CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

[blizzardboy]

And electrolytes! Don't forget the -HCO3.

Thanks Muffy. Will add them to my list. Much appreciated.

[blizzardboy]

I am having my bloods taken. T4, T3, etc are usually not measured if TSH is in normal range but my GP has requested them anyway. She wants me to stay on fluoxetine for now as she thinks this would be best for my autonomic system in spite of potentially aggravating PLMs. I left the GP feeling a bit annoyed due to a couple of her comments. E.g. That I over analyse everything; Use the sleep machine if it makes you feel better but stop if it doesn't; maybe my brain is in an anxious state when I sleep hence reducing my sleep quality; that my sleep may be different than usual because my brain is different than usual. My GP said that her training was completed before sleep apnoea was even heard of. When I mentioned the possibility of silent reflux, she told me to take proton pump inhibitors to see if that improved my sleep as this is what the treatment would be if i was diagnosed with having it, that way I would save time and money.

I left feeling just a bit more confused as to whether or not I really do have SDB that requires medical treatment or not. I think it is all confounded by the fact that I first presented to this GP with anxiety and depression (which is now well treated) so now all my problems somehow branch out of my anxiety rather than being more fundamental in origin. I did comment to the GP that if I hadn't "over-analysed" my first SDB diagnosis I would now be receiving treatment for OSA only.

Before I went to see the GP I contacted a large sleep centre (where sleep research is also performed) to discuss my SDB situation. I think I would benefit from being in a multidisciplinary sleep centre such as this, rather than seeing a stand-alone sleep doctor who I can only see every 6 months or so as he is so heavily booked out. My GP agreed to a referral so I am off for an appointment next week. Be interesting to see what comes of it all.

My GP wants me to discuss PFT, GERD, etc tests with the new sleep doctor.

[dsm]

BB

Pls lemme know what your current settings are and also how the muscle reactions are going - worse or better ?

Thinking of you & your challenges

Cheers

DSM

(Once lived in Woodville Park - long time ago - also was visiting my daughter in Mt Barker last year )

[blizzardboy]

Pls lemme know what your current settings are and also how the muscle reactions are going - worse or better ?
(Once lived in Woodville Park - long time ago - also was visiting my daughter in Mt Barker last year )

Hi DSM, Thanks for your note. Mt Barker is a nice place, really taken off over the past few years.

My current settings are EEP=9.6 PS=3->8. Last night's data: http://users.adam.com.au/sixsome/ASV/0510/050210/

Cheers,

[dsm]

Pls lemme know what your current settings are and also how the muscle reactions are going - worse or better ?
(Once lived in Woodville Park - long time ago - also was visiting my daughter in Mt Barker last year )

Hi DSM, Thanks for your note. Mt Barker is a nice place, really taken off over the past few years.

My current settings are EEP=9.6 PS=3->8. Last night's data: http://users.adam.com.au/sixsome/ASV/0510/050210/

Cheers,

BB

That actually looks better than other data I've seen ! - how about muscle reactions ?

The pressure peaks from SV support seem to be noticeably reduced ! - that seems a good trend. If you wanted to do any further cautious testing, try a night with PS=3.2 then 3.4 & see how that trends. Harmless adjustments but it will be interesting to see if HI comes down a little.

RR is still a little unusual but no really worrying peaks or troughs.

Cheers

DSM

[fiberfan]

I left feeling just a bit more confused as to whether or not I really do have SDB that requires medical treatment or not.

After reading this I searched the thread for something you wrote on Saturday.

I was feeling quite energetic today - definitely no hint of sleepiness. I managed to fly kites with the kids, play wrestles with the kids, play on the trampoline for a long while with the kids and have some joking and laughing with the kids - and then vacuumed the house. One of them commented that I was the most fun ever.

Just thought it might help to be reminded that something has changed for the better. Isn't your current SDB treatment the most likely reasons for the change?

[blizzardboy]

I left feeling just a bit more confused as to whether or not I really do have SDB that requires medical treatment or not.

After reading this I searched the thread for something you wrote on Saturday.

I was feeling quite energetic today - definitely no hint of sleepiness. I managed to fly kites with the kids, play wrestles with the kids, play on the trampoline for a long while with the kids and have some joking and laughing with the kids - and then vacuumed the house. One of them commented that I was the most fun ever.

