NoOnesPerfect therapy thread

[Pugsy]

You probably should learn how to distinguish awake flagged events from asleep flagged events.
http://freecpapadvice.com/sleepyhead-free-software
Watch all the videos here.

Awake/semi awake breathing is very irregular compared to asleep breathing and these machines don't know if you are asleep or not.
All they measure is air flow and they can and will flag awake breathing irregularities as some sort of apnea event (not just centrals but any category of event) and respond per the algorithm to that event...real or not.

So the increased AHI might simply be a symptom of the poor sleep and not necessarily the cause of the poor sleep.
Did you have trouble sleeping like this before you started cpap or is this fractured sleep something new that just started with cpap therapy?

Sleep onset insomnia...trouble falling asleep
Sleep maintenance insomnia....trouble staying sleep
both can have many causes and sleep apnea isn't the sole cause....there's a mile long list of causes and figuring out and fixing isn't always so easy.

I know that when I have a really bad night due to back pain causing me to sleep poorly my AHI is always higher than normal and when I go zoom in on those flagged events I can see that I wasn't asleep when they got flagged. I once had a night with the AHI of 3.6 (unusually high for me) and every single flagged event was related to awake/arousal breathing. Had a nice mix of all 3 categories too.
That night I know was a really bad night for me in terms of pain. I remembered a lot a awakenings and tossing and turning due to the pain.

So if those are awake breathing flagged events...unlikely that tweaking those settings will help and instead you have to work on figuring out what you need to do to sleep better/more soundly.
And yes....I know easier said than done.

I am betting a sizeable chunk of your elevated AHI is SWJ sleep/wake/junk false positive flagged events...you weren't asleep and if you aren't asleep they don't count.

[NoOnesPerfect]

From looking at the flow chart, I would say that the vast majority of events are happening after an arousal event - not necessarily awake, but definitely disturbed sleep. I rarely have trouble falling asleep - I just don’t stay asleep longer than about an hour at a time - very fractured sleep pattern. 20 years ago, the sleep study showed the majority of my events happening during REM, which based on the periodicity and timing may still be the case.

I guess I need to wait another month until my follow up with the sleep doctor, but i’ll stick with the program until them. Thanks for the comments and suggestions everyone.

[NoOnesPerfect]

I reset the machine to the original prescription for now (5-20), while i worked on better mask fit and controlling leaks. Thanks to another forum member, I got to try the F20 AirTouch mask, which seems to have resolved pretty much all my fit and leak issues, although it does require a torque wrench and severe tightening when pressures get close to 15. Doing the light touch and looser straps simply doesn't work at those pressures. At any rate, it still looks like I wake up or have an arousal event every hour, so my sleep is highly fragmented and not exactly refreshing. I also noticed that my breathing patterns are not consistent when I am sleeping - there are obvious increases and decreases in breathing rate and volume with no events.

screenshot-20190605-065028.png

Any ideas what could be causing those pulses? Here is the screenshot for the entire evening. FWIW, this AHI is half what I had been seeing, so I am definitely not complaining. This is real progress, but I still would like to find a way to figure out what is causing the fragmented sleep - my wife is currently sleeping in a different room, as is our cat, so that I can eliminate them as any part of the problem.

screenshot-20190605-065139.png

[Pugsy]

Any ideas what could be causing those pulses?

Are you talking about the clusters of OAs...I don't see pulses anywhere?
Assuming you were asleep when those happened to get flagged....
If that's what you are talking about....when we see clusters of OAs or hyponeas like that we know something changed to cause the pressure needs to hold the airway open and prevent the collapse from happening.
When things change like that it is usually either to someone sleeping on their back or REM stage sleep...both of which are commonly known to cause OSA to worsen and/or pressure needs to be higher to get the job of holding the airway open done.

From the obvious pattern of the clusters, my first suspect is REM stage sleep happening. Those clusters sure correspond with when we normally would be having REM stage sleep. Google "sleep stages" and look at the normal hypnograms and when REM normally can occur during the night.
I have a lot of experience with REM clusters. My OSA is 5 times worse in REM than in non REM and I sometimes need 6 to 8 cm more minimum pressure. Supine sleeping never seemed to cause much of a change in anything but REM sure did and it was documented on my diagnostic sleep study.

