Newbie Needs Help

Hi All, I'm new to CPAP and need some friendly help and advice. I'm male, 57, about 25 pounds overweight and snore like H---. My wife has been complaining about my snoring for years and I never did anything about it. My kids laugh at me because they say they can hear my snoring from their bedrooms down the hall. About a year ago I decided to see a sleep doctor. He had me do a home study. I wore some contraption for a night and then saw him for the results. Turns out I have moderate to severe obstructive sleep apnea. No surprise there. He wanted me to get a titration study done in the hospital but when I found out that it would be over $2K out of pocket I decided to wait until the latter part of 2013 to have it done if I met my insurance deductible. Well of course I never came close to meeting the deductible so no sleep study. Next came the Affordable Care Act. My family insurance cost went from $13K/yr to $21K/yr with an even higher deductible so unless g-d forbid we have a family tragedy the sleep study would still be out of pocket and out of the question. I recently saw my primary care doctor for my yearly physical and low and behold I also am pre-diabetic and my blood pressure is on the high side (although not high enough to medicate, but getting close). So I decided I have to do something about the apnea because as I understand it apnea can be a significant contributing factor to my weight, blood sugar level and blood pressure.

I read a lot on this board and other places and decided purchase a ResMed S9 AutoSet and ResMed AirFit P10 and self-titrate and treat the apnea myself. Sounds no different than what Kaiser patients have to do anyways. And since I'm a reasonably intelligent person I thought how hard can it be. Right?

So I've been self-titrating with the pressure set to the factory default 4-20 for a week now. I have no trouble sleeping with the ResMed P10 pillows. My compliance has been excellent and leak rates appear to be relatively minimal. I always am greeted by the yellow smily face in the morning. But my AHI has generally been hovering around 11 with both obstructive and central apneas each hovering about 5. Representative screen shots are below. My 95% pressure has been hovering around 11-16 so last night I set the low and high pressure to 10 & 17 with the ramp set to 5 minutes at a starting pressure of 8. I also have EPR set to 2.

Have I set the S9 pressure range correctly?
Am I experiencing too many central apneas?
Why is my AHI so high at this point?
How long does it generally take to get my AHI below 5?
How do I get my AHI below 5?
What am I doing wrong?

Any thoughtful help, comments or guidance would be much appreciated.

I'm not good at helping people titrate themselves, but others with that knowledge will come along to help. $2K, IMHO, is way too much to pay for a titration study... my split study (diagnostic and titration combined) here at Mayo Clinic Rochester was $750. That's what was on my bill, and my insurance paid most of that.

Welcome to the Forum; there are many wonderful and knowledgeable people here to help you so come back often with your questions and describe your problems we will help you.

I live in the NY Metro area and everything is more expensive here, especially health care.

Welcome to the forum.
Let's see if we can prevent the Obstructive Apneas better and hope that those centrals are more related to arousal centrals than anything else.
The minimum pressure is too low. It can't get to where it needs to be in a timely manner to prevent the airway collapse that gets the OA flag.
Looks like the median is running around 10 ish.
Can you try minimum of 8 and let's see what happens with the OAs ad cross our fingers we don't see a truck load of centrals?

The centrals don't appear to be related to higher pressures as they are happening at the lower pressures more than at the higher pressures. So I don't know what to say about the centrals at the moment.
It's possible that they are post arousal Sleep/wake/junk.
All I know to do right now would be try to fix what we can with pressure and cross our fingers that the increase in pressure doesn't increase the centrals. If it does....we cross that bridge if we come to it.

Hi Pugsy. I've read a lot of your posts. You clearly are very knowledgable and I appreciate your input greatly.

My minimum pressure was set to 10 last night and max to 17. If I set it to 8 wouldn't it then take more time to react to airway collapses?

BigSnore wrote:Hi Pugsy. I've read a lot of your posts. You clearly are very knowledgable and I appreciate your input greatly.

very perceptive of you identifying pugsy as one of the best people on the forum.

TY

I did not see last night's report above...I missed it. That was the last report wasn't it? I was just looking at the minimum pressure stat and it's hard to read the numbers and since you were using the ramp it still showed the min of 4 starting point for the ramp.

For subsequent reports can you make the graphs and numbers larger and omit the graphs below the leak graph...all we need right now in addition to the AHI and stats on the left are the graphs on the righ...events, flow rate, pressure and leak.
Maybe flow limitation graph if it is very active.

What position do you sleep in? Any one particular position or all over the place.

Last night things looked really good until what appears to be around 2 AM. Makes me wonder what changed to need more pressure.
The usual culprits for pressure needs changing are supine sleep and/or REM stage sleep. What we might be seeing here is REM stage sleep since REM normally increases in duration and frequency during those wee hours of the morning when your report look uglier.
Could be a combination of supine and REM.

I need to mull this over a bit after you tell me how you slept last night and your sleeping position.

I was originally thinking 10 cm minimum but scaled it back to8 cm to be more conservative in case we were looking at centrals related to pressure.

How was your sleep from that 2 AM period? Sleep soundly or did you have some little awakenings for some unknown reason in those wee hours of the morning?

Yes, the last report was last night.

Sorry for the illegibility. I'll make the adjustments to the text in future graphs. I guess that's a setting in Sleepyhead?

I typically sleep most of the night on my sides, but sometimes am on my back. When I am on my back my wife says it wakes her up because she hears the air from the S9 coming out of my mouth and it disturbs her sleep. She gives me a nice push and I go back on my side.

Last night I was stirring about 3am. I think I was a bit restless from about 2-3 but don't know for sure. The leak graph and respiration rate was spiking during that period also. I have to become more aware of things like that as I typically don't remember much in the morning relating to my prior nights sleep unless got out of bed to go to the bathroom.

Is there any way to identify When I am in REM from the info recorded by the S9?

I'll scale the low pressure back to 8 tonight, but when the min was set to 4 in prior nights the AHI wasn't much different from when it was set to 10 last night.

No need to do 8 cm minimum....leave it at 10 cm and let's see what happens over 2 or 3 nights.

No way to identify REM with any certainty from any data we can get from the machine with any certainty. We need EEG brain waves for sleep stages. Some people think they can make an educated guess based on tidal volume but we have no way to know for sure.
Best we can do is make an educated guess based on what the normal sleep cycles are when we sleep semi normally.
Besides...it is what it is...be it supine sleeping or REM or both. We deal with it.
see this link and scroll down on the right side for hypnogram showing normal sleep cycles
http://en.wikipedia.org/wiki/Sleep
I happen to have REM worse OSA myself. When I was using APAP machine I would see pressures twice what I needed when I wasn't in REM sleep.

Ok, I'll keep the pressures at 10 & 17 for the next 3 nights and post new graphs on Sunday. Thanks!

If things get horrible worse....please post back sooner than Sunday....or send me a private message.
Tell your wife to let you know if you end up on your back...try to find out approx what time if at all possible.

OK

As you requested, below are the graphs from the last 3 nights. I made the type larger so hopefully they are more legible but when I look at my post it still looks small. I have tried so many different ways to post my graphs and for the life of me just I can't figure out why I can't make them better looking in my post.

My AHI was much better and centrals lower.

For some reason last night only half the night was recorded. I don't know why.

The past 3 nights I think I slept on my side all night, and when I was waking in the early morning I turned the S9 off so it did not capture when I was stirring during my last hour or so in bed because I was in a semi conscious state half awake.

your numbers look better each day... How do you feel? Are you feeling like you slept?