Apnea wakes me while on Bi-PAP

Thank you. I will ask about that.

Last night, I actually had a better night. I did take an Ambien as I have been doing, but I slept on through my usual 2:30 wake up. The doc raising my IPAP pressure back to 10-20 plus finally getting a mask to stay sealed allowed me to get a bit of badly needed sleep. I'll be hoping for 2 nights in a row tonight.

Thanks,
Tony

Tony,

It sounds as though your doctor is working with you and, since you slept better last night, you are on the right track. You are running in a mode similar to mine. Auto with back-up. It will get better. It's a lot to get used to.

You might consider getting the software and a card reader. It's been very helpful to me to be able to see what happens to me while I sleep. It's not covered by insurance, but totally worth it. Having to run to the DME or DR. to download your reports is a royal pain in the neck. Here is an example of the printout from my machine (same as yours)



Best wishes,
Bev

OutaSync wrote:Tony,

It sounds as though your doctor is working with you and, since you slept better last night, you are on the right track. You are running in a mode similar to mine. Auto with back-up. It will get better. It's a lot to get used to.

You might consider getting the software and a card reader. It's been very helpful to me to be able to see what happens to me while I sleep. It's not covered by insurance, but totally worth it. Having to run to the DME or DR. to download your reports is a royal pain in the neck. Here is an example of the printout from my machine (same as yours)

<snip>

Best wishes,
Bev

Bev,

That chart is an outstanding improvement on the 1st ones you were showing last year.

That AHI score is like mine tends to be now - under 0.5 - was this due to you eventually getting used to the SV part (I see it is very very active throughout the night).

DSM

Doug,

I'm not sure what the difference is from night to night. That particular night is the only one that I can recall where my tidal volume was over 400. It's usually in the 370 range. I rarely have more than one apnea a night, sometimes none. I love that the SV kicks in and makes me breathe somehow. I don't know if I could optimize my settings any more, AHI-wise, but I still wake up often and am always conscious of the danged mask. The noise of the machine doesn't bother me anymore or maybe it just got quieter.

When I travel I use my Auto M and my AHI is much higher, so I'm glad that I made the decision to go with the SV. I can't say that I've ever woken up feeling well rested, but I know that I'm better off now than I was a year ago. So, thank you very much.

And I have to tell you that your gggrandbaby is a bundle of darling!

Bev

Bev

Thanks for that info - I really do look forward to using my SV. I now no longer have any fears about the therapy fading away again as happened so many times before until I obtained the SV. I just wish I had more respiratory knowledge & expertise to be able to articulate in clinical detail just why it makes the difference. As I have said many times, on cpap. auto & even bilevel I get fluctuating results and also get regular cramps (lower legs) in the early hours but with the SV they just don't occur or are so light on the odd occasion one looms, they are gone before I am in any way bothered. Interestingly they do occur but less severely if I use the Vpap Adapt SV so that adds a twist that must translate into a clue if I could just unlock the secret - That ventilation the SV algorithm provides just seems to make the difference between mediocre therapy on conventional cpap vs get up & go daily results off both SV machines.

Cheers Doug

PS - thanks for the comment about young Ryland - everytime I see that pic I feel a glow. He was just over 2 months old when it was taken & by all accounts is an adorable, lovable little baby. His parents are lovely natured and he seems to echo that in bucketfuls.

D

dsm wrote:... on cpap. auto & even bilevel I get fluctuating results and also get regular cramps (lower legs) in the early hours but with the SV they just don't occur or are so light on the odd occasion one looms, they are gone before I am in any way bothered. Interestingly they do occur but less severely if I use the Vpap Adapt SV so that adds a twist that must translate into a clue if I could just unlock the secret - That ventilation the SV algorithm provides just seems to make the difference between mediocre therapy on conventional cpap vs get up & go daily results off both SV machines.

