Why doesn't APAP respond to apneas?

[Arizona-Willie]

The report from the Virginia place indicates that almost all of the events happened when the person ( you? ) was on their back.

Very few non-supine events.

I know tummy sleeping with an Activa is a challenge. That's why I switched to the Quattro and then there are also no issues with mouth breathing and needing tape etc. etc.

My Quattro is virtually leak free. At least at lower pressures. Don't know how well it would work for you but it might be worth a try.

I considered also getting one of those massage tables with the gizmatchy you put your face into and the mask would fit in there nicely. Not all that expensive either surprisingly.

But with the Quattro I can stomach sleep much easier than with the Activa. It really helps me to stay on my stomach. I'm using an APAP right now and this morning I rolled over on my back and I could feel the pressure zoom up and the machine compensated for the position -- or tried to. Haven't checked the data yet. But I bet it went to the max setting of 13 when I rolled on my back.

Sleeping on your stomach is the ideal position for OSA because gravity works in combination with the machine to keep the soft tissues from closing the airway. On the back is the very worst position == but it feel so good sometimes

[OutaSync]

O,

It took months to get into see the Dr. after that test. I came armed with my reports, which he only glanced at and before I could say anyhing he said I was doing fine. When I asked him about the need for a BiPAP, he told me to keep doing what I had been doing because I was doing fine. My AHI was below normal and he did not think I needed a BiPAP. Keep in mind that this Dr. is younger than my son, graduated in June 2007 and I went to see him in August 2007. Not that there is anything wrong with young, freshly educated Drs, I'm just saying..... Do you think I should ask for another Dr. in the group to review my reports?

Arizona-Willie,

I can't sleep on my stomach because it hurts to turn my neck! It hurts to sleep on my side, as well (especially since my shoulder surgery), but I can't stay on my back all night because of my back pain. I guess I do toss back and forth a lot. Each time I change positions I get about 10 seconds of relief before the pain comes back. I'm getting more used to it now. I used to be able to fall asleep and wake up in the same position, From the neatness of my covers, I don't think I ever moved.

The Quattro was the first mask I tried. Leaked terribly and cut my nose. They insisted that I needed a small, but I wonder?

Bev

[ozij]

I don't understand how come you had an Rx for a cpap an not for a Bi-level.
I think you should try another doctor, with the sleep study in hand and your present complaints - expecially the aerophagia.
For some peple a bi-level helps the aerophagia.

Like I said, I would try to raise the min 0.5 cms.

And I would also consider the possibilty that all that painful tossind and turning is disrupting your sleep .

O.

[OutaSync]

I'll raise my min by .5 and turn off the Aflex to see if that helps. Or maybe I should do one at a time for a week, so that I can see which is helping.

For sure the pain doesn't help me sleep, but the pain medication makes me stop breathing way more, so I don't take it. I don't want to get addicted to it anyway.

If I were to get a Respironics BiPap, would I have the same problem with the algorithm ignoring the first apnea? I want one that at least tries to get all of them.

Thanks, for all your help.

[gasp]

O,

It took months to get into see the Dr. after that test. I came armed with my reports, which he only glanced at and before I could say anyhing he said I was doing fine. When I asked him about the need for a BiPAP, he told me to keep doing what I had been doing because I was doing fine. My AHI was below normal and he did not think I needed a BiPAP. Keep in mind that this Dr. is younger than my son, graduated in June 2007 and I went to see him in August 2007. Not that there is anything wrong with young, freshly educated Drs, I'm just saying..... Do you think I should ask for another Dr. in the group to review my reports?

Arizona-Willie,

I can't sleep on my stomach because it hurts to turn my neck! It hurts to sleep on my side, as well (especially since my shoulder surgery), but I can't stay on my back all night because of my back pain. I guess I do toss back and forth a lot. Each time I change positions I get about 10 seconds of relief before the pain comes back. I'm getting more used to it now. I used to be able to fall asleep and wake up in the same position, From the neatness of my covers, I don't think I ever moved.

