Help! Still Sleepy, MyEncore Reports, etc.

Snoredog wrote:But can we positively conclude that Prilosec was what eliminated the central apnea? There is a huge difference between those. If so you may have come up with a cure for central apnea that Scientists have been struggling with for years.

Snoredog wrote:I am still interested in learning how the acid reflux triggers these central events (that is a huge discovery in my opinion), what receptors is it may be influencing, that would be an interesting read.

Actually, it wasn't the few centrals that showed up on Carla's Encore Pro data that I was looking at. There were so few of those that I didn't even consider them to be significant.

What struck me was how bad the Obstructive apneas and hypopneas were on so many of the nights, and then.... suddenly such a good night. With nothing changed in the pressure settings or mode of operation of the machine.

Just reminded me of loonlvr's problem, and what -SWS suggested might be causing it.

Unless a person has had pure, or almost pure Central Apnea turn up on their PSG sleep study, I just don't go looking for "centrals" or start suspecting that obstructives reported on the software data are really centrals that have cleared up on their own before the REMstar's three pressure nudges and enough time has gone by to mark them as NR's (possible centrals.)

Some events could get marked in Encore Pro as "obstructive" when they were actually short centrals. But subscribing to Occam's Razor as I do, I figure most, if not all, of the events that get marked as Obstructive really are....obstructives. Following that perhaps too simple line of thought, then I wonder (because of what -SWS discussed about loonlvr):

"Why so many obstructives with autopap running the pressure up more and more? Why is more pressure not working...not splinting the airway open? Could there be something else going on that has nothing to do with OSA per se....something that's made the tissues in the airway more rigid? Too rigid for Positive Air Pressure to push aside?"

That's all. No discovery about something causing centrals or curing centrals. Centrals didn't enter my mind (no pun intended! LOL!!) at all when looking at Carla's data. I was looking at the stuff marked as obstructives, and accepting those as obstructives.

Nor was I looking at, or trying to analyze, what events were happening at each pressure or what her AHI was at each pressure. Once I saw that good night she had, -SWS's work with loonlvr came to mind. I figured that if acid reflux was an underlying issue for her on the bad nights, it would be like chasing one's tail to try to draw any cause/effect conclusions about how pressure affected AHI on any of her data.

Adjusting pressure either way -- whether more or less pressure -- wasn't going to be useful, I didn't think, until GERD was looked into first. I thought she might need an acid adjustment first, so to speak, before worrying about pressure adjustments which might not even be needed at all. That good night looked pretty darn good.

As a side note, for quite some time I've been wondering.... wonder how many PSG titrations land a GERD sufferer up on a rather high pressure on a night when acid reflux happens to be acting up badly?

curtcurt46 wrote:Dear Snoredog,
You just don't get it. I know how to read and in some cases put 2 and 2 together to get 4. You have latched on to an idea and can’t see some other possibilities. When I take the time to put something in the written form I do so from a most informed mind. To address your question first and then I will propose a question for you.

Snoredog wrote:
“Don't think so bud, where are you getting this variable breathing data?

This is a Remstar Auto it doesn't record variable breathing (VB), maybe if it was a AutoBipap it would, but not the Auto. Don't confuse variable breathing with erratic breathing after an event.”

Take a look at the auto- titration pressure support patent application, page 12-13.
http://lewiston.mit.edu/sleep/autopatent.pdf

Guess what, here is where I got this idea. MyEncore reports the variable breathing data for both auto bipap and auto pap. Variable breathing is a controller in both the Auto pap and the auto bipap. I am not confused, but I believe you may be. Give this a read and then tell me that data is not collected. Also look at Carla’s MyEncore reports and there you will find a whole page showing the VB for each day.

My reading tells me that variable breathing is an indicator of something out of order when the VB spikes above the average VB. I have seen this in my own data and now Carla’s.

Please tell me where the data is that supports that Carla has central apneas. You said there is a pattern, but I didn’t see it. Please show me where X+X+X= central apnea.

I have the patent, I know what it says, I also know the Auto Bipap was developed from the Auto's algorithms, says so in the brochure.

I am looking at Carla's report, you show me where it shows varible breathing?
http://family.wiseoak.com/images/CarlaCarla.pdf

I don't use MyEncore reports, my opinion it is someones interpretation of what the event(s) should mean vs what the mfg says they are even as badly as the database may look. There is NO VB on a EncorePro report unless you have the Auto Bipap machine, if you have the plain Auto there is NO VB shown on the report as in Carla's EncorePro report above, if so tell me where to find it.

FYI: The machine determines what the EncorePro reports look like from machine to machine, the Bipaps will have much more information than the other Auto machines using the same software, the Pro series even less.

Please tell me where the data is that supports that Carla has central apneas. You said there is a pattern, but I didn’t see it. Please show me where X+X+X= central apnea.

