LINK to Sandman Auto HC Screenshots, Reports and Manual

[DreamDiver]

SAG would have to confirm it, but it looks like from your waveform report graph you may have those post-arousal centrals.
do you have a PDF writer printer driver installed where you could print that report to PDF?

The reports can be exported as pdf format straight from the software without additional software. In fact, I received screenshots of the pdf from Anne.

Anne, I can sanitize personal data from a pdf using Illustrator so that all vector (line) data remains intact. Feel free to send me the pdf, and I'll post it with the other data.

[echo]

I am no expert by any means, but I think snoredog has a point - there are many CAs and they only come into play when there are a run of obstructive events and the pressure is too high for a prolonged amount of time.

Also strange that there are no Snores, only Runs or Hypopnea's and Apnea's. Could that mean the Runs are just an artifact and nothing to worry about for the time being?

What was your titrated pressure, Anne? What did they say about the CAs during your PSG and/or titration?

[One Tired Puppy]

I am no expert by any means, but I think snoredog has a point - there are many CAs and they only come into play when there are a run of obstructive events and the pressure is too high for a prolonged amount of time.

Also strange that there are no Snores, only Runs or Hypopnea's and Apnea's. Could that mean the Runs are just an artifact and nothing to worry about for the time being?

What was your titrated pressure, Anne? What did they say about the CAs during your PSG and/or titration?

Echo,

I only had 8 apneas and several hypopneas on my initial sleep study and the titration study gave me a lot more hypopneas. I no longer have my sleep study reports as I just left everything at the sleep doctors office and walked out. I had brought my sleep study reports to show him how cpap has worsened the apneas and hypopneas from day one. I never self titrated until after 3 months of doctor's titrated pressure, which started at 7cm then was raised to 8-9cm because I was having problems breathing.

The doctor saw all the daily readouts from day one to my visit which was in July. I had just started the Sandman therapy software and noticed the cardiac oscillations and was concerned. My family doctor set up the appt with the sleep doctor so I could discuss my concerns about the central aspect and the up and down nature of my readings. The doctor didn't seem concerned about my concerns and didn't even want to look at the sleep lab reports and compare them to my readings to see how cpap made things worse. I had a bad headache and just got up and told him I was finished and walked out. I never walked out on anyone in my life, but I felt he didn't really care.

I will go to a different sleep lab next time and I will be more informed this time.

I do have an occasional snore or two sometimes even three or four, but no more. I am a very shallow breather. In fact, yesterday while I was having a spirometry test I was having trouble expiring enough to please the tech. She was telling me to blow more air out even when I was empty. Then as she was monitoring my breathing on a monitor she told me to breathe normal and I was. She kept telling me to breath normal so I had to really focus on breathing and taking deeper breaths so she would quit saying that. I am not usually aware of my breathing. I only know that I've always found it more difficult to breathe while lying down...at least for years.

My doctor found a heart murmer at my physical. I know those can be innocent so I'm not worried about that. He had an ehocardiogram done and an ekg. The cardiologist told me to breath out, too. I asked him if I could take another breath first. He said just to exhale without taking another breath. I could not exhale hardly much. I don't know if that means anything or not. For me, I think it's just normal.

No CA's were mentioned from my sleep studies but I did have a fast heartbeat show up on a graph. I showed my family doctor and he said he didn't get this same report about the heart rythmn. He ordered the sleep study so he should have gotten this information, but didn't. Maybe this happens to everyone, I don't know.

I have no idea what the runs are or what they mean I just know some days they are low and other days over 200, sometimes 250 or 288 and I think I have had higher. Last night the runs were 251 with flow limitation disabled. A-13 H-6 CA-5 cnt Hypopnea 29

Current pressure is min 7 max 14 command on apnea 10 comfort 8 avg pressure is 7.6

I just want to be normal and be able to get my AHI down low consistently. I don't understand why I can't seem to do it.

That's why I appreciate all the help I can get. I have just never been good at asking and the doctor made me feel like I am concerned about nothing. He showed me a paper that said 100% oxygen yet my sleep report said I dropped to 86% but at other times it was above 90 and I think the highest did go to 98. I don't know where he got the 100% from. How can it be different than sleep report?

Sorry, didn't mean to write a book.

Anne

[One Tired Puppy]

SAG would have to confirm it, but it looks like from your waveform report graph you may have those post-arousal centrals.

