Kenny's CPAP Thread

[tattooyu]

Kenny, I went through a period after a month or two on cpap where I just felt like shit. Thought I was going to be in real trouble. But I seem to have come out of it OK. I think even on cpap, with my AHI being about 5, I am still not 'normal' - stopping breathing 3-5 times an hour is still 24-40 times a night. Is that asymptomatic??

I figure it will just take time. Patience is very difficult in this situation because it affects how you feel daily. I agree, stopping breathing 3-5 times an hour can't possibly make someone asymptomatic. I just hope it is better than what you (and me) were experiencing. Just to clarify, an apnea has to be at least 10 seconds for it to record, correct?

I also don't have a clue about the nature of these cpap resistant 'pressurized Apneas'. Is an apnea that resisted 10cM pressure more severe than one that was avoided? Do the resistant ones last longer? I dunno as I don't have a O2 meter. Maybe... once you are getting better sleep, the bad nights are just that much more obvious.

Good question. I don't know the answer to that, but I would guess it's not just a matter of "worse" but that some variable changed, i.e., body position, sleep stage, that allowed the event to occur. For me, the first week was very blissful, so I think my first bad night really was a contrast.

I also don't know about the hypopneas. I think many of mine are 'centrals' - in fact, I can catch myself as I am falling asleep, breathing way too shallow - like I am forgetting to take deep enough breaths. As I have had to become a side sleeper to accommodate the mask I worry about making it worse with my posture sort of folding one arm over my chest and squishing somewhat. So I do sleep with a pillow to keep my chest less compressed.

ME TOO! I totally catch myself breathing shallow sometimes, but it's usually when I'm on my back. As far as I can tell, it is very common to have CHs when first falling asleep, after sighing, and when shifting position.

Some links to other pages regarding Central Hypopneas:
http://www.sleepnet.com/apnea77/messages/225.html
http://www.sleepnet.com/tech7/messages/1303.html
http://ajrccm.atsjournals.org/cgi/conte ... 158/6/1778 (clinical)

The Nuts and Bolts of Scoring Apneas and Hypopneas (2001)

[tattooyu]

I had a thought while reading the thread below. I think my leakage problems started when I switched to APAP, not necessarily when I added the chinstrap. Maybe I should go back to CPAP and see if things straighten out?

Can APAP cause more leakage than CPAP?

viewtopic/p345302/how-long-to-wait-befo ... essure.htm

[DoriC]

"Leaks and snores will more than likely cause a "runaway" (self-feeding problem) if set in APAP mode".

This is a quote from one of Den's(wulfman) many posts on this subject, I just don't know how to copy them here, not computer savvy. He explains it very well as far as having settings to wide open on APAP and usually advises folks with leaking, snoring problems to try a set pressure or at least a very narrow min/max. I'd try to look for his posts on the subject as I'll get in trouble if I go too far with this! Dori

[tattooyu]

Thanks, Dori. I'll do a search in his posts. I'm seriously considering going back to straight CPAP, but I don't want to make too many changes all at once.

[goose]

Search out Den's posts on the subject!! For sure....
I would say that an increase in pressure can cause an increase in leak rate. It will also increase the "expected leak rate" which you can find in the masks documentation.
I was on a set pressure of 10 for nearly a year before I decided to try the APAP mode using a range. The reason was, though the numbers were good (AHI - 2.5) I still felt like crap and I'd decided that chasing the numbers wasn't as important as how I felt. I changed to a range of 11-15 and the numbers stayed the same. What did change is the way I feel!! I feel much better each day, and I let the machine decide what pressure to use......it very rarely gets to 15.....in general my 90% number is a bit less than 13. Each of us is different in the way we adjust and react to our treatment but I doubt if I'll go back to CPAP mode.
Not making a lot of changes at once is an excellent decision. In general I'll only change one thing at a time and unless it's a major error I leave it that way for at least a week and usually a month.
I still have leak frustration with either mask I use (Headrest and Activa). I've been using the headrest for over a year, but I've recently changed to the Activa and really like it a lot!!!!!
Good luck!!
cheers
goose

[tattooyu]

Thanks, Goose. It just seems like when I went from CPAP (11.0 cm) to APAP (12-18) is when all hell broke loose.

In my clinical manual, it shows the leak rate for mask fit but there is no chart showing the leak rates at different pressures.