The Quattro was the first mask I tried. Leaked terribly and cut my nose. They insisted that I needed a small, but I wonder?

Bev

Zero Gravity
I have no idea if this will work, but you said you sleep inclined - are you able to change the angle at which you sleep? Do you have an adjustable bed? If so, have you tried increasing the angle of the head and raise the feet as well to achieve a 'zero gravity' type setting?

"Zero gravity occurs when the torso is properly angled with the thighs and lower legs positioned above the heart. In this position, the amount of pressure exerted onto the spine is greatly reduced. When the spine is positioned at zero gravity, full body muscle tension is relieved and circulation is improved. It is a completely stress-free position. The principle of zero gravity is an important part in the design of many Relax The Back™ products."
Source: http://www.spineuniverse.com/displayart ... e2976.html

While zero gravity is good for the spine, I'm uncertain if the angle that most benefits your back will benefit your apnea. You can experiment. I have an adjustable bed and it is possible for me to increase the head and feet to achieve a zero gravity like position. My APAP responds by increasing the pressure so I know my airway must still collapse a bit as it does when I'm on my back - although not increasing as much. However, maybe you'd respond differently and less back pain and ability to sleep would be worth it to me. I am able to sleep on my side comfortably. I'm sorry you have shoulder pain and can't do this too.

Pain and Nutrition
Inflammation can be a high contributor to pain. You may experience some pain relief by changing your diet to one that reduces inflammation. I eat similar to this site's recommendations and am the only person I know that has no pain. This is not to say that I never have. I had a serious neck injury when I was young and a back injury a few years later. Through acupuncture, Hellerwork, and nutrition I was able to get back to my athletic self with no pain. My mother asked my help with nutrition after she was diagnosed with Type II diabetes. I changed her diet to an anti-inflammatory one that also meets her Type II needs. Now, she rarely takes pain medication even though she has arthritis and a knee that has little cartilage. She and I believe it is because she has reduced her inflammation. This site has interesting ortho information as well.

"Your nutrition has a major role in how you feel pain. What you eat will give your body the chemistry it needs to make an inflammatory response. Inflammation is what your immune system creates when there is some kind of insult or damage to your tissue. Inflammation is not the only cause of pain but it can make your pain feel more intense and last longer"
Source: http://www.eorthopod.com/public/patient ... ition.html

[Paul56]

I can't sleep on my stomach because it hurts to turn my neck! It hurts to sleep on my side, as well (especially since my shoulder surgery), but I can't stay on my back all night because of my back pain. I guess I do toss back and forth a lot. Each time I change positions I get about 10 seconds of relief before the pain comes back. I'm getting more used to it now. I used to be able to fall asleep and wake up in the same position, From the neatness of my covers, I don't think I ever moved.

The Quattro was the first mask I tried. Leaked terribly and cut my nose. They insisted that I needed a small, but I wonder?

Bev

Have you tried sleeping on a recliner?

I have this huge Laz-Y-Boy recliner that my mom says she gets lost in each time she sits in it... anyways I tried sleeping in it last summer for the first time due to sore back issues. I slept wonderfully well. Unbeknowst to me at the time it may have also helped the apnea issue I had that had yet to be diagnosed.

[jnk]

. . . another doctor, with the sleep study in hand and your present complaints - expecially the aerophagia. . . . For some people a bi-level helps the aerophagia.

O.

Very wise words, those.

I would consider an autobilevel.

[GumbyCT]

My ahi varied on Auto-M too. It was acceptable to the useless doc I had. I do much better on Bi-Pap 18/15. I think I couldn't exhale @17cm and that caused more events for me. Get the Bi-pap

Oh noticed more probs w/10ft hose after I added the Activa mask. I removed the short mask hose and I was fine.