This is where you have a frank obstructive apnea, then the associated arousal from it terminates then it is followed by the post central, from line 2 it appears the CA's follow the obstructive (they show up slightly to the right of the obstructive in the tic in line2 below). Where the tics seen on line1 and
line2 line up vertically, those could be mixed apnea.
SnoreDog, I don't get startled awake. I am a light sleeper but I think I have only experienced a startle once in a blue moon. I am a very shallow breather and have always (at least for years) found it more difficult to breathe lying down.
While there is no better machine for identifying CA's it may not be the best for you therapy wise. You have too many CA's for that machine. The S/T machine might be the better solution. I already mentioned to the sleep doctor about the possibility of needing a different type of machine because cpap has made me worse since day one. He didn't want to compare the sleep studies reports with my therapy reports. He just said that machine costs over 6000.00. I didn't ask him to put me on it, I just suggested I might possibly need it.
Your Sandman reports are screen snaps, do you have a PDF writer printer driver installed where you could print that report to PDF? You can get CutePDF writer (it installs just like a printer and gives you another printer that shows up in your print selection, then when you print to it it asks for a filename.pdf, when you give it, instead of printer to a physical printer it prints your report to the PDF file, you can print one page or multiple. I do have Adobe 8 and pdf writer. The software also writes to pdf.I would like to see a bigger version of your report including what the parameters you are using and what your flow limitation runs are doing. Your CA's show up even at low pressure of 7 cm. Do you consider yourself a shallow breather? Yes. Do you find it difficult to take a nap from constantly being startled back awake? I rarely get startled awake.You may have CSDB but you may do better at a single pressure with current machine. I would start at 7 cm, set Initial and Max at the same pressure in Auto mode so it continues to record event details, I would bump it up every few days and compare to prior AHI and CA avg.

When I was using straight cpap I was on straight 7cm for first month and then 8cm then 9 but my readings were still up and down and all over the place. I could not get them consistently down. I can try it on the sandman just to see if it shows the same or more central or less this way. I haven't tried the sandman on straight cpap yet. I'll try that tonight. I don't want to go to one straight high cpap pressure because of the GERD problem. Right now it isn't bothering me but I had several very bad nights of having to sit upright in bed to get any sleep as the chest and back pain wouldn't subside any other way. I will try it at 7 min 7 max and 7 on command tonight to see what happens on the software. I will give it a try.

Thanks, SnoreDog

[One Tired Puppy]

Looks like the person who programmed the export doesn't know that the I in "AHI" stands for Index.... You "AHI obt." is not 30, that is you AH Total (24+6). Same for the central apneas and hypopneas. Your total for all events (still dealin with the first line only) is 30+37=67. You slept for about 8.75 hours, so your real AHI (index of event per hour) would be would be 67/8.75 = 7.65. On the night in which you commented you slept much better, you had an AHI (once again, total events divided by total time) of 42/8.5 = 4.9 Ozij, thanks for letting me know how to do this calculation. I was just copying the software results. I do have the indexes but haven't gotten around to entering them yet. I should do that.

That't not good, but it's very far from being horrid - which is what an AHI if 67 would have been. If you look at the oct. 11 screenshot, is seem like that one night was inconceivably bad - but if you look at the 11 day hour/index at the right side, its not that bad at all - an AHI of 6. Not saying its good enough, but far from terrifying.

I think that graph is a detailed blow up of what we see in the 11 day report, the green meandering line being your cycle states, the numbers on the side (I would guess) referrring only to the pressure.

The 11 day chart puts the ticks for apneas and hypopneas together - the graph I was wondering lets you see the breakdown. And mixed apneas are no longer recognized - the software reports either obstructives, or centrals.

I would guess that those bunched events - flow limitation, apneas hypopneas and central are all the result of obstructions and arousals. I'm not sure what you mean about arousals. SnoreDog mentioned about being startled awake. Is that what you mean? I have rarely been startled awake but have always been a light sleeper. I mostly sleep on my right side and occasionally on my back because it sometimes makes breathing easier, especially when nose gets stuffy. You rarely have them come along separately. Base on that, if that were my data I would do the following:
Raise the minumum, raise the command for response on apnea, and leave IFL=1 on. I see no reason to turn IFL off, since you only have flow limitations when an obstructive storm is in the making - and the way I read it, it is better to try to eliminate those storms with slightly higher pressure than it is to let them happen. Right now I am concerned about raising the pressure too much as I am just starting to feel better after a bad bout with GERD. I want to be able to get back to sleeping near flat rather than sitting up to sleep because of chest and back pain that only subsides while sitting straight up. I need to put a little more time into healing the GERD before raising pressures beyond 10. If nothing changes by the time the GERD isn't bothering me then I will be willing to try the higher pressures. I just need a little time to try to sleep in a normal position. I don't know about the "fast return" to the minimum.

I will copy your post so I still have the information for later.

I think I will make a folder off line to save all the helpful suggestions from my good friends here. That way I can refer to it when I need to, since my memory doesn't serve me much anymore. Thanks Ozij,

Anne

Echo, on Silverlining, those hypopneas the are not Hypopnea +Fl are probably the equivalent of "Hypopnea Central".