[goose]

Hey Kenny,
Hmm. 12-18 seems a pretty wide range - at least to me.
One thing that happened to me is when I had the upper number high I started to have centrals, which can happen if the high pressure is too high!! So if your reports are showing NR's, you may want to adjust that higher number a tad lower.
What's your 90% number with the range 12-18?? If your 90% number is like 13 or 14 you might want to lower the high limit to like 15. Also if you spend a majority of your time at 12, drop that to 11 and see what happens there.
When I was in my search I changed from CPAP of 10cm to APAP to 11-15 and left it that way for a couple months and I was feeling really good but noticed that I was at 11 most of the time so I dropped it to 10-15. I then was at 10 a majority of the time, but I started feeling a bit more crappy - like when I was at 10 CPAP. So after a few weeks I went back to 11-15 and have been there for about 5-6 months now....
The nice thing about APAP mode and the software is you can keep an eye on things to know how it's working. But for me, the important parameter is how I feel not the numbers. The numbers only validate how I feel (most of the time ).
So the bottom line is -- "How do you feel???"

take care
cheers
goose

[tattooyu]

Hey Kenny,
Hmm. 12-18 seems a pretty wide range - at least to me.
One thing that happened to me is when I had the upper number high I started to have centrals, which can happen if the high pressure is too high!! So if your reports are showing NR's, you may want to adjust that higher number a tad lower.
What's your 90% number with the range 12-18?? If your 90% number is like 13 or 14 you might want to lower the high limit to like 15. Also if you spend a majority of your time at 12, drop that to 11 and see what happens there.
When I was in my search I changed from CPAP of 10cm to APAP to 11-15 and left it that way for a couple months and I was feeling really good but noticed that I was at 11 most of the time so I dropped it to 10-15. I then was at 10 a majority of the time, but I started feeling a bit more crappy - like when I was at 10 CPAP. So after a few weeks I went back to 11-15 and have been there for about 5-6 months now....
The nice thing about APAP mode and the software is you can keep an eye on things to know how it's working. But for me, the important parameter is how I feel not the numbers. The numbers only validate how I feel (most of the time ).
So the bottom line is -- "How do you feel???"

take care
cheers
goose

Goose,

I was titrated at 16 cm. I'm trying to work my way up to that if it's even necessary to go that high. If I'm feeling good and my numbers are good at, let's say, 13, shouldn't I just leave it there to prevent going too high and possibly causing centrals? I'm sure it differs for everyone, but is there a general pressure above which pressure-induced centrals start to occur? I search the board, but couldn't find a number.

I don't have the software yet; I'm saving up for that. What are NR's, non-respiratory events? On the machine itself (clinical menu), it only reports leakage, usage, AHI, AI and HI, so I don't know if I'm having centrals.

At 12-18, the 95% centile has been 12.2-12.6.

Last nights numbers were pretty bad, but I feel like I slept pretty well. Wife reports more mouth breathing, again starting at around 1-2 am, probably when I hit Stage 3 or REM. She says I do catch myself and then close my mouth.

I am really, really reluctant to tape my mouth closed. My doctor, also apneic, says that is just not a good idea (in his opinion). I'm hoping that Raj's mouth exercises, combined with time and patience will allow me to continue to use my Swift LT mask, which I really like; very comfortable. Other than that, a FF mask is the only other thing I can think of to try.

Results for 3/5/2009 (most of the night):
Leakage: 1.3 L/s
Usage: ~6 hrs
AHI: 16.9 (Adjusted = 9.3)
AI: 1.6
HI: 15.3 (ResMed/2 = 7.7)


P.S. After I woke up early (4 am?) to have a sip of water, I set the machine back to straight CPAP (12.0) and fell asleep much quicker, and I think I slept better at that point. When I check the numbers in the morning, they had actually gone down:

Results for 3/5/2009 (second round):
Leakage: 0.9 L/s
Usage: 8:15 hrs
AHI: 12.3 (Adjusted = 6.7)
AI: 0.9
HI: 11.6 (ResMed/2 = 5.

Leak

Leak is derived by analyzing inspiratory and expiratory airflows (via the flow
sensor located in the device). Theoretically, inspiratory and expiratory volumes
should be equal. A net airflow greater than the expected mask vent flow is equal
to the leak. Generally, a leak rate of more than 0.4 L/s (24 L/min) is associated
with patient discomfort, disturbed sleep, and reduced efficacy of treatment.

Notes:
a. If the leak exceeded 0.4 L/s (24 L/min) for more than 30% of the previous
session, the following message will appear on the LCD: High leak in last
session. (I have not seen this on the LCD at all, so even though
my leak rate is very high, it must be less than 30% of my previous session.)
b. The Leak Alert feature, if enabled, will alert the patient when mask leak
exceeds 0.7 L/s (42 L/min) for more than 20 seconds. When the leak exceeds
this level, the autotitrating algorithm ceases to perform optimally.
The leak reported in the Efficacy Data submenu (see Figure 11, The clinical menu
results series, on page 34) is the 95th centile value for mask-on time for each
session, or the median 95th centile value for a selected time interval (last week,
last month, last 6 months, or last year). Non-usage days are not included in
calculations.