Just thought it might help to be reminded that something has changed for the better. Isn't your current SDB treatment the most likely reasons for the change?

Hi fiberfan, Yes, good point - thank you for the encouragement. I suppose that the ignorance of my GP about SDB should be kept in perspective - just somewhat discouraging straight up. Let's hope I can get some useful face-to-face dialogue with the people of the sleep centre. Tenacity is the key, right?

[Muffy]

Did you get a response for

Somewhere along the line I would be looking for:

• Explain the discrepancy between the ETCO2 on PSG, which says pCO2 is in the low 30s in NREM, and the lab -HCO3, which implies that the pCO2 is 50.

Muffy

[blizzardboy]

Did you get a response for

Somewhere along the line I would be looking for:

• Explain the discrepancy between the ETCO2 on PSG, which says pCO2 is in the low 30s in NREM, and the lab -HCO3, which implies that the pCO2 is 50.

Muffy

Hi Muffy, No, he was starting to wrap things up and we ended up talking on other lines. I think I lost focus in talking about CO2 after he played down the reliability of nasal EtCO2 measurements. I will raise this issue at the sleep centre when I visit next Wed morn (mine not thine).

[blizzardboy]

That actually looks better than other data I've seen ! - how about muscle reactions ?

The pressure peaks from SV support seem to be noticeably reduced ! - that seems a good trend. If you wanted to do any further cautious testing, try a night with PS=3.2 then 3.4 & see how that trends. Harmless adjustments but it will be interesting to see if HI comes down a little.

RR is still a little unusual but no really worrying peaks or troughs.

Hi DSM, I didn't notice PLMs when I woke around 0400 on 050210.

I have become focussed on my irregular breathing, looking for stabilisation as an indicator of improvement. Interesting that you comment on SV support reduction as "a good trend." Is this because this an indication that my respiratory effort is increasing or my OSA is better managed?

Tonight I am going to sleep in the recliner using my new, you-beaut EEP=9.6 & PS=3->8 settings to see how stable my breathing looks then.

[echo]

Hm, I understand your frustration with the GP. I tend to over analyze everything too. If I hadn't done that I would never have been diagnosed with OSA and put on hypothyroid meds, so DO NOT DOUBT YOURSELF.

Listen to your body, listen to yourself, and do not get discouraged because your GP is overwhelmed with your info. I understand that trait, you want to get to the bottom of things, doctors are trained to solve isolated problems (in my opinion). You are looking at the greater complexity and interaction of events/problems, you are a trouble shooter at heart, you look in depth. I feel that some doctors are overwhelmed by the approach.

At some point, you might want to step back and take a break. I know how exhausting it is to try to fix all your problems, along with all of life's other demands. On the other hand you feel helpless if you are not investigating, questioning, exploring, brainstorming. But a small break might be a good idea. I think this was discussed a couple of pages back, when your doc told you to step back. I don't mean it in that sense, but just to give yourself a little holiday from all the troubleshooting. Like, one week. Get the bloodwork checked out in the meantime, but give yourself a little rest, so that you can regroup your thoughts and re-evaluate. Go to whatever settings worked best last time (not based on the data, but based on how you felt the next morning), stick to it for a few days. Stop dial-winging for a few days

All the best, may the bloodwork get to the root of the problem (at least your doc is willing to work with on that!) .... throid meds here we come ... oh and remember, what THEY say may be normal ranges may NOT be normal ranges for you. So stay vigilant

[dsm]

That actually looks better than other data I've seen ! - how about muscle reactions ?

The pressure peaks from SV support seem to be noticeably reduced ! - that seems a good trend. If you wanted to do any further cautious testing, try a night with PS=3.2 then 3.4 & see how that trends. Harmless adjustments but it will be interesting to see if HI comes down a little.

RR is still a little unusual but no really worrying peaks or troughs.

Hi DSM, I didn't notice PLMs when I woke around 0400 on 050210.

I have become focussed on my irregular breathing, looking for stabilisation as an indicator of improvement. Interesting that you comment on SV support reduction as "a good trend." Is this because this an indication that my respiratory effort is increasing or my OSA is better managed?

