Started CPAP - now I am more tired...

glyphix, if you are trying to figure out a specific problem then the additional information about oxygen saturation and heart rate may be able to help.

If you are curious about how the body works, once again the additional information about oxygen saturation and heart rate may help you understand.

Air flow data from your CPAP machine gives you one perspective on how things are going. The pulse oximeter adds two additional channels of information.

In the realm of sleep the oximeter doesn't help you overcome sleep disorders. It is important to monitor your CPAP data to make sure you are getting the most from your machine. Once you have things optimized you can take a look at the data from your oximeter to see how things are going with your saturation levels and heart rate.

Thanks much!

Here are some of my readings from last few days (most recent has pulseox).... not sure if anything notible here... though I had this strange drop in ox way early in the night... not even sure if I was asleep yet... not sure if that's legit or a reading error...

As I said last night was an odd night... had a bout of reflux that woke me up for 2+ hours middle of the night. Strangely... I am less tired/fatiqued this morning than previous few days... maybe fatigue will not be ongoing thing....

Anyway - if anything jumps out at anyone from these readings please let me know.

Thanks!

I think your fixed pressure of 7 cm in cpap mode is not quite optimal.

The lack of FL events on your events graph is the result of FL flagging being turned off in cpap mode.
I am betting if you were in apap mode that you would add in considerable FLs along with the snores (which also mean the pressure is sub optimal).
If you were in apap mode I think the machine would probably want to go a little higher (how much higher I don't know).

Now will improving your reports result in feeling better...don't know... but it's worth trying.

Even if I wanted to use fixed pressures instead of auto adjusting pressures I would use apap mode so that I would get the FL flagging turned on.
You can set minimum to equal maximum in apap mode and essentially be using a fixed pressure but you will get the FL flagging turned on. Flow limitations can be important as they are the early warning signs of impending airway collapse.

You probably need a little more pressure.


Den

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Pugsy wrote:I think your fixed pressure of 7 cm in cpap mode is not quite optimal.

The lack of FL events on your events graph is the result of FL flagging being turned off in cpap mode.
I am betting if you were in apap mode that you would add in considerable FLs along with the snores (which also mean the pressure is sub optimal).
If you were in apap mode I think the machine would probably want to go a little higher (how much higher I don't know).

Now will improving your reports result in feeling better...don't know... but it's worth trying.

Even if I wanted to use fixed pressures instead of auto adjusting pressures I would use apap mode so that I would get the FL flagging turned on.
You can set minimum to equal maximum in apap mode and essentially be using a fixed pressure but you will get the FL flagging turned on. Flow limitations can be important as they are the early warning signs of impending airway collapse.

FL flagging is Flow limitation flagging?

So basically you think I might be good to switch my CPAP to APAP mode and perhaps set min max at 5 and 10 or something like that?

Any danger in pressure going too high? I am young and healthy other than a mildly low LVEF (which is probably due to being a couch potato for 15 years... excersising every day for 3 months to see if that gets better)

glyphix wrote:

Pugsy wrote:I think your fixed pressure of 7 cm in cpap mode is not quite optimal.

The lack of FL events on your events graph is the result of FL flagging being turned off in cpap mode.
I am betting if you were in apap mode that you would add in considerable FLs along with the snores (which also mean the pressure is sub optimal).
If you were in apap mode I think the machine would probably want to go a little higher (how much higher I don't know).

Now will improving your reports result in feeling better...don't know... but it's worth trying.

Even if I wanted to use fixed pressures instead of auto adjusting pressures I would use apap mode so that I would get the FL flagging turned on.
You can set minimum to equal maximum in apap mode and essentially be using a fixed pressure but you will get the FL flagging turned on. Flow limitations can be important as they are the early warning signs of impending airway collapse.

FL flagging is Flow limitation flagging?

So basically you think I might be good to switch my CPAP to APAP mode and perhaps set min max at 5 and 10 or something like that?

