Still Tired with APAP, any help???

Hello All- I've been on APAP now since June, I've changed my settings from the doc prescribed 8-12 to 9.2-13 and still feel like I want to go back to bed after breakfast. With straight CPAP set from 8(15 min. ramp) to 12 I felt pretty good except for this horrible GERD and aerophagia. Now the GERD and aerophagia seem to be under control for the the most part but I'm so tired I feel miserable again. I spent out of pocket almost $1,000 for this APAP and now feel like I may have wasted my money. What can I do to feel better? I know I've posted this question before but I am getting depressed about this whole thing now since I feel almost as tired as before CPAP. Is it ALWAYS going to be this way?? Sad and tired once again!!!

Is your tiredness correlated with a higher AHI?
If yes, start nudging your bottom pressure up gently (a Resmed let you do that) and once you get GERD, nudge it down to where you felt better. There are many minimum options between 9.2 - your minimum and 12 - what was good for your sleep but caused you GERD.

An alternative is to go the bi-level track: it helps some people get a handle on their aerophagia, and yet have the necessarey high pressure for exhale.

A third option: Some people feel better with the Respironics or the PB auto than they do with the Resmed. Each auto machine has its own way of treating apneas, and sometimes, one brand's way is simply not good for some people.

O.

If you were titrated at 12 ... then your lower pressure is too low.

As has been suggested to you in the past .... you need to deiced which is worse, GERD/aerophgia or inadequate pressure to treat your apnea.

I would choose to treat the apnea and allow the body to recover from and prevent further damage from hypoxemic hypoxia caused by apneas then work to cure the GERD/aerophagia as secondary issues ... but I'm just weird that way.

Dreamstalker- What would you suggest I use as my lower pressure?? I was under the impression that APAP machines could cover a large range of pressures and still be effective. Why is 9.2 too low?? It was suggested to me a few weeks back to change the lower pressure to 9 and raise the higher one to 13, but I still do not see results. What is your suggestion to help with the GERD ? I take a Pepcid before bed every night already and can't use Prilosec because it gives me stomach aches. An

Additional thoughts/questions.....
Do you know what your 95% pressure is? (where the pressure is going during the night) Pressure changes can disturb sleep.
Are you getting ENOUGH sleep?

Den

sounds like you are stuck between a rock and a hard spot,

you have to decide what you want to fix, if the pain from the aerophagia is more than the tiredness,
then you throttle that by changing the Minimum pressure. Forget about your Maximum pressure changing
that does nothing. Set the Maximum pressure up to 15 or 20 and forget about it.

Next you look at your AI indice, don't really care what HI does but AI is the important number to look at. That value
gets addressed by moving the Minimum pressure up or down. Lower pressure helps reduce pain from aerophagia,
but if you lower pressure to reduce pain, AI goes up when AI goes up that can prolong the pain of aerophagia because
when you have an apnea and laying flat or horizontal, when you recover from the apnea you take a large gasp of air, that
gasp sucks stomach acid up past the LES valve which only bathes it in more stomach acid, and that is the problem which allows
aerophagia to exist, stomach acid as eroded your LES valve where it doesn't seal, this removes the CPAP backstop for CPAP pressure s there is no place for that pressure to back up against so it enters the stomach and even the intestine which causes severe abdominal pain what we call aerophagia. Most doctors have no idea what aerophagia is, your GI Specialist will know.

So what you really need is a good acid pump inhibitor like Prevacid or Prilosec (can tell you Prevacid works much better but it is prescription only and prescribed by a GI specialist).

So at this point, you really need to use the machine you have in CPAP mode with Ramp and avoid frank apnea. You need to set the Ramp pressure very low to reduce the pain so you get to sleep, to help the pain you might try a Tylenol (a NSAID may only make the stomach conditions worse).

But what IS your 95% pressure? That is your CPAP pressure, that is the pressure you need to set your machine at in CPAP mode, then you need to set a LOWER Ramp pressure, very low like 6.5 if you can tolerate that, then set the Ramp timer for the longest time period, on that machine it is 30 minutes. And every time you wake with that machine you have to push the Ramp button.

You also need to elevate the head of your bed by at least 3-1/2". But if the aerophagia persists, you may have to see a GI specialist for more advanced treatment of a dysfunctional LES. But your GI specialist will ask how long you have had GERD and if you had it 5 or more years they will want to do an endoscopy exam of your esophagus and LES (they knock you out for that). But during that exam they can fix your LES with the laser where it may heal and seal up much faster, that means your GERD can go away sooner and once your LES heals and seals again the aerophagia should resolve where CPAP treatment can work its magic.