Tonight I am going to sleep in the recliner using my new, you-beaut EEP=9.6 & PS=3->8 settings to see how stable my breathing looks then.

That Pressure support graph is useful in indicating how often the machine needs to boost your volume & the early charts you have show it was doing it an awful lot of the time. That latest chart showed a marked decrease & that trend shows your breathing is more normal - what it could mean of course is that previously with the unusual settings you had (esp EEP=8), that you were experiencing a lot more apneas - both obstructive and possibly central & the machine was having to react a lot more. As I understand it, the Vpap Adapt SV does not distinguish between obstructions & centrals & treats them all as centrals when it comes to keeping to volume targets. So 2 things can trigger excessive PS, one is centrals which for some people, happen when Ipap goes too high in normal respiration (in bilevel mode which is when no SV triggered extra PS is being added) or because EEP is too low & the person is experiencing obstructive hypopneas & also obstructions & the machine tries to restore target volume & usually has to go high and fast to do so - you had lots of high & fast in your early charts. That also leads to other complications & I would not be at all surprised if your cramping etc were related to that.

My guess is that in particular the low EEP=8 was causing a chain reaction of results.

Have a think about that experiment of 3.2 PS then 3.4 PS to see which way your HI score trends.

Cheers

DSM

[Muse-Inc]

BB, might wanna check red blood cell count, RDW, and hemocrit as they are elevated in people fight oxygen deprivation (living at altitude, have apnea events with desaturations). Mine are still at the top of the range and I started CPAP therapy Aug 20, '07...some of us recover more slowly than others

[SleepingUgly]

I left the GP feeling a bit annoyed due to a couple of her comments. E.g. That I over analyse everything; Use the sleep machine if it makes you feel better but stop if it doesn't; maybe my brain is in an anxious state when I sleep hence reducing my sleep quality; that my sleep may be different than usual because my brain is different than usual.

I hate to hear these sorts of comments by doctors. I absolutely cannot stand to hear any variation on "you're overanalyzing", "chill out", etc. (although admittedly no one has ever told me my brain is different than usual... does she have imaging to back up that statement?!). When she offers her psychological explanations and advice, tell her she's practicing outside her area of competence.

My GP said that her training was completed before sleep apnoea was even heard of.

She must be ancient!

When I mentioned the possibility of silent reflux, she told me to take proton pump inhibitors to see if that improved my sleep as this is what the treatment would be if i was diagnosed with having it, that way I would save time and money.

Well, she has a point about that. Otherwise you are talking about having an upper endoscopy, a pH study (e.g., Bravo probe), or possibly an upper GI x-ray.

What makes you think you have reflux?

I left feeling just a bit more confused as to whether or not I really do have SDB that requires medical treatment or not.

Well, I can't speak to that because I don't understand a word you all have been saying about hypoventilation, etc.... BUT the "your brain is different" explanation is not a very compelling alternative one, in my opinion.

I think it is all confounded by the fact that I first presented to this GP with anxiety and depression (which is now well treated) so now all my problems somehow branch out of my anxiety rather than being more fundamental in origin.

You're probably right.

My GP wants me to discuss PFT, GERD, etc tests with the new sleep doctor.

GERD should be discussed with a gastroenterologist. If you discuss it with a sleep doctor, they will tell you that if you have aerophagia, you have reflux, so sleep on a 30 degree wedge and take PPIs. Now sleeping on a wedge is not a bad idea for an apnea patient anyway, and certainly can't hurt you, and there's not a lot of risk associated with taking PPIs. Will you know if the PPIs make you feel better if you have "silent GERD", though? I think it's hard to tell if they help when there are no symptoms (i.e., what would be your dependent/outcome variable?).

[blizzardboy]

My guess is that in particular the low EEP=8 was causing a chain reaction of results.

Have a think about that experiment of 3.2 PS then 3.4 PS to see which way your HI score trends.

I think I am sold on EEP=8 being too low. Interesting to see last night that I had a decent stable patch (2320-0000) while in the recliner: http://users.adam.com.au/sixsome/ASV/0510/050310/ and my AHI=1.2 was good. I will fiddle with PS min to see if there are changes. I think I am also sold on reclining giving me more stable respiration. I feel good today. Plenty productive at work. Now to find a wedge...