Just had my first follow-up, please help

[digitalepiphany]

Well last night didn't go so well. I had tons of leaks again. I do remember waking up about 3 times, every one of which was because my lips were open. I guess I'll have to try taping tonight.
It is interesting that the largest leaks line up with regular apneas, while the clear airways line up with the smaller leaks.

[robysue]

digitalepiphany,

All those green Apneas during the high leak periods are actually "Apneas of unknown type". They are apneas where the FOT algorithm was unable to determine whether they were CAs or OAs. The most likely reason the machine could not classify them was the presence of a large leak (prolong leak over 24 L/min) makes it much harder for the FOT algorithm to work correctly.

[digitalepiphany]

I'm more interested in the clear airways, as that is what I was having some trouble with. Pugsy suggested that the large leaks I was having could be the cause of the CAs. What I meant about finding it interesting that the Apneas lined up with the larger leaks is that the CAs didn't line up with those larger leaks. This could mean that I do have a fair number of CAs on a regular basis.

I went ahead and zoomed into an area that showed a lot of CAs so that I could get a better look at the leak data during that time period. A lot of the CAs are below the 24 L/min threshold. The second pic is of the last half hour of my sleep.

[robysue]

The thing is: Mos of those green "Apneas" may be CAs. Or they may be OAs. Or they could be be a mix of both CAs and OAs. The machine could tell you were not breathing; but it could not determine the patency of your airway.

[Pugsy]

I was hoping that the centrals were awake centrals...with awakenings caused by the leaks or the awakenings (or arousals that you might not remember)
meaning maybe lots of sleep onsets and thus the greater chance to have a sleep onset central.
Since we can't tell sleep stage with these machines we have to try to eliminate whatever we see that needs fixing and hope that sleep itself gets fixed in the process.
If the obstructive apneas are causing arousals or awakenings (which is common) then preventing them might also prevent any potential arousal or post arousal central. Since excessive leaks will allow obstructives...we want to fix the leaks first.

I am now wondering if you are going to be like johnthomasmacdonald....have really good nights on occasion to be followed by horrible nights and we don't know why. Bad nights out numbering the good nights... I do know that we took leaks out of the equation though when working with him.

That's about all know to do...fix what is obvious first..and it has to stay fixed so that we can then evaluate trends or patterns.
I bet you slept horribly last night...are we seeing poor sleep with lots of awake stuff being flagged by mistake or are we seeing poor sleep from lots of centrals that are sleep onset or just plain CompSA centrals?

Normally people with CompSA don't ever have a good night like your night before last.

And the obvious first thing to fix.....leaks. They don't have to be perfect but they do have to be better controlled than last night.
If nothing else they are big enough and frequent enough to simply keep your body in and out of sleep stage 1 and sleep onset.

[digitalepiphany]

The last screen shot I posted shows CAs occurring about every minute, with leaks below the 24 L/min threshold. Any idea what that could indicate, other than it actually detecting CAs every minute?

[Pugsy]

Any idea what that could indicate, other than it actually detecting CAs every minute?

Awake/semi awake breathing irregularities being flagged by mistake. Not exactly false positives because I think the machine is likely recording those accurately...I don't doubt the Central flag...I am doubting whether you were asleep or not...or at least in deep sleep.
It's a limitation to the machine...it doesn't know if you are awake or not...it just calls them like it sees them and it's up to us to figure out how important they are. If they are awake/semi awake events getting flagged..they aren't important.
If you were indeed asleep...then they are important.

[digitalepiphany]

I checked all the areas where there weren't huge leaks, and they looked pretty much like that one. And, they were spread throughout the night.
I guess I'll just see how taping works out tonight.

[Pugsy]

I checked all the areas where there weren't huge leaks, and they looked pretty much like that one. And, they were spread throughout the night.
I guess I'll just see how taping works out tonight.

Yeah, I know...I looked at those also...
I am trying (crossing my fingers) to find a way so you don't have to go to ASV machine. Not that it's bad deal itself but if you have trouble keeping mouth closed now..just wait the the ASV shoots off a canon burst of pressure to jump start your breathing.

If you told me that "I slept great last night...lights out and didn't wake up till I got up" and the leak line was acceptable...we would be having a different discussion. I would be telling you to beat feet towards whatever you have to do to get ASV machine.

I know you are tired of me harping on leaks...but the fact is even if they aren't huge they can significantly mess with sleep quality...cause a lot of arousals and fragmented sleep. Fragmented sleep can give us ugly reports because a lot of awake/semi awake stuff gets flagged by mistake.
Is that what is going on with you? I honestly don't know but since it can...I like to try to fix the easier stuff first. It's not like we can do much else anyway.

You are with the VA???? You might want to schedule a follow up appointment as it likely will be in the future as they never do much very quickly...and if we get lucky and get things sorted out then you can cancel it..if we don't get lucky...keep the appointment.

Oh...you don't take any sort of pain medication do you? Sorry, also have to ask..recreational drug use? You don't have to answer publicly but just be aware that either could suppress respiration (if that is what we are seeing here which I doubt).

Oh...when you came home from the office party the other night...did you have much alcohol in your system? Alcohol tends to prevent some of the deeper stages of sleep where apnea events often are worse.

