CPAPtalk.com

Hi Everyone! Thank you to all the selfless souls who help a cranky sleep-deprived newbie like myself figure all this out..

OSCAR Data: https://i.imgur.com/60H3BX3.png
Stats: 44 yr Male, 5"7, 215 lbs, 145/95

So I had a sleep study ~ 10 yrs ago, but didn't sleep a single wink all night, and the tech told me I didn't have any kind of sleep disorder, (despite me protesting that they couldn't possibly know that as I hadn't slept).
Fast-forward ten years /w daily energy being about 70% what it should be, and focus/concentration much less, (I do also have ADHD, which I'm treated for), and my dental hygienist told me that she had taken numerous courses on Sleep Apnea, and that my trachea was quite narrow, my tongue very large, and she would be surprised if I didn't have Sleep Apnea. Also, my BP is around 145-150/95, I'm 44 yrs of age, I weigh about 215 lbs, and am 5"7.

Shortly after the dental appointment, (about 2 months ago), my new ADHD specialist was questioning me about my sleep habits, and I told him that my partner tells me I sometimes kick, punch and scream, occasionally very hard, in the middle of my nightmares. My new pdoc was astute enough to suggest that I may have pseudo-REM Sleep Behaviour Disorder /w Sleep Apnea. Apparently Sleep Apnea can shut down the neural mechanism that is supposed to inactivate motor movement during sleep. When I went home and read about this, I started to really hope it was Sleep Apnea, because I learned that another major reason for these movements and vocalizations during REM sleep, can be that you're in the early stages of a neurodegenerative illness, and statistically will have over a 90% chance of dying of Parkinsons or Lewy Body Dementia in the next 5-15 years, (unfortunately it seems its also possible to have both Sleep Apnea and isolated REM Sleep Behaviour Disorder).

Anyway, with this knowledge I was way too anxious to let the Canadian medical system take it's sweet time in delivering a second opinion after three months or more, and managed to get a hold of a Resmed Airsense 10 Auto CPAP /w humidair, (but don't have a heated hose yet). I started therapy two nights ago, (OSCAR image of 1st night's data: https://imgur.com/60H3BX3.png), at 4-12 cm, 15 min ramp, humidifier @ 4. The OSCAR data revealed that I had an AHI of 19.27, 57 "Clear Airway" events, with 48:55 being spent in apnea over a long 11:03 hrs of CPAP therapy, (I took about 40-50 min to fall asleep if I remember). The second night's sleep data is not very useful, as I took my ADHD medication too late, and couldn't sleep until about 5 AM. Even with an AHI of 19.27, I woke up feeling more "with it" than usual, (maybe a 15% improvement in energy and cognition from a normal night), and throughout the day, with my ADHD meds, was able to make a strategic plan in my job search in a way that I' hadn't been able to come up with before.

I know no one is allowed to give official medical advice, but I'd be so grateful for anyone's input regarding whether its likely I have sleep apnea, based on these results from the first night of CPAP therapy. Also, does anyone have any suggestions on how I could adjust the pressure settings. Since its almost hitting the max. pressure, should I raise the upper limit to 20, since its on auto? Should I raise the lower limit as well? Even though I have the humidifier set to 4, my mouth gets very dry as I fall asleep, and remains so in the morning. Is there a specific kind of heated tube that would help best with that?

If anyone else has any recommendations or observations based on my data, or the information I've given, please feel free to chime in!

Thanks so much!

Ben

Just to clarify - it's the min. pressure setting that 'does the job', the max setting is often left at e.g. 20, as it is not the main worker. So many people can't breathe at 4 cm min., so start at e.g. 6 (with the max at 20 or not a lot lower) for at least a few nights to see how things go, and ideally use Oscar to get all the info. It's also better to leave the max higher til you know more as it can inadvertently 'cap' the min. when that wants to go higher. I'll leave the other possible diagnoses to others here.

Bento78,

Welcome to the forum.

The short answer to the question posed in your title is: Yeah, there's a pretty good chance you have OSA and if you have OSA, there's a pretty good chance that you need more pressure to treat it.

But it's not as simple running your APAP wide open. (More about that in a bit.)

The first question: How much did you actually sleep on Tuesday night?

The second question is: While it looks like there are a lot of centrals, are they real centrals or are they part of what's called "sleep-wake-junk"?. Sleep-wake-junk (SWJ) are places where you are not really asleep and you simply take longer than the machine expects to inhale, perhaps because you are transitioning wake and sleep. On an in-lab sleep study, the tech would have a whole lot more data to determine whether you were physically asleep and whether those represent a real central apnea or whether they are just an artifact of the fact that you're not yet totally asleep and hence not to even score them.

Next an observation: You had more than twice as many OAs scored as CAs. That's why I'd say you probably do have OSA. But it still depends on the answer to Question #1: How much did you sleep during the night?

Now since there's a pretty good chance you do have OSA and since you said you did feel somewhat better after this night, I'd say that it's very reasonable to continue the APAP experiment.

But clearly you need to think about the pressure range.

