CPAPtalk.com

Carla:

I forgot to ask, how are you feeling with the use of lower pressure?

With the frequency of events in the past you probably have a pretty good sleep deficit built up, so it is good to see you are getting 8-9hrs of sleep, 9hrs is ideal if you can swing it.

Snoredog wrote:I stand by my previous theory that the machine was misreading your apnea and was triggering pressure induced central apena even though they didn't note anything on your PSG

That's certainly a possibility. I for one don't really know what's happening with Carla, with the amount of information that has been presented so far. But I do know that episodic factors tend to bear much better patterns over several nights of data, versus one, two, or three. I also agree with all those posters who acknowledge that there is not enough information to reach solid conclusions. However, my thought is that Carla may not have had a remiss PSG. Rather, her episodic factors simply may not have presented themselves during her single-night in the sleep lab. Wasn't it Forest Gump's mother's upper GI specialist who always used to say: "Episodic is as episodic does"?

As a side note, Den correctly pointed out that pressure-based fluid dynamics at the LES can actually work both ways. While CPAP pressure more often than not alleviates GERD, there have been some patients for whom higher pressures actually exacerbated GERD. In this latter case, pressurized CPAP air enters the stomach through the LES, where it accumulates. However, LES closure is variable and not at all constant for most of us. That LES closure happens to be more variable for some of us and less variable for others. But when high pressure exacerbates GERD in the manner Den brought up, LES closure adequately contains that pressurized air for quite some time. Then, a variety of factors (including sleep position, abdominal muscular activity, LES muscle closure itself) can eventually allow that pressurized air to reverse in the cranial or backwards direction. When that happens, that pressurized reverse airflow can even bring fluid along with it.

If Carla's NR events are steadfast vocal chord closures in response to acid reflux eruptions, you actually have a theoretical scenario for obstructive apneas that are indirectly pressure induced. I won't go so far as to say that may be what's happening in Carla's case, but the theory itself demonstrates how potentially complex and under explored sleep science may be. I agree with SAG's, Snoredog's, and others' comments that Carla's potentially very complex case is best managed in a clinical setting rather than a message board. I personally think it's time for a new doctor any time the current one lends a deaf ear to symptoms that are both outstanding and debilitating. Hint, hint, Carla. .

Snoredog wrote: I forgot to ask, how are you feeling with the use of lower pressure?

With the frequency of events in the past you probably have a pretty good sleep deficit built up, so it is good to see you are getting 8-9hrs of sleep, 9hrs is ideal if you can swing it.

Well, all things considered it seems to be improving....I'm increasingly overwhelmed and stressed at that has me worn down too, but I haven't noticed being drowsy at the wheel or that drop dead feeling in the afternoons. Basically if you took out of the equation all the stress that's been increasing, I'm sure I'd feeling much better. Make sense?

Aerophagia is definitely better. I haven't had one of those really bad nights where I wake up doubled over in pain, with a bucket of air *stuck* inside, IYKWIM. Come to think of it I don't think there's been much discomfort even in the morning....I'll try to notice that absence tomorrow morning and be grateful. ;>

I try my best to get the most sleep I can, but there's always something I feel guilty about leaving undone. Most of all I hope I can get back to being able to get out of bed by 6:00...instead of hugging the mattress till the kids come in at 7:00 and I run around trying to get everything done and leave late....

Tonight's experiment....keeping the lower strap of my Swift from riding up....checked the archives, got some inspiration....wish me luck...
-Carla

-SWS wrote: That's certainly a possibility. I for one don't really know what's happening with Carla, with the amount of information that has been presented so far. But I do know that episodic factors tend to bear much better patterns over several nights of data, versus one, two, or three. I also agree with all those posters who acknowledge that there is not enough information to reach solid conclusions.

I'm hoping I've picked a good doc this time around who is really willing to explore all the potential issues with me...

However, my thought is that Carla may not have had a remiss PSG. Rather, her episodic factors simply may not have presented themselves during her single-night in the sleep lab. Wasn't it Forest Gump's mother's upper GI specialist who always used to say: "Episodic is as episodic does"?

Ugh. it just occurred to me that even I succeed in getting my new PSG, with my luck it will be one of those "good" nights and won't accurately reflect the "problem" nights I need to address. <sigh>

I agree with SAG's, Snoredog's, and others' comments that Carla's potentially very complex case is best managed in a clinical setting rather than a message board. I personally think it's time for a new doctor any time the current one lends a deaf ear to symptoms that are both outstanding and debilitating. Hint, hint, Carla. .

I'm almost there! Called for appt, they need official referral, left a message for my family doc for that....
But I'm so glad I came to the board for advice....I've learned so much and it gives me a much better basis for feeling out the new doc's knowledge to make sure he's the right one for me!

You guys still want updates as I tweak along? Or am I annoying y'all yet?
-Carla

Carla wrote:You guys still want updates as I tweak along? Or am I annoying y'all yet?

You most definitely won't annoy us, Carla! Please continue to fill us in all along! .

And......I still stand (well, actually I'm sitting at the moment) by my previous thoughts and suggestions.
From these last charts, I see events happening at the low pressure (it's just a little TOO low) and then events happening at the pressure changes (which caused which?). Has anybody noticed how the Leak charts in these last two nights almost mimic the Pressure Charts?

