and pains do not go away with panadol too. It simply relives a but of ache but the tiredness and lack of concentration is not there. I dont think i have depression or any other psychatric problem.

please help!

[Wulfman]

Hi guys....

I have this painful situation and need to do something of abotu this asap.

sorry for the long story but i need it to express myself.

I am 27, 6'2", 225 pounds and just came to HK from tokyo. I was diagonosed with sleep apnea after sever tiredness and day time sleepiness I had in office. my AHI was 33.4 (mostly hypo-apneas). in 2006 I had my surgery for my nose because of deviated septum. I seldom do excercise but generally do light walk or 10-15 mins.

I started using cpap in september 2007 and my situation improved. I did not improve my tiredness (just by 20%) but reduced my day time sleepiness significantly. I used resmed s8 vantage at 4-8 pressure (apap). After moving to HK, my doctor in tokyo asked me to buy goodknight 420E as resmed was not easily available there. I have been using the goodknight for a month now.

The problem is that my tiredness has become worsened after moving to HK and with the new job. when i wake up, i have head ache in the forehead and at the back of the head and neck. Also my eyes are tired and i feel stress and pain at the back of the eyes. Imagine wathcing the TV for 10 hours (the kind of stress you feel). at office, i can not concentrate on work. the moment i start to thingk or focus on something, the head ache multplies.!! i feel i am physcially and mentally exhausted. it becomes better if i just do something whcih does not require much thingking (like chatting wiht friends etc). If i place my hand on the forehead and press it , it relaxes me. I also feel pressure in my temples too. At night i only remember that i wake up avg 2~3 times and then sleep again. the software shows there are no apneas and ahi is only 3.3 .

I checked the result of my treatment on the software and i have placed the screen shots at

please review and tell me what do you think is the cause of my problems

http://www.flickr.com/photos/23068939@N ... 970480249/


A few things i have tried

1. my thyroid is working properly and t he test were normal
2. the head ache and pain in the eyes is not due to leask as the leak in the fostware is only 0.8 cm on avg and i have tried making the mask a bit tight so that it completely stops. But this does not help
3. I have tried using humidifier but no help
4. i have got my BP checked and that is also fine.
5. i taped my mouth to make sure i dont breathe from my mouth
6. the doctor asked me to keep pressure at 4-8. but i tried vrious ranmges liek 5-10, 8-11 but it did not help either.

i use goodnight 420E and activa masal (resmed)

my nose remains half closed (one nosril mostly blockeD) and the soiftware shows i do have runs and acoustical vibrations.

Its veeeeeeeeeery difficult for me to live like this. my work is gettin affected as i work in a bank and have work pressure too. my peronsal life is geting effected too. please help on what do you think can solve my problems.

The head ache and pains do not go away with panadol too. It simply relives a but of ache but the tiredness and lack of concentration is not there. I dont think i have depression or any other psychatric problem.

please help!

Your doctor is a clueless idiot.....IMHO.
Your bottom pressure is TOO LOW and unless you are prone to Central Apneas, your upper pressure may be too low, too.
Did you actually have a titrated pressure?......or did they just hand you an Auto and hope for the best?
Did you review any data from your Vantage? It would have been available in the LCD each morning.

Good luck,

Den

[Guest]

I definitely would also have my MD refer me to a neurologist. If your BP is consistently good (especially in the morning), then you need to be seen for other uninvestigated possibilities that may have nothing at all to do with OSA, or only be incidentally related.

[TXKajun]

Welcome to the forum, bsc. You've got a GREAT machine!! (I know, I've used one for the last 3 years.)

Looking at your slides, it seems like your pressure is set from 4-12 or so, right? It also looks like your AHI (which is ALL from hypopneas, as far as I can make out) is still around 12 most nights. That's still considered low to moderate OSA, so what you're doing doesn't seem to be working too good.........oh yeah, you can tell that by how you feel.

You said you upped your pressures, but did you just use the raised pressures for one night or for a week or so? Usually it'll take about 3-5 nights to notice what's really happening after you make a change. One night or 2 nights just isn't enough for your body to get used to the changes.

You say you tape your mouth....that's a good thing. That should eliminate mouth breathing. It looks like you're trying really hard to get your treatment optimized. Good job.

Now, I'm not a Dr, nor a resnpiritory tech or any kind of medical professional, but you've got an APAP that you should be able to work with quite well. Most of us with APAPs find a pressure about 2 cm below and 2 cm above our 90% value to work quite well. From your reports, it looks like your 90% pressure is 10 or 11 cm. So you might try a + 2 cm from either of those numbers and see if that helps.