Doug, I just took a brief look through medical literature to see what I could find out about that. I came up empty handed regarding anything specific to CPAP modality or model. I could be very wrong, but I don't think your experience with leg cramps relative to certain machines/modalities is common.

Another hypothetical area for consideration might be the sleep architecture that each machine modality manages to indirectly produce for you. If the BiPAP autoSV manages to yield more Slow Wave Sleep (SWS), for instance, then diminished oxidative stress in your leg muscles may explain those allayed muscle cramps:
http://www.sciencedirect.com/science?_o ... ecca894893

Okay, the above interesting link is about the brain ("cortical circuits"). However SWS is where cellular replenishment throughout the entire body supposedly occurs. So if your leg muscles are a bit prone toward oxidative stress, machine modalities not yielding adequate SWS may allow for leg cramps. Conversely, if autoSV yields better SWS, perhaps those leg cramps are allayed via less oxidative stress.

-SWS wrote:

dsm wrote:... on cpap. auto & even bilevel I get fluctuating results and also get regular cramps (lower legs) in the early hours but with the SV they just don't occur or are so light on the odd occasion one looms, they are gone before I am in any way bothered. Interestingly they do occur but less severely if I use the Vpap Adapt SV so that adds a twist that must translate into a clue if I could just unlock the secret - That ventilation the SV algorithm provides just seems to make the difference between mediocre therapy on conventional cpap vs get up & go daily results off both SV machines.

Doug, I just took a brief look through medical literature to see what I could find out about that. I came up empty handed regarding anything specific to CPAP modality or model. I could be very wrong, but I don't think your experience with leg cramps on certain machines is common.

Another hypothetical area for considering might be the sleep architecture that each machine modality manages to indirectly produce for you. If the BiPAP autoSV manages to yield more Slow Wave Sleep (SWS), for instance, then diminished oxidative stress in your leg muscles may explain those allayed muscle cramps:
http://www.sciencedirect.com/science?_o ... ecca894893

SWS

Many thanks for the link I will go visit it. Just to add to the comments made earlier I do get deeper sleep with the Bipap SV than with the Vpap SV - I picked up on that the very 1st day I tried either (approx 18 months back) but the daytimes are good on both with a possible slight edge to the Vpap SV.

My doctor prescribed quinine which I bought the day before switching back from Vpap SV to Bipap SV & that bottle now sits on the shelf unopened.

Doc said he had nothing he could tell me about what caused the cramps. Only other clue is that I would often get them after either (or both) drinking red wine / doing lots of jogging. These are muscle cramps mostly in the lower legs but sometimes would be all the way along the legs.

Again tks

DSM (now off to that link)

Read the abstract & there is a lot to absorb in it. The full doc is purchase only. Will do some more re-reading of it.

-SWS wrote:Okay, the above interesting link is about the brain ("cortical circuits"). However SWS is where cellular replenishment throughout the entire body supposedly occurs. So if your leg muscles are a bit prone toward oxidative stress, machine modalities not yielding adequate SWS may allow for leg cramps. Conversely, if autoSV yields better SWS, perhaps those leg cramps are allayed via less oxidative stress.

These Google search links may be more "on target" regarding relationships between Slow Wave Sleep and cellular-regeneration/oxidative-stress in muscles:
http://scholar.google.com/scholar?hl=en ... tnG=Search
http://scholar.google.com/scholar?hl=en ... tnG=Search
http://scholar.google.com/scholar?hl=en ... tnG=Search

Maintaining that "deeper sleep" via the BiPAP autoSV may plausibly be your key to keeping those leg cramps away---exactly as you observe.

Hypocapnia can cause dizziness, numbness ,cramps in the extremities.
If one of the machines causes hyperventilation....

O.

ozij wrote:Hypocapnia can cause dizziness, numbness ,cramps in the extremities.
If one of the machines causes hyperventilation....

O.