[digitalepiphany]

I checked all the areas where there weren't huge leaks, and they looked pretty much like that one. And, they were spread throughout the night.
I guess I'll just see how taping works out tonight.

Yeah, I know...I looked at those also...
I am trying (crossing my fingers) to find a way so you don't have to go to ASV machine. Not that it's bad deal itself but if you have trouble keeping mouth closed now..just wait the the ASV shoots off a canon burst of pressure to jump start your breathing. That won't be any fun. I know the other option is a FFM, but I can't sleep on my back. I can get to sleep on my back (sometimes), but I never stay that way. I always wind up on my stomach with the side of my face buried in the pillow. If I have to go FFM, the only way I can think to do that would be to sleep on a recliner (and shave). Not sure how comfortable that would be long term, nor do I currently own one. Or have room for one, for that matter.

If you told me that "I slept great last night...lights out and didn't wake up till I got up" and the leak line was acceptable...we would be having a different discussion. I would be telling you to beat feet towards whatever you have to do to get ASV machine.

I know you are tired of me harping on leaks...but the fact is even if they aren't huge they can significantly mess with sleep quality...cause a lot of arousals and fragmented sleep. Fragmented sleep can give us ugly reports because a lot of awake/semi awake stuff gets flagged by mistake.
Is that what is going on with you? I honestly don't know but since it can...I like to try to fix the easier stuff first. It's not like we can do much else anyway.

You are with the VA???? You might want to schedule a follow up appointment as it likely will be in the future as they never do much very quickly...and if we get lucky and get things sorted out then you can cancel it..if we don't get lucky...keep the appointment. He said that he was going to set up an appointment to get the ASV. I know he mentioned doing a split study to see what's going on, but I'm not sure if he's going to do that in addition to the ASV, or if it was just an alternate suggestion. I guess I should call him to find out. Like I said before, my original study was take-home, so he was thinking about the split study. His major worry is that I'd go in for the study and not have any CAs that night.

Oh...you don't take any sort of pain medication do you? Sorry, also have to ask..recreational drug use? You don't have to answer publicly but just be aware that either could suppress respiration (if that is what we are seeing here which I doubt). I take no medication of any kind. Not even supplements.

Oh...when you came home from the office party the other night...did you have much alcohol in your system? Alcohol tends to prevent some of the deeper stages of sleep where apnea events often are worse. I had 6 beers over the course of 5 hours.

Would taping still work with the ASV, or would that random cannon burst of air be strong enough to dislodge it?

[Pugsy]

I know he mentioned doing a split study to see what's going on, but I'm not sure if he's going to do that in addition to the ASV,

I would hope a split study with cpap first so they could see the development of centrals with certainty...then with ASV to titrate but ASV titration might take too long so I don't know if there would be enough time in one night.
Ideally to get the best picture...split night with first half without cpap to see if you had centrals pre cpap..then second half with cpap (assuming no centrals pre cpap) and followed up by full night with ASV to play with.

Would taping still work with the ASV, or would that random cannon burst of air be strong enough to dislodge it?

Unknown at this point because we don't know how big of a burst you would need. The tape isn't cemented and we don't want it to be.
It's would depend on the size of the burst. Some people only need a little burst but some people need big blasts. We have no way to know what you might need at this point. So my thoughts for those questions..cross that bridge if and/or when we come to it.

[digitalepiphany]

I was just looking into FFMs and came across the Oracle 452. I'm thinking that that would work for me if it also had nasal pillows. Do you know if there's a mask like that?

[robysue]

Their oral interfaces are not like the Oracle 452, but have you given any consideration to the hybrid masks:

Hybrid Full Face CPAP Mask with Nasal Pillows and Headgear by InnoMed
Mirage Liberty™ Full Face CPAP Mask with Nasal Pillows including Headgear by Resmed

[Pugsy]

There isn't a mouth piece (like the Oracle) full face mask with nasal pillows.
There are the Hybrids with nasal pillows (ResMed's version is the Liberty) but they would be a bit more problematic with the beard.
https://www.cpap.com/productpage/RespCa ... -Mask.html
I think I might have one that has been gently used...do you want it? Don't know the history on it as it was donated to go to the box of stuff that I accumulate from people who don't want the stuff.
It appears to be complete and not horribly used and would at least give you an idea if it might work. It is the Hybrid and not the Liberty..so has the 3 sizes of cushions. Send me a Private message if you want it and include mailing address.

People with beards do use full face masks but it takes some additional work to get and maintain a good seal. So not impossible to do...but does require more effort.

[digitalepiphany]

My issue isn't really the beard. I'd like to keep it, but I don't mind losing it if it means a good night's sleep.

My main issue is my side sleeping. I had too many problems with the nose mask getting moved to one side of my face or the other due to rolling over on my side. Of course, this caused a bunch of leaks that actually woke me up, which resulted in still crappy sleep.

Do you think I'd have the same problem with the hybrid? The guy at the VA actually showed me a picture of one as one of the possible solutions to what's going on, but all he did was have a good laugh at how funny it looked, then moved on to other issues. He's a nice enough guy, just not very good at sticking to one issue through resolution.