The double events (I said triple before, it only needs double events and 3 pressure increments events preceding the NR event highlighted in the red boxes, you have to use the Respironics Auto simulation program to see exactly how it responds in real time but give it 3 apneas in a row in the NR simulation, it will increment each by .5cm pressure, when it has done that 3 times the gets logged as NR event and it drops pressure by -2cm and then pauses for 15 minutes (pressure response shows that in Carla's reports, they resemble the graphs below for NR).

The machine cannot physically determine if they are central apnea so they call them Non-Responsive Apnea. But the events have already elapsed so logging occurs after the event. So to find the events that triggered the NR you look at the events in the immediate timeline just before the NR is logged (see below).

Each gold NR tic represents 3 pressure increases and 2 apnea events, so if you look immediately in front of the NR and down to the OA line you see the apnea I outlined in the box, those OA events are actually central events (or apnea that didn't respond to previous 3 pressure increases). If you then look up to the pressure chart you will see it stair stepping up 3 times then suddenly drop by -2cm, then a straight line for approx. 15 minutes where it repeats.

While you can hypothesize that is swollen tissue which is harder to stent open that even 19cm pressure cannot stent it open OR it is an actual central apnea event which doesn't respond at all to increased pressure. With obstructive apnea your pressure simply doesn't vary by that much from night to night, if it did they could never use cpap pressure for everyone as they say. Below is how the NR algorithm functions, then below that are the hypopnea events, below that in the 3rd is the NR events highlight vertically looking at the pressure response to each double event, straight line after is the NRAH hold period representing roughly 15 minutes time, only thing machine is responding to during this period is the snores at the bottom which can only make the situation worse. Notice on her 12/8 report she didn't snore very much.
Non-Responsive Apnea (from simulation program)

Non-Responsive Hypopnea:

Carla's NR events:


If you add up those events either obstructive or central it is a long time to not be breathing.

SWS wrote:

Your daughter finished dental school already? And now she's on to specializing in her profession? Aren't you a proud dad? Very Happy Cool .

Yep I'm pretty proud of her, nah she's still in school (think she just likes being a full time student), she just finished up her final final in obtaining her Masters degree in Oral Biology, she already holds BA's in English and Psychology and of course finishing up her doctorate in Denistry, she is getting a lot of pressure to stay and go through the Periodontal course where she can do oral surgery and implants which is what she really wants to do. She is still taking 42 units a semester, seeing 2-3 patients a day, a ridiculous schedule if you ask me.

Snoredog wrote:This is a Remstar Auto it doesn't record variable breathing (VB), maybe if it was a AutoBipap it would, but not the Auto... There is NO VB on a EncorePro report unless you have the Auto Bipap machine, if you have the plain Auto there is NO VB shown on the report as in Carla's EncorePro report above, if so tell me where to find it.

While its true that VB isn't displayed on EncorePro reports for an Auto they are kept in the EncorePro database. VB events are recorded in the SQL table SleepTherapyVBEvents and VariableBreathingMinutes are stored in the table SleepTrendEventLog.

There's a whole pile of ifs here, centering on perhaps 2 major issues.

What is the true nature of the events recorded in the software (are they "real" or not); and what is their origin.

Now, by history, Carla, you have extraordinarily severe OSA. Of course, that was 30 pounds ago.

Asthma, GERD and PLMs are also being mentioned, yet the severity or even existence of each is not clear (for instance, in the PLMs, despite the incidence that you noted, if they were in the study where the 122 AHI was, they could have been a scoring result of the OSA).

On the other hand, if they are real, with the right set of circumstances, even PLMs could generate an unwanted APAP response and/or perhaps an increase in Variable Breathing. Given the lack of reproducibility in the VB, tho, from your data:


that's probably not real high on the list. While you got 4 pretty obnoxious nights there, I'm not sure what really constitutes an "obnoxious night" re: VB. But if they're twice as bad as baseline, that should say something.

As the Joint Council of Allergy, Asthma and Immunology points out in the work by Teramoto:

An association between bronchial hyperresponsiveness and GER has been postulated for several years. Multiple studies have demonstrated that GER is a common medical problem. Depending on the criteria used to diagnose reflux, between 45% and 65% of adults with asthma and 25% to 80% of children with asthma have significant GER.

And while that cause-effect relationship is not well-established, one could argue that if all these disease states are in fact present, then statistically the relationship has a better shot at being GERD>asthma>untoward APAP response rather than GERD>OSA>untoward APAP response.

And finally, this might also be attributable to position. If 12/4 was a supine night (and you are position-dependent) that could be the simplest explanation of all. Hmm, GERD could be position-dependent, too...