Any danger in pressure going too high? I am young and healthy other than a mildly low LVEF (which is probably due to being a couch potato for 15 years... excersising every day for 3 months to see if that gets better)

That's NOT what she said. And, if a range of pressure has been disturbing your sleep previously, it's still going to if you go back to it.

Min pressure = Max pressure if using APAP mode or straight pressure in CPAP mode.


Den

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if a range of pressure has been disturbing your sleep previously, it's still going to if you go back to it.

I started CPAP just a week ago... never tweaked settings before. So don't know if APAP ever bothered me.

Earlier she said

If you were in apap mode I think the machine would probably want to go a little higher (how much higher I don't know).

So I thought she might be recommending APAP mode to let it tweak my pressure for me.

later she said

Even if I wanted to use fixed pressures instead of auto adjusting pressures I would use apap mode so that I would get the FL flagging turned on.
You can set minimum to equal maximum in apap mode and essentially be using a fixed pressure but you will get the FL flagging turned on

So I thought she was saying she suggests APAP mode even if I want CPAP and in that case just set min and max to the same. But this way I get CPAP with FL flagging....

All that said - Sounds like both of you think I might do good with higher than 7... which is what led me to think maybe I should try that... and if APAP lets the machine do some smart adjustments... I am all for trying that... and just set up APAP with a slightly higher max... though I don't know how high is a little higher... 7.5? 8? 10? 15?

Will my doc see I changed my settings and think I did something wrong? Or is it pretty common for people to tweak their CPAPS on their own given they are technically savvy enough.

Is there a downside to higher pressure than 7? Like could I be putting myself at any risk if I go higher than 7 either CPAP or APAP?

Also... curious how RERA's are detected... Resp Effort Related Arousal... how does it now if I was aroused?

Is there a thread that explains the different flags and their relevance?

And do you think my one huge did in o2 sat early on 11/4 was just a bad reading on pulseox sensor? I guess I just need to wear it multiple nights to find out?

Thanks again for all the input!

5 to 15 is NOT what I would do...it's already apparent that 7 cm is not getting the job done optimally going down on the minimum to 5 cm isn't going to make it any better just because it can go up to 15.

Actually I would consider 2 options if it were me.

If I thought that changing pressures was affecting my sleep I would seriously limit the machine's ability to change pressures.
These machines won't go where they don't think they need to go for some reason other but sometimes the reason isn't maybe an urgent reason...
And I would either try APAP mode with minimum to equal maximum (maybe 8 cm in this situation since 7 cm is almost getting the job done)...or I might try a really tight apap range...like 7.5 min to 9.0 max and see if it tops out the 9 any). It may not even go to 9 for all we know.

If changing pressures didn't seem to affect my sleep quality I would start with apap mode and 7 cm minimum and open it wide up and see where it wants to go. Just because it can go somewhere doesn't mean that it will go there. The maximum is really irrelevant if the machine never comes close to it.
I see reports where the apap range is 5 to 20 and the machine never goes above 7 cm...it doesn't matter what the maximum is if the machine doesn't need to go there.

Now sometimes it wants to go somewhere that might cause someone a problem...like a little higher pressure causes aerophagia. When that happens we compromise a bit when we can.

For newbies with all this new stuff to get used to...I actually think limiting the APAP range might be a more prudent choice until we see what the machine wants to do and how the changing pressures could potentially impact sleep quality.
So what I might look at is.
1...trying 8 cm fixed but use APAP mode with minimum to equal maximum
2...trying apap mode with tight range...7.5 minimum and 9.0 maximum and just see if it wants to go to 9 or not..
Then look at the reports (get 4 or 5 nights worth at a setting change before changing unless the results are horrible) and decide what to do after there's a few reports to evaluate.

Never going changing things daily based on last night's report (unless the results were horrible) because it's common to see some change in the reports without ever changing anything.
You will be forever chasing your tail if you do that. Be prepared to allow a few nights at each change.

I actually think your 7 cm is really probably pretty close to optimal ...just not quite there yet.
I don't know how much more is really needed..might be as little as 0.5 cm or might be 2 cm more.