Will a Bipap machine help or have been better? I don't think so, that ONLY works if your main SDB is Hypopnea, if the primary events seen are Apnea, then that is taken care of by EPAP pressure which is same as CPAP, so using a Bilevel or Bipap most likely wouldn't help you either.

Ramp is what you need to avoid the pain and get to sleep, once you are a sleep the pain from aerophagia should not be noticed, however, chronic muscle-skeletal pains have been known to interrupt your sleep architecture, so if that is possible you can assume that stomach/intestinal pains can do the same thing.

You may NOT have even known you had GERD before CPAP. CPAP lets you know in a hurry you have severe GERD, consider that a blessing before the symptoms showed up on their own, because they are finding untreated GERD as being one of the leading causes of stomach cancer (reason a GI specialist will want to do a endoscopy exam, they also do a biopsy to check for cancer and h-pylori bacteria).

So at this point, my suggestion is:

1. Elevate the head of your bed by at least 3-1/2", put a 4x4 under the legs, this will keep stomach contents in stomach.
2. Set your Vantage to CPAP mode so you can use the Ramp feature, don't recommend use of EPR at all, in fact I'd discourage it.
3. Set the lowest Ramp starting pressure you can, don't go any lower than 6.0, set timer for maximum 30 minutes.
4. Set CPAP pressure to last seen 95% or titrated pressure.
5. Use the Ramp every time you go to fall asleep, if you wake up during the night use the ramp.

Alternately you can use AutoSet mode with a low to high range:

1. Set Maximum pressure well above your titrated or 95% pressure if that is 13 set it to 16 or 20.
2. Set Minimum pressure to lowest you can tolerate without starving for air, I suggest 6.0 cm.
3. Machine has Settling feature, set it to 30 minutes and use it when you start therapy.

IF you want the aerophagia to go away you have to avoid frank apnea, those are what suck stomach acid past the LES and prevent it from healing. Use just the CPAP pressure needed to prevent that.

P.S. This may seem totally contrary to anything you have read or heard but try: eating a small bowl of Honey Nut Cheerios before bed, don't know what it is but that seems to absorb stomach acid real good and may help with the aerophagia, maybe one gets hung up on the LES I don't know.

IF your "apnea" is showing up above 10 cm pressure, then using the Auto mode will allow those above to go by untreated. If that is your condition you observe the AI indice and adjust Minimum pressure up until AI gets to 1 or sub 1. But if you have aerophagia, you have to allow the LES to heal before you apply pressure to fully resolve that.

WOW thanks for that detailed post!!! I am most grateful!!! My AI and AHI numbers are very low, usually 1.something and often 0.2 or 0.1 for AI even when set at APAP mode with pressures of 9-13. When set in CPAP mode my pressures where 8-12 with a ramp of 15 min. I was under the impression that LONG ramp periods where counterproductive to apnea treatment in that they would not "catch" many apneas while ramping and you would wake feeling even LESS rested. Is this not the case?? When I use a low pressure with the APAP machine I feel even less rested the next day. For example when the doc prescribed the initial APAP pressures of 8-12 I felt like crap!! This may sound STUPID but how do I know what my 95% pressure is-is that what is recorded the next morning on my efficacy data? I do know what I was titrated at- 12. I guess I sound pretty dumb huh? I have a wedge pillow that I use every night and it helps some with the GERD but I am now having some mild muscle spasms from sleeping on my back all the time and at a slant , puts pressure on the lower back I think. I can't sleep on my side- it makes the aerophagia much WORSE. I feel like I am a broken "mess", nothing seems to work well anymore and when it does it usually doesn't last very long. I am just so tired of feeling tired. I think you are right though about using the CPAP- I did feel better when on that except I suffered so badly with GERD and the aerophagia was beginning to be a real pain- no pun intended!! Maybe I will try CPAP again with the pressures lower in ramp(like maybe 7) and then use my upper pressure of 12. Starting CPAP with a pressure of 9 seems to give me GERD right away, but when I use it in APAP it seems fine. Is the pressure harder in CPAP mode? Sounds ridiculous doesn't it but it is the truth. A few nights ago I tired CPAP with starting pressure of 9(like in APAP) and I couldn't tolerate it more than 5 minutes before I felt the GERD, so I switched back to APAP with a starting pressure of 9 and I feel right asleep with no GERD. What's up with that?? THANKS for all the suggestions-I guess I am just going to have to bite the bullet and try CPAP again for awhile. Why did I even bother to buy the APAP if I am just going to use it in CPAP mode?? Live and learn!!!!