Your APAP is currently set 4-12 (on this night) and you're topping out at 12 with a 95% of 11.96 and a median pressure of 10.72. All of that point to you needing more pressure to control the obstructive events. But because of the centrals (which may not be real), you still need to be a bit cautious about the dial winging and you need to keep an eye on the centrals. Because if they don't come down in a few days or if they start to increase during times you know for sure you were sound asleep, then you might have some things going on beyond simple OSA. But deal with that after you have more data.

My recommendation would depend on whether you are comfortable with breathing at a pressure of 8 or 9 cm. Because I think you probably need to increase the min pressure to at least 9 cm, and maybe 10 cm. But if you can't stand that right now, then try to increase the min pressure to at least 6 or 7.

I'd be inclined to first increase the max pressure to only 15cm. But I'm kind of cautious about pressure increases because I've had to deal with aerophagia caused by even low pressures.

In other words, try running at 9-15 or 10-15 if you can stand it when you turn the mask on and it's blowing at 9 or 10cm. And see what happens.

I'd try a setting of min 10, max 20, based on what you've got there, 9 for a minimum is too low, based on how the pressure keeps jumping up when it gets down that far. Of course, with EPR, it's actually giving you a minimum of 6.

Alternatively, you can set the max, and a lower EPR, ie, an EPR of 2, min 9, EPR 1 min 8.

Thank you so much Julie, robysue1 and palerider for your insightful replies. To the best of my knowledge, I slept fairly soundly after falling asleep after about 40-50 min. It’s possible I might have gotten up for water or the bathroom once, I don’t even remember, but I definitely wasn’t waking a lot during the night.. I kind of think I slept straight through for about 9 hours.

It wouldn’t surprise me if I have a combination of CSA + OSA, I’m wondering if any of my medications might contribute to CSA in some. I’m going for a consultation with a sleep doctor on the 29th, and I’m sure they’ll send me for a sleep study. In the meantime, tonight I’ll take both your advice to set the min at 10, and I’ll try setting the upper limit at 17, and see what happens.

I shall report back with my progress. A million thanks to you three, I know nothing, and you’ve been so helpful.

Thank you!

Ben

I found this post on CPAP induced CSA events interesting..

RE: Can EPR use cause Central Apnea Events?
My interest in this subject was instigated by the observations that with CPAP treatment my sleep apnea which was diagnosed at an AHI of 37, has been significantly reduced to about 3, but now the ratio of apnea incidents have become central sleep apnea (CSA) dominated. This raises the question of how one optimizes CPAP settings to minimize AHI and in this case CSA events.

The advice on how to do this is kind of all over the map, but the most frequent advice is to keep the maximum treatment pressure as low as possible. And after that it is often suggested to limit or eliminate the use of Expiratory Pressure Relief (EPR). Why would this be? Well there is a fairly common theory as to why CSA event frequencies are revealed or even elevated when CPAP therapy is introduced. Greatly simplified, your body adapts to higher levels of CO2 in your blood due to untreated general sleep apnea. When CPAP is introduced the efficiency of breathing is suddenly improved, and CO2 levels go down during sleep and treatment. Your body responds to the lower CO2 by suppressing respiration, and that can cause CSA events.

Basic physics tells us that when we put higher pressure air in our lungs it will contain more oxygen, and as we know breathing is much easier at sea level than it is on top of Everest. If we limit the maximum pressure in the lungs, then breathing efficiency is reduced and CO2 is relatively elevated. With the EPR pressure is even further reduced in the exhale cycle. This improves the total air mass transferred during each inhale and exhale cycle. If EPR is limited or eliminated then breathing efficiency is again reduced and CO2 increased. Again a good thing in trying to avoid CSA events.

The dilemma of course is that this may be the opposite strategy to what we want to use to minimize obstuctive sleep apnea (OSA). So what does one do? If one is in this situation there is some good news. Studies have found that in the majority of cases this is only a temporary condition. This quote from an emedicine article is a good summary of the study knowledge:

"Central sleep apnea may emerge during titration of CPAP in patients previously diagnosed with obstructive sleep apnea. This syndrome, termed complex sleep apnea, has become a controversial topic in the sleep literature [9] and has been raised as a possible type of difficult-to-treat obstructive sleep apnea. As many as 6.5% of patients with obstructive sleep apnea may develop emergent or persistent central sleep apnea with CPAP treatment. CPAP emergent central sleep apnea is generally transitory and is eliminated after eight weeks of CPAP therapy. Persistent CPAP-related central sleep apnea has been observed in approximately 1.5% of treated patients.

In other words in about 75% of cases the incidence of CSA will be reduced over the first 8 weeks of treatment. As a result of this I have come up with a personal strategy on how to deal with my situation. I will ignore CSA events and optimize my CPAP setup based on OSA and hypopnea events only. Then after 8 weeks I will review the situation again, and only if necessary then will I reduce maximum treatment pressure and EPR use. But of course, I will hope that this is not necessary.

Here is a good article from Fisher & Paykel that does a good summary of the issue.

The True Prevalence of Central Apneas in CPAP

And if you want to do a deeper dive there is the emedicine article that the quote above was taken from.