Best wishes,

Den

Wulfman wrote:And......I still stand (well, actually I'm sitting at the moment) by my previous thoughts and suggestions....

Heheheh! Snoredog's standing by his position, your humorously sitting by yours, and the rest of our backs are getting sore from being in such non-committal positions. .

Carla:
My only suggestion for your next PSG is that you need to make sure your GP doctor understands that your case is complex and that the sleep lab's assisting doctor knows your case is complex so they don't put some green tech on your case to titrate you, I know what it is like I had the same thing happen in my own case. You need someone very experienced to titrate you.

In fact, they should test you for CSDB and rule that out, I would also make sure you get the full PSG report and not just a partial page report. Make it known, you want a complete copy coming from the lab. More specifically you want them to rule out any CA or MA events, rule out any PLMD or RLS syndromes and any spontaneous arousals that may be interrupting your sleep besides OSA. I had my first PSG more than 5 years ago and they provided all that info and more, then on my secondary titrations, the tech wasn't afraid to explain some of the findings seen on the raw data that never showed up on that report.

All you want to know is what disorders you have so you can deal with it, they should not withhold any of that info from you no matter how trivial.

Just wondering how Carla is doing.

Also a link to a recent thread with one highly theoretical episodic factor ("fluid loading") being tested by sleep researchers: viewtopic/t15978/quotFluid-Displacement ... heory.html

Renal, cardiac, and even water-weight issues in general (all potential contributors to soft tissue "fluid loading") just may turn out to affect night-to-night AHI variability for at least some of us.

I'm almost through my week of straight CPAP. Interestingly, I again had a great night the first night of new settings (ahi of 1.7) and then declined again. Though certainly better than last month!

The Swift is really starting to irritate my nose. very sore and tender during the day, tried to loosen up again on it last night, but my leaks went up. :/ I am getting taping down much better...but very annoying for night visits from kids and dh rambling at bedtime. ;> My pantyhose trick has made the strap issue disappear though!! I am curious about the Opus now....can't wait to see how that goes over....

It's funny how spoiled I get. I used to just want to be under 5.0 and now I'm longing for more of the 1 or 2 range....

I updated the web pages a bit, hope they are easier to read now....
http://family.wiseoak.com/sleep.html

Thanks for following my adventures!
-Carla

Thank you for continuing to fill us in, Carla!

Optimizing CPAP therapy through trial-and-error sure has been a central theme on this message board from its very inception. You may eventually decide to try straight CPAP with CFlex turned off as well. Plenty of nightly data trials will tell you if this is simply a matter of optimizing your xPAP settings, or if episodic physiologic factors must be chased down.

The posters on this message board are one fantastic consulting team in my opinion. I look forward to following your "trials by data" and I also look forward to hearing the varied opinions of others. Good luck, Carla!

Here is what prompted my question.

This output looks very similar to my own, does this suggest that I have a central apnea problem (central nervous system based), OR.. that central events are diferent than central apnea.

Sorry about the mis-posting,,, intended for another topic

dataq1 wrote:Here is what prompted my question.

This output looks very similar to my own, does this suggest that I have a central apnea problem (central nervous system based), OR.. that central events are diferent than central apnea.

dataq1 wrote:...does this suggest that I have a central apnea problem (central nervous system based)...?

Not necessarily. The red rectangles on that example are labeled "central event". However, in my opinion the red-rectangle labeling should really say something like "resistant apneas" instead. Respironics' own designation of NR (non-responsive) is intentionally left as an undifferentiated designation.

By undifferentiated I mean that Respironics does not and cannot adequately differentiate central apneas from obstructive apneas from (single-event) mixed apneas---and therefore neither can we. While that sample graph may very well show central apneas in reality, that sample graph is also what a graph of purely "resistant" obstructive apneas might look like. And logic thus follows that this same sample graph might also represent (single event) mixed apneas or a mixture of obstructive, central, and/or (individual-event) mixed apneas as well.

In my opinion we thus cannot assume they are central apneas with any degree of certainty. When we see a densely-packed string of apneas or hypopneas (that do not seemingly respond quickly to pressure increments) then it's probably best to think of those as being "resistant events" rather than attempting to differentiate them as "central events" or "central apneas".

-SWS wrote:

dataq1 wrote:Here is what prompted my question.

This output looks very similar to my own, does this suggest that I have a central apnea problem (central nervous system based), OR.. that central events are diferent than central apnea.

dataq1 wrote:...does this suggest that I have a central apnea problem (central nervous system based)...?

Not necessarily. The red rectangles on that example are labeled "central event". However, in my opinion the red-rectangle labeling should really say something like "resistant apneas" instead. Respironics' own designation of NR (non-responsive) is intentionally left as an undifferentiated designation.

By undifferentiated I mean that Respironics does not and cannot adequately differentiate central apneas from obstructive apneas from (single-event) mixed apneas---and therefore neither can we. While that sample graph may very well show central apneas in reality, that sample graph is also what a graph of purely "resistant" obstructive apneas might look like. And logic thus follows that this same sample graph might also represent (single event) mixed apneas or a mixture of obstructive, central, and/or (individual-event) mixed apneas as well.

In my opinion we thus cannot assume they are central apneas with any degree of certainty. When we see a densely-packed string of apneas or hypopneas (that do not seemingly respond quickly to pressure increments) then it's probably best to think of those as being "resistant events" rather than attempting to differentiate them as "central events" or "central apneas".