Good luck and keep us informed, please.

Kajun

[ozij]

Tx and Wulfman, I really disagree with you! (By the way Den, bsc1280 is using Silverlining)

1. None of bsc1280's pictures give us a claculated AHI. sleep 1 and sleep 2 are the same picture, that gives data for one, single seession, a total of 12 hypops in 7 hours and 34 minutes.

2. Sleep 3, also a totals (and not index) table, has more hypops (H) and flow limitations (Count of Flow Limitations) after the last 2 setting changes, when the configruation was changed.

3. Most important: Both Sleep 1 and Sleep 4 indicate massive leaks.


bsc1280,
Here's what I'ld do:

Mask and leaks:
1. SilverLining reports leaks in litres/per second. Your leak is therefore about 48 litre per minute -- way above what it should be. Between 6 and cm pressure, your averag leak should no more than 0.4 L/s to be at the Acativa's exhaust vent pressure (Page 11 of the manual.

2. I was told by my RT that the Activa won't function well below 8 - the seal won't blow up propely.

You have to find a solution to the mask leaks[/b]

Machine settings

Unlike other Auto's, the PB 420E is planned for you to setup the recommended pressure as the initial pressure, a safe minimal pressure to drop down to if breathing is stable, and a savf maximal pressure to go up to when necessary. It is programmed to give preference to the initial pressure, and will go there quickly when it finds the present pressure too low. It will also check if this return to initial is enough before forging ahead. (My source for this description is the the various patent descriptions e.g.Flow chart 1. Flow chart 2
and

http://www.fda.gov/cdrh/pdf3/k031470.pdf

In Automatic mode (APAP mode), the practitioner sets a maximum and minimum pressure range above and below the prescribed reference pressure and between 4 and 20 cmHz0.

My emphasis added.


I would suggest that for the next week or two you set you initial pressure at 6, your minimum at 4 and your maximum at 8.
That way, the machine will be more careful about lowering your pressure to where you start snoring badly again, and won't return to too low a pressure after it takes care of the events.

But nothing will help if you don't control those leaks. The Activa is meant to worn very loose - if it won't blow up properly when your pressure is low, you may need to look for another mask.

PM me if you want to send me your *.pat file.

And I agree about seeing a neurologist. You're not getting the therapy you need now - but there may be other reasons for the way you feel.
O.

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): 420E, activa, AHI, seal, auto

[Snoredog]

very difficult for me to view your reports as the details are so tiny, but I didn't see any Apnea or Central Apnea on your reports?? If so, that is good. Only thing I see is a high amount of Flow Limitation runs, that is not good, a sign of unstable sleep.

I think your bottom pressure is too low, I would bump that up to at least 6.0 or 6.5 cm pressure. I think the head/neck pain is from the mask straps and/or simple tension from wearing the mask, try flipping the headgear upside down for a night that will change how it rides on your neck.

My guess is you feel bad because your sleep architecture is totally destroyed, but we cannot see that from the reports. Ever have a PSG? what was seen on that report besides SDB? Any leg/limb movements? Any spontaneous arousals noted? what was found for the following:

Stage 1:
Stage 2:
Stage 3/4:
REM:

Based upon your 420e reports my guess is your SAO2 levels were fairly normal?

I would open up the machine pressure range and set it to 6.5 cm to 20 cm, from your reports I see no reason or CA's that would call for the need to limit the Max pressure. I would also consider a different mask, I don' think your leak is bad enough to result in the poor reported sleep (has to be another cause). I would seriously consider the Soyala nasal mask, if you currently wear a Medium in other masks get it in a Large. The Soyala will be the quietest mask you have ever used, seals great and much smaller and lighter than the Activa, I never obtained very good sleep with the Activa either.

You might also try turning 1FL off on the 420e (Command on Flow Limitation), you can also increase the Minimum pressure and setup Auto Ramp with 6.5 cm, then if you cannot fall asleep hit the ramp button.

This part is only a crap shoot:
Some other things you may try, get some Unisom and/or Tylenol PM, try taking one of those to see if you don't sleep more soundly. Melatonin would also be worth a try with the goal being to increase deep sleep. If you have any kinds of pains like back pain and/or sciatica try taking an aleve before bed.

