CompSA, Hypoventilation, PLMs, Bradycardia and Hypotension?

blizzardboy wrote:

-SWS wrote:More detailed comments from me later

Looking forward to it.

Rough night last night. The migrating joint pain seems to have progressed to multi-joint pain. Feet, hands, wrist, groin/hip and neck painful last night. Kept me awake quite a bit. Also, my leg movements were strongly present when I woke up. Lots of toe curling and leg stretching. This joint pain is not something I have experienced in the past, only starting up mid-way through my S9 Autoset trial and now progressing while on the Adapt SV. Sometimes I take paracetamol or Nurofen to help me sleep. The worst is the pain in the groin/hip, makes me groan when I move in bed. Could this pain be due to the pH balance of my blood being shifted through the application of XPAP?

Also, I wanted to mention that in the longer term my aerophagia has probably been just as bad on the Adapt SV than it was on the S8. Wouldn't want to be a contributor to the fuzzy world of chat-room fables by casting aspersions on the S8, now would I?

Just took a look at the Bipap Auto SV (Advanced) data charts. My 1st reaction is your epap is too low at 8.

Interestingly that machine (the advanced) model has settings for auto-titrating epap but that doesn't appear to
be activated.

I would imagine you need closer to 10 CMs for Epap as there are a lot of obstructive apneas showing on the chart.

You could try setting Min Epap to 8 and maxEpap to say 10 or 11 & see what the machine reports as your average Epap.

Good luck.

DSM

blizzardboy wrote:

jnk wrote:And personally, I wouldn't want to be on an SV machine unless I had proof that I needed to be.

Hi jnk, I had come to believe that ASV was the new gold-standard in CPAP therapy due to its rapid response and minimised pressure support. If one took away the question of price, wouldn't the majority of CPAP users be as well/better off on ASV?

I would be really interested to learn more about your hesitation to use ASV unless absolutely necessary.

I really thought that I had proof for my need of ASV in the form of the recommendations contained within my titration PSG report: http://users.adam.com.au/sixsome/PSG_combined.pdf. What do you reckon?

Cheers,

Blizzardboy.

The ASV machines are becoming very generic - in that as more algorithms are added, they become capable of a wider range of responses to different types & forms of SDB. The advanced Bipap Auto SV just recently had auto-titrating Epap added which greatl expands the type of people it can help.

There was a time (even in this forum) when people would say things like "don't use a bilevel unless you really need one, they are really only for COPD patients" - sometimes it seems nothing changes

By and large the ASV machines are the more sophisticated machines but a good state-of-the-art cpap like the S9 can be equally as good for the right type of SDB user. ASVs do cost so much more & in reality that is what people really mean when questioning why someone needs one. But, there is also though the risk that with some brands, there are so many settings that can be fiddled, that the machine in the wrong hands, might be more harmful than beneficial.

Cheers

DSM

dsm wrote:for the right type of SDB user

Hi DSM, That is the question: What 'type' of SDB user am I?

Here's my data from last night during which I slept in the recliner to see the effect of sleeping inclined on my ASV results (e.g. reduce silent GERD):

http://users.adam.com.au/sixsome/ASV/0410/042810/

seems to be the most stable breathing on the ASV to date. What do y'all think? D-day tomorrow.

blizzardboy wrote:

dsm wrote:for the right type of SDB user

Hi DSM, That is the question: What 'type' of SDB user am I?

Here's my data from last night during which I slept in the recliner to see the effect of sleeping inclined on my ASV results (e.g. reduce silent GERD):

http://users.adam.com.au/sixsome/ASV/0410/042810/

seems to be the most stable breathing on the ASV to date. What do y'all think? D-day tomorrow.

Looking at the data - I am still wondering about EEP being 8 but that is worth exploring & am sure SWS will have some considerations re that value. You do have some leaking that on that brand & model of SV can cause issues. Otherwise it looks ok but I need to look at it in more depth.