O.

[One Tired Puppy]

SAG would have to confirm it, but it looks like from your waveform report graph you may have those post-arousal centrals.
do you have a PDF writer printer driver installed where you could print that report to PDF?

The reports can be exported as pdf format straight from the software without additional software. In fact, I received screenshots of the pdf from Anne.

Anne, I can sanitize personal data from a pdf using Illustrator so that all vector (line) data remains intact. Feel free to send me the pdf, and I'll post it with the other data.

DreamDiver,

Thanks, I appreciate that. I will try to get to that later today. So you want me to send the whole pdf not screenshots of it, right?

I have an appointment I have to get to so it will be several hours before I get it to you.

Thank you for all your help. I have so much to learn, but I love to learn so that's ok.

Anne

[DreamDiver]

Hi Anne,

I've received the files.
Thanks for sending them.
I'll post them tomorrow, as I'm past my bed time.

Cheers!

[DreamDiver]

Couldn't resist.
Sanitized hi-res pdfs are now available here:
http://www.montfordhouse.com/cpap/Sandman_Auto/

Also notice a new set of non-thumbnailed large jpegs
in original size and quality received, also sanitized.

Password to open pdfs is available on the pdf page.

Thanks again Anne!

[Snoredog]

Maybe -SWS can look at Anne's reports and give us his opinion, too many CA's seen to call that "treatment" in my opinion.

That machine is okay if you only have a few centrals per session like echo's, but the count seen on your report is pretty high. When you figure that most of those CA's seen can result in a wakening. Could explain why you are tired.

The problem as I see it is there is like 50 some SDB events and about 43 centrals and that is on the machine. Now the machine you have can do an excellent job resolving the "obstructive" events but it can only report the CA events. A machine like the SV or other machine designed to treat that central dysregulation can cycle you to a backup mode with fixed settings and resolve the breathing to eliminate those centrals. The machine you have simply cannot do that.

Another concern is those centrals can also be related to severe oxygen desaturations depending on their length. Do you have a pulse oximeter to determine if your oxygen levels are remaining normal? Did your doctor only look at machine cost and not consider that with this machine? If you had a lab titration using this machine and/or pressure range and it confirmed your oxygen levels remained up then that is okay. If not, I would be asking your doctor for a recording pulse oximeter to confirm it.

Based upon what I've seen with your waveform report, your CA is nearly as severe as the obstructive. I've always read when Central Apnea exceeds >11 per hour it is your primary disorder and should not be ignored. Don't meant to frighten you, but if you have questions about your sleep and therapy, that is what I'd be asking questions about.

[DreamDiver]

So this machine is great for detecting centrals, but won't actually correct centrals over 10cm pressure, right? Anne, I'm glad we could get a look at your numbers. As Snoredog and others suggest, this may not be the machine for you. We've served two purposes with the thread - giving you perspective on your therapy and giving the rest of us perspective on a really super cool new machine.

My original idea was to buy this machine. However, now I wonder if I'd be better of renting and buying the software separately. If I don't really have a central problem, this machine will show me. Then I could just buy a cheap tank and be happy. But if I need a really need a machine that corrects centrals, I'd have to stop using this machine and buy a considerably more expensive one, probably again through insurance because at that point my out of pocket would be cheaper. So many pros and cons. Cheaper vs. better software and humidity control. Hmmm...

Any thoughts about Anne's therapy? Renting/owning?
From the movie Galaxy Quest, "Hey, I'm just jazzed to be here!"

[-SWS]

Anne, I see on the spread sheet that you skipped CPAP one night because of problems with GERD.

We have seen some message board posters who presented much higher obstuctive and central apnea indexes when GERD was not properly controlled. My best guess regarding that situation goes something like this: GERD eruption(s) followed by defensive airway closures and even defensive breath holding (at times synchronous, at times asynchronous or "defensively anticipatory"). If that's what's happening, there you have a possible run of defensive obstructive events scored followed by some central events scored as well (both apnea types perhaps complements of GERD's repeated airway stimuli).

That situation is altogether different than a primary case of central sleep apnea (CSA), although it does seem to manifest as if it were a complex SDB pattern.

[echo]

So this machine is great for detecting centrals, but won't actually correct centrals over 10cm pressure, right? Anne, I'm glad we could get a look at your numbers. As Snoredog and others suggest, this may not be the machine for you. We've served two purposes with the thread - giving you perspective on your therapy and giving the rest of us perspective on a really super cool new machine.