Do you recall dreaming in like the last year? If you are pretty wound up, try drinking a decaf green tea an hour or so before bed.

[ozij]

very difficult for me to view your reports as the details are so tiny, but I didn't see any Apnea or Central Apnea on your reports??

Click on the "all sizes button" Snoredog, and the reports won't look so tiny any more.

Lot's of important details in them too. Like the leak data in the "details screen" in sleep 4.

You might also try turning 1FL off on the 420e (Command on Flow Limitation),

By doing that, bsc1280, you'll disable the system's reponse to all Hypopneas that are not concomittant with flow limitations. I would say that is unadvisable considering most of your events were hypopnes, and that sleep 3 shows them majority of your events are hypopneas, and not hypopneas + flow limitations (H+Fl).

O.

[dsm]

bsc1280,

I can't add anything beyond what Ozij has already said.

Hong Kong pollution shouldn't be a problem if you work in a Bank (am guessing you will be in Central or Admiralty),

The machine you have is unlikely to be your problem (excellent device).

One extra theme I would pursue is how you as a person feel about working in HK. Is it any sort of a personal challenge (coming from Tokyo, HK will seem quite different). There may be more than cpap behind your symptoms.

Good luck

DSM

[rested gal]

bsc1280, it looks like someone has set the "Max pressure for command on apnea" at "6" in the advanced settings of the PB 420E. That should be left on the factory default of 10 unless the doctor deliberately ordered that setting to be changed.

It's unlikely such an extreme reduction in that particular setting would be ordered unless a person had a serious problem with central apneas rather than obstructive apneas. I've got a feeling that setting was changed by the person setting up the machine due to not understanding what that setting is/does.

If it were me.....

1. I'd go into the Advanced Settings menu via the software and change that particular setting back (Max for command on apnea) to the factory default of 10.

2. I'd set the machine's pressure range for 7 - 15 with starting pressure at 7.

3. I'd check the "Acoustical Vibrations" line of the 96 hour graph each morning. IF I were sure I had mask/mouth leaks well under control, I'd keep raising the minimum pressure setting until there were no snores (acoustical vibrations) or at most a random few scattered through the night. Both 420E's I used responded very aggressively (raising pressure) when a snore was marked on the data.

4. If:
a) I was sure I had leaks under control
b) Was not registering any, or an occasional VERY random, acoustical vibration
c) But was still seeing jagged, steep pressure increases....

I'd raise the minimum pressure to 8 (using a range of 8 - 15)
or 9 (using a range of 9 - 15.) Whenever I changed the minimum pressure, I would also raise the starting pressure to be the same as the minimum pressure I had set.

5. If, after all that, the pressure line did not smooth out considerably, and I was still seeing many steep pressure increases, I'd turn off IFL1 in the Advanced Settings. I'd keep IFL2 on, and I'd keep the Max Command on Apnea at 10.

I would not worry about the number of "runs" appearing on the data.

I would worry about the number of acoustical vibrations, as snores (and the higher pressures those acoustical vibrations can cause with a 420E especially) can often be an indicator that the minimum pressure is not set high enough.

Keep the straps of the Activa mask as loose as you can. That's a mask which works best if the straps are almost floppy loose. I had no problem with the Activa sealing fine even at low pressures such as 5, 6 or 7. You might even need to loosen the lower strap in particular AFTER you lie down, as the back of neck tends to get thicker in sleeping position and can make a strap become tighter.

With an Activa mask, loose straps allow that mask's unique bellows cushion to fill out and seal well once the air starts blowing -- even at fairly low pressures. The forehead adjustment to tilt the mask more toward or away from the face can work wonders at stopping leaks -- tightening the straps more can be counter-productive with that mask.

Despite the fact that you didn't see any improvement using a heated humidifier, I'd go back to using it, at least on low heat. I use distilled water for mine, and I don't dump out the unused water in the morning. I just add more distilled water when the water gets low.

Hope things get better for you soon, bsc!

[ozij]

Bsc
I notice you give us details for your Feb 9 session. We don't know the varoius configurations you used on all the other sessions - could you post them? You could show us the relevant configurations if you posted a screen shot of what you see after you click on the third button in the compliance screen.

Screen shots of the "detailed record" using the magnifying glass tool (squarish thing near the the pencil tool) will also help.

Are you aware that you can export data from the detailed record? You will get 3 CSV (comma separated values) files, the one with the 96H extension will give you leak data - especially which percetnage of you time you are spending above the machines capacity to compensate.

O.