Cheers

DSM

dsm wrote:I am still wondering about EEP being 8 but that is worth exploring & am sure SWS will have some considerations re that value. You do have some leaking that on that brand & model of SV can cause issues. Otherwise it looks ok but I need to look at it in more depth.

Yes, -SWS has previously commented that maybe my OSA was being under-treated. Tonight I will set EPAP=10 on my VPAP Adapt SV Enhanced and see what the data looks like tomorrow.

I look forward to learn what you find in the depths.

blizzardboy wrote:

dsm wrote:I am still wondering about EEP being 8 but that is worth exploring & am sure SWS will have some considerations re that value. You do have some leaking that on that brand & model of SV can cause issues. Otherwise it looks ok but I need to look at it in more depth.

Yes, -SWS has previously commented that maybe my OSA was being under-treated. Tonight I will set EPAP=10 on my VPAP Adapt SV Enhanced and see what the data looks like tomorrow.

I look forward to learn what you find in the depths.

Maybe 2 CMs is too big a jump ? - perhaps try 9 & see where that leads then based on feedback perhaps go higher.

Cheers

DSM

blizzardboy wrote:Here's my data from last night during which I slept in the recliner to see the effect of sleeping inclined on my ASV results (e.g. reduce silent GERD):

http://users.adam.com.au/sixsome/ASV/0410/042810/

seems to be the most stable breathing on the ASV to date. What do y'all think?

Obstructive patients sometimes elect to sleep upright to lessen the severity of upper-airway occlusion. Since gravity's vector changes its relative angle in physiology by sleeping upright, in many cases obstruction becomes less severe.

I suspect your recliner-chair experience mentioned above and especially your S9 data reveal that your obstructive component is under addressed by your current EEP of only 8cm. BTW, that 8cm EEP was the correct obstructive-addressing value according to your sleep study that found 8cm adequately addressed your snoring and obstructions. But again, your S9 data very strongly hints that 8cm EEP is not sufficient to address your airway occlusions on some nights. I'll explain below:



--------

S9 April 9th:
Let's examine the handful of obstructive events that occurred between hours 02:00 and 03:30 on April 9th:
http://users.adam.com.au/sixsome/S9/S9_trial_11.JPG (bottom graph)

Next, let's see what pressure the S9 was running during that time frame: (bottom graph)
http://users.adam.com.au/sixsome/S9/S9_trial_09.JPG

Now let's see what your snores and especially (obstructive) flow limitations were up to on April 9th at those pressures:
http://users.adam.com.au/sixsome/S9/S9_trial_12.JPG (top and bottom graphs)

CONCLUSION: Pressures above 10cm did not completely address your obstructive component on April 9th.


------

S9 April 10th:
Let's examine that denser cluster of apneas that occurred on April 10th between the hours of 01:15 and 02:00:
http://users.adam.com.au/sixsome/S9/S9_trial_08.JPG (top graph)

As in the first example, let's see what pressure the S9 was running during that time frame:
http://users.adam.com.au/sixsome/S9/S9_trial_06.JPG (top graph)

Now let's see what (obstructive) flow limitations were up to on April 10th at those pressures:
http://users.adam.com.au/sixsome/S9/S9_trial_09.JPG (top graph)

CONCLUSION: Pressures above 10cm did not completely address your obstructive component on April 10th either.


---------------------------------------------------

ADAPT SV CONCLUSION: An EEP pressure of only 8cm is probably insufficient to address your obstructive component. An EEP pressure of only 10cm might be insufficient as well.


--------------------------------------------------

-SWS wrote:Placeholder Comment: I just took a very quick peek at the above data... and I think there's a chance your obstructive component might be variable and under-addressed on some nights. If that's the case, then an under-addressed obstructive component might explain at least some of the erratic/low tidal volume behavior we are seeing on your Adapt SV charts...

More detailed comments from me later----or possibly even a retraction of my initial thoughts above----after I take an integrated look at ALL of your posted data in the next day or two.

Done deal.