With so many possibilities, the significant weight loss, the high original AHI (BTW, were there significant desaturations?), asthma (and on top of all of this, you plan on getting pregnant?) I don't think there's any way you can avoid getting another PSG. Even if you were able to generate "good" results after tossing down a handful of PPIs, there's too much at stake to go about not knowing the nature and extent of disease(s).

restedgal wrote:As a side note, for quite some time I've been wondering.... wonder how many PSG titrations land a GERD sufferer up on a rather high pressure on a night when acid reflux happens to be acting up badly?

I suppose it depends on where you're having the test done. With that in mind, I'm going with "none."

As an opportunity to lobby another point, how well do you think this case could be managed utilizing "portable testing"? Noam, where are you!!
SAG

Snoredog,

I guess we just have to beat this one to death.

I originally looked at the below charts that came from EncorePro Analyzer in Carla’s first posting. It was there I focused on the VB and it’s relationship to having rather bad AHI’s. I didn’t care what the machine was scoring, I only new that she was have a bad night and VB spikes point to this. Centrals were not the issue; it was the sleep disordered breathing I was looking at.

http://family.wiseoak.com/carlacharts.html


I know from my reading and own experience that a spike in VB above the normal must indicate something else is at play. Sometimes these spikes can be the result from PLM arousals, Asthma episodes, upper respiratory distress, and allergies to name a few.


I never indicated that any Encore Pro report showed VB. It’s there but not presented as a report. I can only find the data presented in MyEncore or the EncorePro Analyzer. The VB data is a piece of information, I have found to be useful when looking at the data reported by Encore Pro.

I acknowledge that Carla may have had some centrals, but I am not able to read the data and draw that conclusion because of my own limited experience. I go back to what I said earlier, the Encore Pro daily report was never intended to indicate when a central apnea occurred. If it was then you would have a line for central events. I am sure they don’t have that line because it can’t be determined with a reasonable amount of surety that a central event occurred. You yourself indicated that the only sure way is the go to the lab for a PSG.

I would like to hear how Carla is doing and hope she keeps posting and shares her experiences as she deals with the many aspects of her SDB.

I'd still like to see a chart of a night of straight pressure. Looking at this last Encore Pro chart, I see a lot of events happening at pressure changes.....is this a chicken or egg situation with some snores or hypopnea events starting the pressure increases? In view of the statistics showing that her average apnea event is averaging around 12 seconds, I'm wondering if they're really Centrals (even though the chart shows some NR events).
In addition to looking at where the events ARE happening, I was looking at where the events were NOT happening......and it seems to me that when her pressure is constant, there are few(er) events.
AND, do the pressure changes affect the GERD? If it does, then it's a spiraling situation.
One thing that I will always agree to is the fact that there are WAY too many things that can affect this therapy.

Best wishes,

Den

I'm just wondering how well this patient would have done with an alternative treatment such as Pillar and a dental device? probably better!

I thought this chart was interesting, notice what happens after 10cm, another one of those chicken or egg quandaries I guess:

Snoredog,

I know....that's the chart on which I based my original post. Above the setting of 9, things start getting worse for her.

Den

Wulfman wrote:Snoredog,

I know....that's the chart on which I based my original post. Above the setting of 9, things start getting worse for her.

Den

yep that was the first thing that got my attention too, notice the HI's don't change much all the way across the pressure span yet the OA's skyrocket. I agree around 9cm is ideal or if in auto mode setting the Max to 10cm.

Snoredog, (or anybody)

I (personally) haven't had any experience with GERD and haven't had any "acid indegestion" (heartburn) experiences since starting CPAP therapy....so, here's my question:
Would/could the changing pressures affect a person's GERD? (either Carla's or anybody's)
Or, whether Carla does or doesn't have GERD, could the pressure changes create an esophageal reflex action that the machine interprets as events that it needs to raise the pressure?

Thanks,

Den

Wow. Sorry I didn't get to post anything yesterday but I got caught up in a bunch of holiday projects all day.

First off, here's some data I remembered...I've been on the apap and hybrid since mid october....that's when I got Encore and was able to chart, too, so no data before that.

Sleep positions: curiously before the new mask and machine I was sleeping on zero-gravity pillows to raise my head. My intention was to encourage the air to stay out of my tummy--read that advice somewhere. Wonder how that might have benefitted me though, if the GERD thing is really an issue. I had to ditch them though because they kept me on my back in exactly one position which I hated, especially since I was a born side or stomach sleeper.
Now I'm *usually* sleeping on a big U pillow, mostly for comfort though as my dh insists we sleep on a firm mattress that feels like wood to me. ;> I'm starting to trust my masks enough to sleep on my side a little more.