We are never really told exactly how these machines come up with RERA flagging other than the definition given in the manual. Sometimes I just have to trust the machines.

We've combined the terminology and definitions for most of the common terms here
http://sleepyhead.sourceforge.net/wiki/ ... p/Glossary


RERAs
Respiratory Event Related Arousal... a sequence of breaths characterized by increasing respiratory effort leading to an arousal from sleep, but which does not meet criteria for an apnea or hypopnea.”

RERA Detection in the Respironics System One data..Respiratory effort-related arousal..defined as an arousal from sleep that follows a 10 second or longer sequence of breaths that are characterized by increasing respiratory effort, but which does not meet criteria for an apenea or hypopnea. Snoring, though usually associated with this condition need not be present. The RERA algorithm monitors for a sequence of breaths that exhibit both a subtle reduction in airflow and progressive flow limitation. If this breath sequence is terminated by a sudden increase in airflow along with the absence of flow limitation, and the event does not meet the conditions for an apnea or hypopnea, a RERA is indicated.

FL

Flow Limitation is a partial obstruction of the airway as detected by a change in the shape of the flow signal.

Flow Limitation Detection in Respironics System One..Auto Mode Only scoring only..Straight CPap or Straight BiPap modes does not score this event. The device looks for relative changes in the peak, flatness, roundness, or shape (skewness) of the inspiratory portion of the airflow waveform. These changes are observed both over a short period of time (groups of 4 breaths) and over a long period of time (several minutes). Statistical measures are used to help minimize false event detection while allowing the device to be sensitive to even small changes.

Since you are really new to this therapy and we don't know if the pressure changes will disturb your sleep or not (or really we don't know how much they might change)
I would suggest either 8 cm in apap mode with min and max to equal 8 or the really tight range in apap mode that I mentioned above.
Your choice.
Den gets his sleep disturb by the least little pressure change so he is keen on single pressures that are fixed and I sleep through from 6 to going to 22 all night long.
I have no way to know if you are going to be like me or like Den or something in between.

Either way you choose...you can always try the other way if you want to. Give one way a couple week trial and then try the other way for a couple of weeks.

When I was using my apap machine...my minimum was 10 and most of the night I stayed around 11 or 12 but in REM sleep I would sometimes see 18 cm. That went along with my diagnosis which was REM sleep made my OSA markedly worse. I slept right through those changes to 18 cm...but not everyone is that lucky.
I don't know which way you will be so I prefer to be cautious in my suggestions.
Ultimately...my job is to explain the options and offer ideas with pros and cons and you get to decide what you want to do based on your understanding of the options.
I want you to choose something because you understand it and why you are doing it and not because I said to go do something. You don't learn how to manage your own therapy if all you do is follow what someone says to do. I prefer people understand what they are doing and why and not just because Pugsy said so or Wulfman said so.

Pugsy wrote:Since you are really new to this therapy and we don't know if the pressure changes will disturb your sleep or not (or really we don't know how much they might change)
I would suggest either 8 cm in apap mode with min and max to equal 8 or the really tight range in apap mode that I mentioned above.
Your choice.
Den gets his sleep disturb by the least little pressure change so he is keen on single pressures that are fixed and I sleep through from 6 to going to 22 all night long.
I have no way to know if you are going to be like me or like Den or something in between.

Either way you choose...you can always try the other way if you want to. Give one way a couple week trial and then try the other way for a couple of weeks.

When I was using my apap machine...my minimum was 10 and most of the night I stayed around 11 or 12 but in REM sleep I would sometimes see 18 cm. That went along with my diagnosis which was REM sleep made my OSA markedly worse. I slept right through those changes to 18 cm...but not everyone is that lucky.
I don't know which way you will be so I prefer to be cautious in my suggestions.
Ultimately...my job is to explain the options and offer ideas with pros and cons and you get to decide what you want to do based on your understanding of the options.
I want you to choose something because you understand it and why you are doing it and not because I said to go do something. You don't learn how to manage your own therapy if all you do is follow what someone says to do. I prefer people understand what they are doing and why and not just because Pugsy said so or Wulfman said so.