Ozij - that is where I think the difference is between the machines - Bipap SV seems to prevent hypocapnia (my usage) vs other machines.
Have long suspected CO2 washout being a cause.

The links SWS has provided shd also prove interesting info

So the next question that comes to my mind is - does this demonstrable set of conditions (e.g. cramps & possible hypocapnia) relate in some
way to why some of us on cpap therapy, get initial daytime benefits then watch it it fade away. If I could demonstrably reproduce this situation
in my own usage is it possible that many other people fit into a similar situation & that lack of clinical research has not come up with this
'syndrome' largely because so few regular users of cpap have extensively tried an SV. The cramps are one long standing clue. The other is
my own (as I see with so many others) initial boost from cpap then the fade away to the point it caused me considerable anxiety as to why
cpap theapy looked like a salvation only to begin to disappear. Going Bilevel delayed the fade longer that straight cpap had. SV appears to
all extents & purposes, created the benefits and provided a consistently good experience to the point my health & weight appear now to be
the best they have been in years (it was approx 25-30 years ago I weighed in at 80 KG & perhaps 20+ years ago that I was this fit).


I view the SV as being a Bilevel with 2 added plusses, 1) is the auto rate tracking & 2) is the ventilation if av peak flow (or vol) is dropping
off target. The Bilevel aspect of the machine quite adequately (in my case) addresses OSA, is then the SV & rate tracking providing an extra
kick that has lifted me past that threshold of inadequate daytime alertness caused by some other situation such as either what SWS has
honed in on, or some sort of hypocapnia that Ozij has highlighted. PS have changed masks part way through the period of SV use. That
change made the Vpap SV more tolerable - it was a swap from a Ultra Mirage FF mask to a quattro.

Some thing has to explain why the past 12+ months have been such a marked & big improvement. Kind of like being resurrected from a
very prolonged slow death.

Tks DSM

ResMed wrote:The minimal pressure support during normal breathing or hyperventilation prevents over-ventilation and hypocapnea

Resmed documentation quoted

Since a proprely titrated VPAP adapt SV is supposed to avoid overventilation and hypocapnia, and since we're discussing a VPAP adap SV is on self titrated settings, then if it were me, I would certainly consider a wrong setting - possibly in the minimal pressure support - as a root for that problem.


O.

ozij wrote:

ResMed wrote:The minimal pressure support during normal breathing or hyperventilation prevents over-ventilation and hypocapnea

Resmed documentation quoted

Since a proprely titrated VPAP adapt SV is supposed to avoid overventilation and hypocapnia, and since we're discussing a VPAP adap SV is on self titrated settings, then if it were me, I would certainly consider a wrong setting - possibly in the minimal pressure support - as a root for that problem.


O.

Ozij

In terms of pressures as measured from the machines using a dial manometer, they are identical. But I agree the different machines do work differently but I would have to argue that these machines are not that minuscule in their adjustments that close to identical settings are going to make a radical difference. Also just want to reiterate that ...
- cpap/apap result in the worst of the cramps + failing therapy effectiveness
- bilevel less so than the above but still occurring
- Vpap SV similar to bilevel re the cramps but consistently good on daytime effectiveness
- Bipap SV the cramps go away but there is a slightly (very slightly) less daytime effectiveness compared to the Vpap SV

The really odd part is describing the differences between Vpap SV & Bipap SV

With Vpap SV - light sleep but always wake early & have a good day - struggle with mask issues
With Bipap SV - deep sleep (so much so I look forward to it (dream machine)) - no cramps - but occasionally feel a tad sleepy in daytime

(This comment may seem a bit bizarre but it is an honest observation: over time I find that I want to keep enjoying sleep with Bipap SV &
grow a little less inclined to get up early when compared to the Vpap SV. Have been back on the Bipap aseveral weeks now & am starting to
notice this oddity again. I really do like sleeping using the Bipap SV. The reason I switched last time to the Vpap SV was because of a very
similar pattern taking place even though it was over months. I commented on this in a thread I was running in 2008 about the Bipap SV).