I see that everyone is trying to help you with your sleepiness, but has your doctor ruled out other issues like your thyroid? I was constantly feeling tired even tho I felt I got enough sleep (before CPAP which I have been on about a month) and they found out my thyroid was low. So now I take meds for that and when it started kicking in I felt a not as tired and sleepy as before but still tired.

Just a thought on my part.

grumpygirl wrote:WOW thanks for that detailed post!!! I am most grateful!!! My AI and AHI numbers are very low, usually 1.something and often 0.2 or 0.1 for AI even when set at APAP mode with pressures of 9-13. When set in CPAP mode my pressures where 8-12 with a ramp of 15 min. I was under the impression that LONG ramp periods where counterproductive to apnea treatment in that they would not "catch" many apneas while ramping and you would wake feeling even LESS rested. Is this not the case?? When I use a low pressure with the APAP machine I feel even less rested the next day. For example when the doc prescribed the initial APAP pressures of 8-12 I felt like crap!! This may sound STUPID but how do I know what my 95% pressure is-is that what is recorded the next morning on my efficacy data? I do know what I was titrated at- 12. I guess I sound pretty dumb huh? I have a wedge pillow that I use every night and it helps some with the GERD but I am now having some mild muscle spasms from sleeping on my back all the time and at a slant , puts pressure on the lower back I think. I can't sleep on my side- it makes the aerophagia much WORSE. I feel like I am a broken "mess", nothing seems to work well anymore and when it does it usually doesn't last very long. I am just so tired of feeling tired. I think you are right though about using the CPAP- I did feel better when on that except I suffered so badly with GERD and the aerophagia was beginning to be a real pain- no pun intended!! Maybe I will try CPAP again with the pressures lower in ramp(like maybe 7) and then use my upper pressure of 12. Starting CPAP with a pressure of 9 seems to give me GERD right away, but when I use it in APAP it seems fine. Is the pressure harder in CPAP mode? Sounds ridiculous doesn't it but it is the truth. A few nights ago I tired CPAP with starting pressure of 9(like in APAP) and I couldn't tolerate it more than 5 minutes before I felt the GERD, so I switched back to APAP with a starting pressure of 9 and I feel right asleep with no GERD. What's up with that?? THANKS for all the suggestions-I guess I am just going to have to bite the bullet and try CPAP again for awhile. Why did I even bother to buy the APAP if I am just going to use it in CPAP mode?? Live and learn!!!!

Yes, your 95% pressure should be in the efficacy data in the morning (in APAP mode).

Did you ever try CPAP mode with EPR? (and which setting?) EPR is available in CPAP mode but not in APAP mode on the Vantage. However, I've heard that ResMed's new model APAP is supposed to have exhale relief in Auto mode.

Den

I see you have a nasal mask, but have you ever tried either a full face one or else mouth taping - unless you know for SURE you don't open your mouth while asleep, letting out all the 'good' air? That happened to me and a lot of others here, and once taken care of, feel a whole lot better. I also think you really need to address the GERD with meds rather than just elevating your bed.

Hi Grumpygirl

I am in the same boat as you are - still feel like a limp noodle all day. I went from a cpap which I used for about a year and a half to an apap for the last year and a half with not much difference. My numbers on apap are about what they were on cpap. I did request my doctor end my bp meds after doing a little research because I felt they were the cause of my constant fatigue. I had about a 70 percent reduction in fatigue after stopping my regular bp meds and using a dieretic only.

Gradually over the last 1/2 year I have grown more fatigued as the days go on. It didn't help much when I took my Provigil either, I found to function I needed to have at least 6 cokes a day to have enough energy. I have a lot of allergies and work in a dusty dirty place which caused me to take zyrtec daily. Thinking Zyrtec might be part of the problem I stopped taking zyrtec and it seemed to help somewhat. I don't know if my allergies are a big contributor to my fatigue or not but I am thinking of having some testing done. Maybe if I can identify some problem areas I can avoid them which may or may not help.

Don't give up on your apap - maybe your problem lurks in other areas. As mentioned by someone else thyroid levels could contribute and I don't know your age but I have recently found out it is possible for menopausal issues to contribute to fatigue because of some medications not being absorbed at the same rate because of lower hormones. This came from a phsychiatrist concerning depression medication.

good luck

Dale