+1

Den

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Wulfman... wrote:

Pugsy wrote: Ultimately...my job is to explain the options and offer ideas with pros and cons and you get to decide what you want to do based on your understanding of the options.
I want you to choose something because you understand it and why you are doing it and not because I said to go do something. You don't learn how to manage your own therapy if all you do is follow what someone says to do. I prefer people understand what they are doing and why and not just because Pugsy said so or Wulfman said so.

+1

Den

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+2!!!

I am definitely one who beleives (in all things... not just CPAP) I want to know the concepts so I can apply them myself rather than be given a set of steps to follow. (i.e. Teach a man to fish feed him for life...)

I think you have struck a great balance, between providing some gentle guidance based on your experience, while still making sure to explain the reasoning so I can apply logic and start to make my own decisions when the training wheels come off.

A few questions.

1.

we don't know if the pressure changes will disturb your sleep or not

Is this
1. something I will notice obviously? Like I keep getting woken up?
2. Or is it something where it's like a micro-arousal where.
2a. If I notice anything it would be more like I feel less rested the next day, and it's really a matter of gauging how good of sleep I feel like I got subjectively?
2b. I look for flags/things on the sleepyhead software to notice the sleep disturbances?

2. Will my doc see I changed my settings and for lack of a better phrase "get mad at me"? Or is it pretty common for people to tweak their CPAPS on their own given they are technically savvy enough.


p.s. I really appreciate all the time you have taken to explain all this. You are a godsend and I don't know how you have enough time to be so thorough and helpful but hats off to you!

glyphix wrote:Is this
1. something I will notice obviously? Like I keep getting woken up?

You may or may not even notice it. Wish it were that simple. We don't remember all our awakenings anyway.
What I usually recommend is after we have the therapy optimal (at least on paper and yours isn't) and a person is still complaining of feeling like crap or poor sleep and they are using a range of pressures that maybe the changing pressures are a factor and fixed pressure trial might be worth investigating.

You are going to find that often with this sleep apnea therapy everything comes with a big YMMV sticker and most of the time we aren't given the luxury of a clear cut black and white situation.

Then if they still feel like crap or their sleep is still of poor quality despite the reports looking good and a trial of both cpap and apap mode...then we start looking at meds and other things.

I didn't go into all that with you because there's room for improvement on your report (which may or may not help how you feel once you get cleaner reports) and I figured try the obvious first.

I wish it was so simple...get a nice software report and all our issues go away be most of the time it just doesn't work that way. Yeah...a few lucky souls have it happen but most of the time it doesn't work out that way. There's just so much stuff that can mess with our sleep and thus how we feel that isn't related to sleep apnea and the best cpap therapy in the world can't fix something that is unrelated to sleep apnea.
We all want it to..but it just doesn't work that way.

glyphix wrote:2. Will my doc see I changed my settings and for lack of a better phrase "get mad at me"? Or is it pretty common for people to tweak their CPAPS on their own given they are technically savvy enough.

I don't know how your doc will react. Some have a serious God Complex and get their panties all in a big wad when we dare to change something. Others are happy when their patients understand the problem and are proactive about dealing with it. My doc was okay once I showed I understood what I was doing.
If he hadn't been okay...it wouldn't have mattered to me though...I don't do well with docs that have a serious God Complex. I have worked with too many of them over the years to let them get away with that crap. If they don't respect my thoughts I sure as hell am not going to respect theirs. They don't walk on water despite what they might think.

The changes I propose...very small in the great scheme of things and he might not even notice. The changes I made on my own weren't so small...RX from the titration sleep study was fixed 8 cm which worked fine when I wasn't in REM sleep but totally was insufficient in REM sleep...but I only got 6 minutes of REM sleep during the titration sleep study so it really wasn't a big surprise that they got it wrong.

Thanks! I think I will try the 7.5-9 APAP for a while.