You need a little more minimum pressure to prevent those clusters from happening. The baseline pressure is just too low and the machine can't increase fast enough to get to where it needs to be to prevent the airway from collapsing. During the actual events the machine won't/can't do anything....it works best by preventing in the first place and not trying to fix something after the fact.
You just need to give it a little better head start to get to where it needs to be to hold the airway open better and prevent the airway from collapsing to start with.

Do you have large leak flagging turned off? There are a few spikes into large leak that aren't showing up on the Events graph.
Were you awake when those happened? Brief refit of the mask maybe? They do correlate somewhat with the cluster of events and the pressure increases but if you were awake refitting the mask then obviously the flagged events aren't real if you were awake.
The 03:00 AM stuff....obviously awake stuff happening there because you turned the machine off and then back on again.

So if you were asleep when those other clusters happened...you need more minimum pressure.
If you weren't asleep and those OA clusters aren't real asleep events (and we can have false positive OAs and hyponeas but the machine will still respond thinking they are real) then more baseline pressure isn't needed.
Instead trying to figure out what is causing the wake up is needed. It might not be the OAs and subsequent pressure increase that came first. Meaning it is possible that the arousal came first and then the OA flagging and pressure increases came because the machine thought the irregular arousal breathing was the airway collapsing.

I see this happen a lot myself....I see a little cluster of events and the machine will increase the pressure in an effort to better prevent them from happening again but if I go look at the events I can plainly see awake/arousal breathing prior to all the flagged events and the pressure increases afterwards. The machine only knows to respond to air flow irregularities....it doesn't know that we aren't sound asleep.
One night I had an AHI of 3.6...unusually high for me and a nice mix of all 3 categories of events. I took the time to look at the clusters and the sporadic random events...not a single one was real. Every single flagged event was preceded by arousal/awake breathing that was so blatantly obvious if wasn't even an "iffy" situation. That was a night when I had really bad back pain causing a lot of fragmented sleep. What was surprising was that non even one flagged event was real....I expected some SWJ but not all SWJ.

[NoOnesPerfect]

Thanks for the response pugsy. The events seem to be almost exclusively when I am awake or close to it now. The pulses I mentioned show in the first graph as rhythmic increases and decreases in the amplitude on the flow chart. It looks like my breathing gets deeper, then shallower, followed by a bit of normal sleep breathing. Eventually, the breathing becomes more and more shallow, followed by an arousal or an event.

[NoOnesPerfect]

The large leaks flag is turned on, but only seems to get triggered if the leak is at least double the preset of 24l. The ones you mentioned were absolutely from trying to eliminate the leak noise by adjusting the mask fit.

[Pugsy]

More likely it's not so much that the leaks need to be doubled the 24 L/min mark to get flagged as they just need to last a bit longer than a quick refit of the mask will last. Duration plays a big factor in the flagging of leaks. I see flagging for 29 L/min leaks when I mouth breathe sometimes. So it doesn't have to be doubled to get a flagged but it has to last more than a few seconds.

I don't know what to make of the flow rate waveform that you are wondering about.
Hard to say for sure from this scale but it just looks like a bit of arousal type of breathing since it is not nice and rhythmic breathing we normally see when asleep. I suppose it could be simply a little periodic breathing going on and periodic breathing is not a big deal. It's just a waxing and waning of the flow rate that sometimes happens to all of us and we don't necessarily know why much less what to do about it. It's relatively short lived and I would just ignore it if it were me.

Given what you have said....I think you have crappy sleep from something causing arousals but it doesn't appear to be related to the airway collapsing. Now what that might be is anyone guess and involves a lot of detective work to figure out and even more work to fix if you can even figure out what the cause is.
I have crappy sleep quality myself but it's because of pain issues and not airway issues.
People often want/expect the machine to fix all crappy sleep no matter what causes the crappy sleep but the cold hard fact of life is that the machine can only fix crappy sleep that is related to airway issues.

There are millions/billions of dollars spent every year by people wanting to fix crappy sleep by all sorts of ways. Can't say as I blame them either. These people don't have OSA or airway flow issues either. They just have crappy sleep from some other reason.
First thing we look at when people have crappy sleep is of course medication side effects...it's that common.
I take a medication for pain that comes with a big "may cause drowsiness" sticker on it because that is the most common side effect but in little bitty print there is the notation that for some people (very small percentage of people) it can cause insomnia. For me it's sleep maintenance insomnia...I can go to sleep easily enough but I can't stay asleep very long...I end up about 2 hours later being wide awake and cleaning house at 2 AM. For that reason I have to take something else for pain management at bedtime.
If I didn't take anything then the pain would wake me up a gazillion times a night.
In my case I have a fairly good idea what causes my crappy sleep....and it's still a struggle to manage it and get decent sleep quality.
I still see a lot of arousal breathing on the air flow rate graphs but not so many blatant full awake air flow rates. I know it isn't perfect but it's the best I can do given what I have going on and my options for trying to fix it.