[Snoredog]

Snoredog,

I tried lowering the pressure earlier in the summer and , as you predicted, my AHI went way up and the aerophagia wasn't any better. Considering the length of my apneas, it felt as though I hadn't gotten any sleep at all. I will try turning Cflex down to 1. I have Aflex set at 3. It shows up as Cflex on the Analyser.

<snipped>


Any clues in there?

any clues?

Your sleep lab results show you were titrated on Bilevel and did your best at 19/15 with only 2 events seen.

You need either a Bilevel machine set to 19/15*** or a Auto SV machine. You have central apnea and mixed shown on your lab titration, add to that difficulty tolerating CPAP that indicates Complex Sleep Disordered Breathing (CSDB) to me.

Aflex Report: While the Aflex report is not bad, in light of your lab results being posted, you have to assume a lot of those residual events seen on your Encore reports can very easily be Central and/or Mixed events.

As for which machine is better for you, obviously they tried different titration pressures and modalities, that titration table is about the best one I've seen. If you pick the best from that it is 19/15 with the fewest events. If you compare that pressure to your Aflex you are very close to that 15 cm EPAP pressure with the Aflex. However, since you need that 15 cm EPAP pressure to control your events (Encore reports seem to suggest the same) you would probably do the best on a Bipap machine. While you can use the Aflex and obtain acceptable results, Bipap may be able to make that higher pressure much more comfortable for you. I'm surprised they didn't give you a Bipap from the start.

*** while 19/15 showed the fewest events from your titration, that pressure also didn't produce any REM sleep, you have several other pressure combinations with similar results which produced REM but you probably should consider the RDI seen and weigh in the lowest RDI along with REM and fewest events seen. You are kind of all over the place in finding that which makes your SDB complex suggestive of the Auto SV. With the lower RDI seen that would suggest more stable sleep (i.e. fewer microarousals seen).

You may have to see a GI Specialist about the aerophagia, they may be able to repair your LES and STOP the aerophagia where you can use the CPAP therapy more comfortably. Obviously when your pressure requirement is that high you would benefit (comfort-wise) with a Bipap machine over the Auto.

[-SWS]

You need either a Bilevel machine set to 19/15 or a Auto SV machine. You have central apnea and mixed shown on your lab titration, add to that difficulty tolerating CPAP that indicates Complex Sleep Disordered Breathing (CSDB) to me.

I think that's a possibility, which is why I was wondering if excessive cyclic alternating pattern (CAP) was scored. It's usually not scored, and the sleep report reveals that they weren't looking for any particular CAP patterns (again, most labs don't). But pain can also cause excessive CAP, so this is not exactly a high specificity indicator for suspected mild cases of CSDB/CompSA---which can be inordinately uncomfortable at a biologic level.

Anyway, the Respironics BiPAP AutoSV machine can be set up as an ordinary BiLevel machine at 19/15 or it can be set up as an auto servo ventilation machine. It also offers BiFlex capability, which may be a great comfort feature for Bev. No guarantees with this machine, which makes it an awfully expensive experiment. Regardless, that's the platform I think I'd personally lean toward as well if I were in Bev's situation. Even if ASV doesn't work out, she's still got ordinary BiLevel with or without BiFlex to fall back on. And that may help with aerophagia at the very least.

[-SWS]

http://www.cpapauction.com/auction-list ... to-sv.html

[Snoredog]

http://www.cpapauction.com/auction-list ... to-sv.html

Now that I look at her Encore Report again and compare it to the lab titration, she actually is doing better on the Aflex than what
she did in the lab on Bilevel. The presence of Centrals and Mixed along with no clear pressure finding on the lab results suggest
Auto SV, but her AHI on Encore is NOT that bad in fact it is pretty good with all things considered.

I mean let's assume the AFlex is really dumb here (and it is), lets also assume there are Centrals and Mixed Apnea showing up while she sleeps using the Aflex machine just as was seen during the PSG study and on that lab report.

We know that the Remstar Aflex cannot differentiate those central events from obstructive and therefore IS going to score any centrals and/or mixed apnea seen as obstructive and will be included on that report as obstructive.