DD - 2 clarifications:
1) This machine won't correct any central's - but it will make sure not to deliver pressure above a certain preset pressure if the event is an (obstructive) apnea.
2) As for the 10cm: If you're in APAP mode, you can set the maximum pressure at which it responds to apnea's. Let's say you're running at 7-12 APAP (too wide a range IMO but useful for the example). It could be that at above 10cm of pressure, obstructive apneas turn into central apnea's, so you can set the machine so that above 10cm, it does not respond to apnea's, and will only respond (increase pressure) when it detects hypopneas, snores, and flow limitations. 10cm is the default value for that setting. Alternately, maybe you start getting central's at 9cm -- you can then set the value for limiting responses to apneas to 9cm. Between 7 and 9 cm, it will increase pressure in response to all events. Between 9cm and 12cm it will increase the pressure to only H's, Runs, and Snores. This is called the "command on apnea" setting in the 420E, and I assume also the Sandman Auto.

And thank you for helping out Anne and posting all that info, DD!

Anne -
Snoredog's right about the GERD.... in fact some call it "silent GERD" because it can cause sleep problems without your noticing it, and even if you don't have reflux during the day.
Personal anecdote: My therapy has felt like it wasn't working even though my AHI was acceptable - last 3 nights I've taken an acid reducer for the GERD and 2 of the nights I slept soooooo well and didn't wake up with the bad taste in my mouth in the morning.

Through some mechanism(s) I'm not yet completely sure of (but there are many posts on this topic in the forum), GERD affects OSA and OSA therapy very negatively, and it seems that people using CPAP tend to get (silent) GERD due to the air increased pressure.

So first thing I would do - go talk to your GP, or preferrably a Gastro-Intestinal specialist, about GERD. I would encourage you to also get an endoscopy/gastroscopy to make sure any GERD that you do have is not damaging your esophagus (it can lead to cancer after years of acid exposure).

Second thing to do (after hiring a hitman for your previous doc - ha ha just kidding )... and in addition to what snoredog already suggested about getting a pulse-ox (I would strongly encourage you to get your hands on one)... find another doctor and/or sleep clinic that can help you through this. If you do have complex sleep apnea, then possibly a CPAP or an APAP will not be sufficient for you.

In the meantime, I was thinking maybe you should lower your command on apnea to something like 7 or 8, and disable IFL1 (because you're shallow breathing, and my understanding is that those can also be marked as flow limitation runs, even though they're not). But I wouldn't do this unless you first have some data as to how your AHI responds when you run at 7 or 8cm straight CPAP. Have you tried that yet on the Sandman? It would be very useful to see how your CA's respond to the straight pressure, and to see how many Obstructive Apnea's you still have left at that pressure. I guess it can't be any worse than it is now???

Conventional wisdom (or recent posts??) seems to indicate that CA's produce more O2 desaturation than obstructions, and/or they are longer in duration.

In any case we are just shooting in the dark, IMO. I think you need to find a good doc that can help you with complex SDB.

Also, you still have a legal right to all your files, even from the doc you fired. Depending on how you want to approach it, either call, or write them a signature-certified letter asking for your complete files. Under HIPAA you have a right to request and receive this information, so don't feel bad or scared about asking for it!!

[-SWS]

Here's a message board case of GERD-related increased AHI way back in 2005:
viewtopic.php?t=5551

I'm not sure but I think that may be this message board's first detailed discussion about the GERD/AHI phenomenon.

[mindy]

SWS - thanks so much for that link! It's given me much to think about. Mostly my AHI is fairly low now but every now and then I do seem to get a cluster - more likely when on APAP than straight CPAP. I'll be interested to see what my upcoming Sandman shows. I do have GERD - have had it for a number of years. Interestingly I had noticed recently that I don't need as high a dose anymore; I'm now down to 20 mg per day instead of 40 mg. I had wondered if it might be due to xPAP but have read so much about people finding their GERD worse with xPAP. In that linked thread there was also reference to GERD with both apparent effects. So I will be interested to see if my improvement continues.

Mindy

[Snoredog]

Anne, I see on the spread sheet that you skipped CPAP one night because of problems with GERD.

We have seen some message board posters who presented much higher obstuctive and central apnea indexes when GERD was not properly controlled. My best guess regarding that situation goes something like this: GERD eruption(s) followed by defensive airway closures and even defensive breath holding (at times synchronous, at times asynchronous or "defensively anticipatory"). If that's what's happening, there you have a possible run of defensive obstructive events scored followed by some central events scored as well (both apnea types perhaps complements of GERD's repeated airway stimuli).

That situation is altogether different than a primary case of central sleep apnea (CSA), although it does seem to manifest as if it were a complex SDB pattern.

See my added note above on the Waveform report, I just noticed they combined AI and HI on line(s) 1 and 2 on that report. Hypopnea, Hypopnea+FL is no longer reported separately. This is why the frequency of events seen on these lines are so high.

SO it looks worse on the report than it really is.