Both machines have the same Epap & same Ipap & same PS (as measured by a dial manometer)
To achieve this, the Bipap SV is set 11/14-20 max vs the Vpap SV set 10/13-20 max.
Both sets of data show similar patterns of PS & tidal flow. Also it is worth adding that the greatest weight loss and exercise regime
occurred while using the Vpap SV (despite the occasional cramps that were occurring).

I am happy to try variations of settings but remember that the only diff between Bipap SV & Vpap SV is that some cramps do occur with
the Vpap SV whereas with cpap they occur much more regularly (several times a week).

DSM

PS - every user of a Vpap SV I have spoken to (some face-to-face) all agree they tend to sleep lightly with the Vpap SV machine. A common
theme with that machine (& interestingly the Vpap III as well - I have o idea why).

PPS - one extra comment that may seem quite odd but is an honest observation: using the Vpap SV seems to engender the best daily
exercise attitude whereas using th Bipap SV seems to bring about the calmest daily moods & nicest sleep ?. I suspect I will be tempted to
switch machines again if the current liking for sleeping in keeps growing ! (yes it seems quite odd to me too but the choices thus far
have struck a very good balance & produced consistent long term results ).

I also favor the general theory that autoSV "ventilation" itself indirectly helps to keep DSM's leg cramps at bay. And that's essentially the theory DSM has been maintaining for quite some time, regarding inefficient gas exchange w/out SV. Along those lines, DSM mentioned feeling "stretched" on APAP (pulmonary stretch, right??). So one possibility along that gas-exchange theory is excessive inspiratory stretch followed by inadequate elastic recoil---thus not all CO2 is adequately expelled. This stretch-without-full-recoil theory essentially converts part of the lungs' capacity into additional CO2-retaining dead space. So there's a hypothetical possibility for CO2 buildup toward those leg cramps with pulmonary stretch followed by inadequate CO2 expel. The SV machines can help DSM avoid that hypothetical etiology with adequate (and on-demand) inspiratory volumes and much easier expiration facilitated via EPAP/EEP's instantaneous pressure drops (the core purpose of servo "ventilation").

Even though I also favor that theory of gas-exchange problems being more related to DSM's leg cramps, I have always favored generating multiple theories for consideration. Sound analysis always loves multiple theories! Remember when Katrien B. Hertegonnea, Bart Rombautd, et al discovered a slight difference yielded in sleep architecture between the more basic Resmed and Respironics APAP models?
http://content.karger.com/ProdukteDB/pr ... tNr=224278

That's the basis for suspecting that Adapt SV and BiPAP autoSV can indirectly yield different sleep architecture patterns, compared to CPAP or any given APAP model in DSM's case especially (thus indirectly improved/consolidated sleep architecture via adequate stenting paired with needed ventilation is perhaps a possibility here). DSM, if you **do not** experience leg cramps from extended (wake based) sleep deprivation, then I would probably favor that first CO2-retention theory of yours versus a cellular-restoration/oxidative-stress theory that is sleep-stage based.

However, even in that case, there's still a teeny bit of hypothetical room to continue entertaining yet another machine-based sleep-architecture theory based on hypothetical cramp-inducing PLMs sometimes being more prominent in specific sleep stages. So this theoretical case would entail PLM-susceptible sleep stages that are architecturally enabled/eclipsed by your various machine modalities being used on any given night (BiLevel, CPAP, APAP, Adapt SV, AutoSV).

Might some docs want to do an extremity doppler ultrasound exam with someone of a certain age mentioning certain symptoms? Or no?

jnk wrote:Might some docs want to do an extremity doppler ultrasound exam with someone of a certain age mentioning certain symptoms? Or no?

Jeff, your suggestion of having DSM's doctor check out circulatory function in the lower extremities or legs sure sounds like a good idea to me.