We don't stop trying though...we don't give up because we never know what might be around the corner that might be the key to better quality sleep.
I think a lot of people who say "cpap didn't help" were expecting the cpap therapy to fix a problem that the cpap machine simply can't fix. It fixed my OSA airway issues easily...it doesn't do such a great job with the arthritis and back stuff.

[NoOnesPerfect]

Thanks again for the comments pugsy. I will be seeing the sleep doctor the beginning of next month, so I will push him for help identifying the causes of my sleep issues. I too have sleep maintenance problems. I fall asleep easily, but wake up frequently - I just can’t stay asleep. I do believe the APAP is dealing with my apnea, although tweaking will be back on the agenda now that the major leak issues seem to be under control, but it isn’t even close to resolving my overall EDS problem.

[NoOnesPerfect]

After comparing the timing of the apnea events shown in OSCAR to the sleep stage info from my FitBit, it really looks like the only events I am getting now are during REM sleep. At that point, the events start and the pressure goes from 5 to 15-20 in a very short time. Other than raising the minimum pressure (I may wait until my sleep doctor visit to do that), are there any other steps I could take to deal with REM related apnea? I did order the Dr Dakota collar to either deal with or eliminate the probability of positional issues. At this point, I wake up every time I hit REM sleep, and can’t get more than 4-5 hours of total sleep nightly.

[Miss Emerita]

How interesting! I know from reading Pugsy’s posts in a variety of threads that REM can bring on OAs for some people. I wouldn’t be surprised if raising the minimum pressure will help.

When you talk with the doctor, you might want to suggest that any pressure increases be made gradually, especially as you go above a minimum of around 7. Ideally the doc would agree that you will make those gradual changes yourself, spending at least a few nights at each new pressure so your body can adjust and then using your experience to tell you how much the next increase should be.

Keep us posted!

[Diotima]

Try a different mask...I can't tolerate the F20 or N20 for some reason. Get trial for Bleep Dreamport if possible and a chin strap?

[djams]

After comparing the timing of the apnea events shown in OSCAR to the sleep stage info from my FitBit, it really looks like the only events I am getting now are during REM sleep. At that point, the events start and the pressure goes from 5 to 15-20 in a very short time. Other than raising the minimum pressure (I may wait until my sleep doctor visit to do that), are there any other steps I could take to deal with REM related apnea? I did order the Dr Dakota collar to either deal with or eliminate the probability of positional issues. At this point, I wake up every time I hit REM sleep, and can’t get more than 4-5 hours of total sleep nightly.

Sure looks like REM cycles. Can't tell with 100% certainty even with the fitbit. If it is, you need to find the min pressure that gives the machine enough of a head start to handle the REM periods. You're obviously not sleeping well, and probably not feeling well, and you're a month away from your next appointment.

I'm not going to try to tell you what to do. Another month of 4-5 hours sleep won't help much. If you aren't comfortable changing your prescription without the doc's blessing, at least call and explain what's going on, and what *you'd* like to do about it.

I'm a big fan of small weekly adjustments, as Miss Emerita suggested. I did 0.4 adjustments of min and max pressure weekly until I reached my goals. It's very normal to to have trouble with pressure increases in the beginning. This approach made it really easy for me.

But please do something. Call and get permission, or have them implement your plan, or make the adjusting yourself. Don't spend another month getting 4-5 hours of sleep.

[NoOnesPerfect]

Last night was one of the worse nights yet - leaks are under control though . I called the sleep doc today - we’ll see what comes of that.

[djams]

Last night was one of the worse nights yet - leaks are under control though . I called the sleep doc today - we’ll see what comes of that.

Will be very interested to hear the response. Glad the leaks are under control - that's a big deal.

[NoOnesPerfect]

Pressure is being changed to 8/20, so definitely a step in the right direction. Of course, if I wait for the DME to do it remotely, it could be a while