Central Sleep Apnea Syndromes

Bento78 wrote: ↑

Thu Sep 22, 2022 9:41 pm

I found this post on CPAP induced CSA events interesting..

RE: Can EPR use cause Central Apnea Events?

Yes, it can, for a relatively small percentage of people.

You don't have a CSA issue, at least not on what you've posted so far, you need to work on reducing your obstructive apnea before you even start thinking about CSA.

Totally agree with Palerider.

We don't know for sure that your centrals are for sure asleep centrals. They could very well be arousal related due to the obstructive apneas causing awakenings/arousals.

Fix what you know for sure needs fixing ...and can be fixed...and then see what's left. Right now the obstructive stuff is the main problem and you fix that with more minimum pressure. Reduce the OAs/hyponeas and once that is done to an acceptable level THEN start worrying about the centrals....if you have enough of them to worry about.

Do remember that it is normal to have a few centrals show up. We all have them happen. So an occasional central is to be expected.

Bento78 wrote: ↑

Thu Sep 22, 2022 5:00 pm

So I had a sleep study ~ 10 yrs ago, but didn't sleep a single wink all night, and the tech told me I didn't have any kind of sleep disorder, (despite me protesting that they couldn't possibly know that as I hadn't slept).

Point of fact, the tech would (or at least should) be in a far better position to know whether or not you slept.

It has been my observation that people with a Sleep Efficiency of <70% often claim that they didn't sleep at all, and nearly all of them significantly underestimate the amount of sleep they actually got.

Interesting article.

Something to think about when your charts don't look like such a hot mess.

Bento78 wrote: ↑

Thu Sep 22, 2022 9:41 pm

In other words in about 75% of cases the incidence of CSA will be reduced over the first 8 weeks of treatment. As a result of this I have come up with a personal strategy on how to deal with my situation. I will ignore CSA events and optimize my CPAP setup based on OSA and hypopnea events only. Then after 8 weeks I will review the situation again, and only if necessary then will I reduce maximum treatment pressure and EPR use. But of course, I will hope that this is not necessary.

I agree with PaleRider and Pugsy: I would definitely not be worrying about CSA yet.

You said that you think you were asleep most of the night and your obstructive events are not under control. That points to OSA.

Yes, a few people have problems with centrals emerging from beginning PAP therapy for OSA. But for most of those people, the problem does resolve after a few weeks.

So for now you need to worry about getting the OAI and HI and (OAI + HI) all under control while still sleeping well with the mask on your face. And if you're going to track data, it's also important to track how you feel when you wake up and before you look at the data. (Too many newbies allow the data to determine how they "ought" to feel.)

Rubicon wrote: ↑

Fri Sep 23, 2022 8:19 am

Bento78 wrote: ↑

Thu Sep 22, 2022 5:00 pm

So I had a sleep study ~ 10 yrs ago, but didn't sleep a single wink all night, and the tech told me I didn't have any kind of sleep disorder, (despite me protesting that they couldn't possibly know that as I hadn't slept).

Point of fact, the tech would (or at least should) be in a far better position to know whether or not you slept.

It has been my observation that people with a Sleep Efficiency of <70% often claim that they didn't sleep at all, and nearly all of them significantly underestimate the amount of sleep they actually got.

Yep. That's one problem with insomnia---you're so worried about not sleeping that you vastly overestimate the time you are awake and hence underestimate the time you were asleep.

Back during the darkest, dark days of my difficult CPAP adjustment period when the insomnia monster was running wild in my bedroom, I, however, was an outlier even in this: I'll never forget my first BiPAP titration in-lab sleep test in November 2010. When ask the question, "How much sleep do you think you got?" I dutifully answered the question as honestly as I could and said "About 4 hours." When I discussed the actual results, I was shocked when the PA told me the lab tech scored a whopping 111.5 minutes of actual sleep for a sleep efficiency of 28.8%.

Bento78 wrote: ↑

Thu Sep 22, 2022 5:00 pm

I do also have ADHD, which I'm treated for

The medical profession has a long history of diagnosing sleep apnea as ADHD.

Results: Attentional deficits have been reported in up to 95% of OSA patients. In full syndromal ADHD, a high incidence (20% to 30%) of OSA has been shown. All 6 interventional studies reported improvements in behavior, inattention, and overall ADHD after treatment of OSA.

https://pubmed.ncbi.nlm.nih.gov/21808754/

Thank you to all the additional people who have shared their insights. ChicagoGranny, you bring up an excellent point, I’ve been wondering how much my SA is contributing to my ADHD.. thanks to everyone’s help, I’m confident I’ll find out before too long.

Just wanted to give a quick update, I accidentally left the bottom pressure at 4 last night, and only changed the top one, to 17. On top of that my mask was leaking over 30% of the time, so I didn’t post last night’s data, (I slept for about 9 hours and had an AHI of 9 point something, down from 19 the previous night, now that the upper pressure was increased from 12 to 17). Anyway, I’ve set things properly now, and will make sure I re-fit and tighten the mask to minimize leaks, and hope to have better data tomorrow!

Till hose-heads rule the world,

Ben

Best of luck sleeping tonight Ben!