[ozij]

Kenny,
Central apneas are no worse that obstructive apneas - the majority of people don't have them when their pressure is right, and if you ever run into to them when you're at the right - high - pressure - there are ways of dealing with that.

At this point, you should really concentrate on the here and now. And the here and now is huge leaks, and an AHI which is too high - even when you adjust it. Now, I agree with Rested Gal that Resmeds always report relatively more hypopneas than other machines - I've seen it time and again when people report their results, but I think we should be very careful with this "halving" business, since some people do really have more hypopneas the need to be eliminated.

You have to solve the leaks: Stick a CPAP 12 for a few days and see what you can do about those leaks - because on your Resmed, with your Resmed mask, your leak rate should be zero, or a tiny bit above it. You're practically outside the leak rate bounds the machine can handle.

NR's is a term Respironics uses for "non-responsive" apneas. Basically, a series of apneas, on Respironics machines, that continues despite 3 pressure jogs in considered non-responsive and the pressure is taken back down.
Non-responsive apnea are suspected of being central since they do not respond to the rising pressure.

Resmed does not have that. Resmed defends against mistaken pressure jogs by deciding that when the pressure is above 10, the machine will respond to apneas only if there are snores or flow limitations accompanying the apnea.

O.

O.

[tattooyu]

ozij,

I agree. My biggest problem are these huge leaks. When I first started, my leak rates were really good. Of course, I was on CPAP with a pressure of 10.0 at that point. If I can't improve them within a week or two, I will ask my DME rep about getting a replacement mask since this is affecting me getting good therapy. If that's not an option, my wife said she will split the cost of a new mask for me. I guess I could try a Quattro FF mask, since that's what a lot of people on here use and seem to like. It was rated the highest on CPAP.com.

I'm going to stick with CPAP at 12.0 for a week and see how it goes. I really don't think it's my mask that's leaking at all, even when I'm on my side. It has to be the mouth breathing! My wife is right... I just can't shut my mouth.

Strangely enough, I still feel a lot better, but I'm sure I would feel even better without these damn leaks and HIs.

[tattooyu]

I decided to bite the bullet and stop flying blind. I'm getting my ResScan 3.7 and card reader!

[goose]

I decided to bite the bullet and stop flying blind. I'm getting my ResScan 3.7 and card reader!

Great decision!!!!
With your 90% number, 12 is a good place to sit for a while to determine where to go next. Once you get the software and learn to analyze what it's telling you, it'll be much easier to make those choices.
Once the leaks are under control you may find you don't need to change anything!!!!

When I first got diagnosed and knew I'd have a xPAP machine to deal with, I consciously worked on teaching myself to not breathe through my mouth. Every time I caught myself mouth breathing I closed my mouth and forced my nose to do what it was supposed to do by pushing my tongue to the top and working on the muscle control. It seemed to work for me. It was a few months before I got my machine and by that time I was no longer mouth breathing. At one point I was chasing leak rates and tried the Polident strips, which worked ok, but I found I wasn't mouth breathing, so.....having facial hair, I can't really tape. I don't want to trim by pulling it out at the roots.....

Keep at it!!!! Take care
cheers
goose

[tattooyu]

Definitely. I'm sticking with CPAP @ 12.0 for now.

Funny thing is... I nearly always breathe through my nose during the day. It's nearly 100% of the time, unless I'm going for a walk and even then I try to breathe through my nose.

It's done! My software and card reader should be here next week hopefully.

[DoriC]

So glad you're getting the software, give your wife a hug. It will make a world of difference in your therapy, especially for such an analytical guy like you. Then I can ask you questions! It's become part of my daily routine, like brushing my teeth(I do that first!). BTW, I know you may not be ready for a FF mask yet, but if the data proves that you're mouth breathing and can't control leaks, my hubby got used to the FF pretty quickly and he and I were pretty nervous about everything at first. People sleep differently from night to night, sometimes mouth open, sometimes snoring, sometimes stuffy, but the FF allows for all that. You can try the Quattro or the UltraMirage, just make sure the size is correct. You're going to be great. Dori

[tattooyu]

DoriC,

I adapt very quickly when I want something to work as badly as I do my CPAP therapy. I don't think I'll have a problem with the FF mask, if I need one. I'm truly hoping that if I stick with my nose breathing exercises, I can train myself to keep using my Swift LT. Either way, I just want to have effective therapy, you know?

Pretty soon, I'll be able to post pictures of my own graphs!