When you consider those residual apnea seen on her report resulting in a low AHI=2 or less, she actually does better on the Aflex than what they found in the lab. That AHI on the Encore report is going to include any obstructive or central events seen. While she might gain some comfort from another machine it obviously won't improve her treatment result.

[dsm]

I'd be very surprised if a Bipap SV didn't make a substantial improvement to your therapy. Looking at the numbers of standard & mixed centrals shown I also can't help wondering why your doctor is so confident you are doing ok when you know you aren't. He clearly doesn't use this equipment & is commenting based purely on inexperience & theory. Also, the desats shown are also enough to ring alarm bells.

If you don't buy that SV I will - they won't be making that quality of machine for much longer (very expensive to build) but IMHO a regular dream machine - the best therapy device I have ever come across. I'd be depressed if mine broke so a spare is an interesting reality. Other machines can hold the fort against OSA & SA but the Bipap SV goes on the offensive and for me has been a great restorative device.

Re the Quattro Mask - I switched to one some months back - another very good move. I have also grown a beard and like Arizona-Willie the mask works great for me. My SV can and will adjust pressure up to 18+ CMs and I am never really aware it has done so & there are rarely any leaks shown for those peaking moments. Prior to owning the SV I would have bet that that type of pressure increase would 1) cause arousals & 2) cause leaks but in months of use none of those situations are consistently demonstrable. I sleep long & well.

DSM

PS IMHO, SV = Supreme Ventilation (or Superior Value))

PPS - just tested its price (the one SWS linked to in cpap auction). My guess is the reserve will be just over $2000. Its there for the taking.

[-SWS]

Bev, I addressed my above message to Snoredog because I specifically wanted to coax out and hear his line of thinking. I'll quote Snoredog below, but the line of inquiry, thoughts, and answers are primarily for you. And I'm always most interested in hearing the opinions of all posters who have been kind enough to offer their thoughts and knowledge in this thread---as I am sure you are!

When you consider those residual apnea seen on her report resulting in a low AHI=2 or less, she actually does better on the Aflex than what they found in the lab. That AHI on the Encore report is going to include any obstructive or central events seen. While she might gain some comfort from another machine it obviously won't improve her treatment result.

Well, I believe this is essentially the crux of what Bev's sleep doctor is also saying: the data looks pretty good, and therefore so are treatment results.

Reading between the lines, over the months, I think Bev has been repeatedly saying that she still doesn't sleep and feel rested despite those results. Well, that assessment is undoubtedly true from a subjective perspective. That realization essentially yields two broad options: 1) keep treatment as-is and live with the symptoms, or 2) employ treatment trial-and-error, hoping to gain improved results.

Bear in mind that aerophagia, cortical arousals, slight periodic breathing can collectively cause extreme biologic discomfort while yielding good treatment numbers in Encore Pro. On that basis I think I would still lean toward trying that ASV, since it offers conventional BiLevel with or without BiFlex as a treatment fallback. You know the old saying that has been kind to so many SDB patients on the message boards:
"If something doesn't work well, then try something else." Try something else within medical reason, of course.


Other opinions for Bev please... Any and all!

[Snoredog]

I'll raise my min by .5 and turn off the Aflex to see if that helps. Or maybe I should do one at a time for a week, so that I can see which is helping.

For sure the pain doesn't help me sleep, but the pain medication makes me stop breathing way more, so I don't take it. I don't want to get addicted to it anyway.

If I were to get a Respironics BiPap, would I have the same problem with the algorithm ignoring the first apnea? I want one that at least tries to get all of them.

Thanks, for all your help.

there is really nothing wrong with your report or settings, I wouldn't change a thing.

That machine rounds up, doesn't report .5 cm events so any events seen at 13.5 will only show up under next higher pressure or 14 cm.

Go for the lowest AHI and consider those residual events seen on your Encore report as possibly being central as seen during your lab titration. If that is the case, they won't respond to the increased pressure anyway.