Changes since Nov 23rd? That was Thanksgiving,I had horrible headaches that weekend (too many unintentional couch naps sans machine!) and I recall getting sick in the airport on the way home Sunday the 26th. It was horrible chest congestion, but no nasal involvement. Lasted a little over a week. Then broke up into a little runny nose and drainage. Still lingering. I guess I hadn't thought of that, since I was so used to *nasal* congestion being a problem before the Flonase was prescribed, and chest congestion doesn't pose an immediate issue with the mask, like nasal congestion. I'm a believer that it matters now though! Also, haven't been managing to exercise since that week either due to the holidays and feeling so freaking awful. I was doing daily exercise pretty conscientiously before that.

Ready for the big news? Friday night I set the pressure at 6 to 10. Used
my Swift instead of Hybrid. I hated the idea of giving it up, but knew I
didn't have time to figure out any leak issues with it right away.

Took NyQuil Saturday night after thinking about my congestion and figured
the acetominophin might help with my muscle aches.

With the Swift I taped the first night and still didn't like it. Also had it way too tight and was really sore. Saturday night I did my chin strap the first half then skipped it the second part of the night. With a max pressure of 10, I didn't even have a blow-out. Wow. that was like the hugest problem with the Swift I'd had the first go around! I was constantly waking with mouth blown open and dry as a bone, even with a strap so tight it hurt. Now I need to figure out how to get the Swift straps from slipping around the back of my head and I won't mind that mask so much--I'll be searching on that later.

Here's the data:
Encore Pro Analyzer for the last week.
http://family.wiseoak.com/charts2.html

Encore Pro Full Details for those new 2 days.
http://family.wiseoak.com/images/CarlaCarla2.pdf

Saturday night is messed up because I woke up with *severe* pain caused
by the day's craftwork and couldn't get back to sleep for a couple hours. But
even at that...look at the improvement. I'm operating off a few hours of
sleep (lots of kids coming in issues starting before 6:00 that don't show)
and feel just as good as all those 7 or 8 hour nights I've been putting in!!!

Amazing. I'm still considering the big picture, including GERD
possibilities (I hate to admit my late night "snacks" of pop and a whole
pizza--cillakat please ignore that!), and I'll be managing congestion
issues that I thought were just annoyances to put up with. I'm just so
psyched to see some improvement so quickly. And maybe it'll clear my
brain up enough to start looking into more stuff!!!

It's just the beginning...I'm certainly not done...but I feel much more
excited about trying out these tweaks now, versus feeling like I'm stumbling in
the dark.

Lastly, Here's copies of my original PSR for anyone curious.
http://family.wiseoak.com/study.html
I guess it was 114 not 122, but still not great.

I guess "WOW"!!! That's a LOT better.

Keep us informed. (I still think a straight pressure of 9 would be worth a try.)

Best wishes,

Den

Hi Carla,

I have had GERDS for many years, 15+ at least........eating before you go to bed, especially pizza and pop, are probably the worst things you could do for acid control.

The pizza is very acidic and the pop has gas in it that makes you burp etc.

Here is my regimen that works perfectly.....do NOT eat at least 3 hours before you go to bed....very important!....then, the very last thing you do before you hit the pillow, is chew 2 Extra Strength Tums or take some type of liquid antacid.....don't do anything after you take the stuff, just go to bed...the idea is that it will coat your esophagus etc and help with any reflux.

Lastly, I take Prilosec, every day......but I don't take it right before I go to bed. The BEST time is to take it upon waking up...the very first thing you do when you get up, is take it with a glass of water.

I also have the head of my bed frame raised about 5 inches. All these things combined have eliminated my GERDS!!

Hope that helps.

I agree with Den, that is a HUGE improvement.

However, last nights report wasn't as impressive, but you clearly do better at lower pressures than wide open.

If you look on last night's report at about therapy hour 2 just past it the cluster apnea returns and you flat-line at 10cm pressure. I would even try lowering the Maximum pressure to 9cm, it will continue to help your aerophagia. Looks like snores may be playing a part in driving up your pressure. Again, following the time line with a vertical rule you see right before hour 2 a snore tic, then it is followed by 2 hypopnea then the cluster of apnea (we still don't know which kind they may be).

You mention your lungs seem congested, have you examined the back of your tongue with a spoon in a mirror? If you see that thick clear mucosa? if so you might want to consider a decongestant like Claritin-D (it may also make you sleep better, but don't take more than 3-4 days), you would also need to take it before bed about 1hr. Even though they say non-drowsy on the box they can still make you drowsy.

I would also suggest maybe writing down what you consume during the day, like all medications, all supplements, sodas what you had for meals etc., then you may be able to correlate that to your reports and give you a hint as to what is happening, you could have some kind of a food allergy. When you have a rough night like a holiday like Thanksgiving you almost have to discount that night due to possibly wine consumption or the tryptophan turkey contains. Hey its the price we pay for good eats