Good summary. I will attempt to play devil's advocate here if you don't mind, since Ms Muffy is probably too busy at work
(and I don't understand all the pulmo stuff, sorry)

central apnoeas increasing frequent during last cycle of diagnostic

Exactly how many central's did you have on the diagnostic? Could they actually be sleep/wake onset types of centrals? sorry if this has been discussed to death in the previous one million pages of this thread.

SBD ISSUES: conjectures

The perfectionist in me would ask you to rank these in order of "likely" to "less likely"... and to group similar items together. No I will not remove that pole ...!
Anyway, fibro, maybe less likely if the pains are recent.
CHF, or COPD, are there reason to think you might have heart of lung problems (family history of heart diease, high cholesterol, smoking, exposure to asbestos etc)?
Reason I say this, if you go to your doctor with a "wild" list, the chances that they take you seriously are ......
Well let's just say that I had that experience once, the doctor got completley overwhelmed and didn't know where to start and just ended up giving me a prescription for SSRIs.... ugh. Anyway the list is still a great idea, just be ready to back everything up, and don't shock them by "doing their job", you know? I hope your doc is better than mine was

WHAT NEEDS TO BE FIXED

Source of my OSA
Source of my arousals

Huh???? Is THAT what we are trying to fix? Shucks, source of OSA = bad genes, being overweight, facial structure. Throat closes, apnea happens.
Source of arousals = hm, how do we know you are having arousals?

I _think_ what we're actually trying to fix is a mixture of still not feeling well on the ASV, continued PLMs, as well as whatever your nightly pulse-ox is showing (heart rate, SP02).

Also , you are unsure of whether current ASV settings are optimal?

Oh whoops, I think there I went again and misinterpreted what you meant by "what needs to be fixed". So what we miss here is the "Thesis" of the whole story, what is the PROBLEM we are trying to solve. This can be a combination of how you feel (now, and/or versus before), your strange pulseox/BP measurements, and anything else out of the ordinary. What are the SYMPTOMS?

WHAT CAN BE MEASURED/CHANGED/TAKEN/IMPROVED

Again for this list, you need to make a priority list, I would say. For eample, why are cortisol measurements important? Why do you want to get the brain function tested? Are there other things that can/should be addressed first, and other tests that can come later? Sort of the binary tree search approach, right? Again, if you show this list to the doctor, you need to have a motivation for each point.

---
Please don't take these comments as negative criticism, just my personal opinion of how I would structure everything. I think it's great that you're doing this, it will help you organize all the various info in this thread plus whatever else is in your head, and will give you 'ammo' so to speak, when discussing further with your medical professionals!

-SWS wrote: I suspect your recliner-chair experience mentioned above and especially your S9 data reveal that your obstructive component is under addressed by your current EEP of only 8cm. BTW, that 8cm EEP was the correct obstructive-addressing value according to your sleep study that found 8cm adequately addressed your snoring and obstructions. But again, your S9 data very strongly hints that 8cm EEP is not sufficient to address your airway occlusions on some nights. I'll explain below...Done deal.

Hi -SWS, Well I can't fault your reasoning - good work I say. Tonight I'm going to blast myself with EEP=10 leaving the inhalation pressures as is. Aerophagia here we come! Obstructives here go? Watch this space. If all goes pear shaped then I will try EEP=9 as suggested by DSM. I never was one to chip out on the fairway, usually opting to try to thread the ball through the trees and then hook it around onto the green all in one go.

echo wrote:Good summary. I will attempt to play devil's advocate here if you don't mind, since Ms Muffy is probably too busy at work

Hi Echo, I feel like I am doing "SDB Summaries 101" at CPAP University at the moment (reminds me of sitting in Physics 101 and trying to connect deeply to Newton's Laws.) I am definitely a newby giving it a go. I really do appreciate your comments. No devils or negativity in my mind. Just trying to build the case.

echo wrote:

central apnoeas increasing frequent during last cycle of diagnostic

Exactly how many central's did you have on the diagnostic? Could they actually be sleep/wake onset types of centrals?

1. Not sure, hard to tell from the PSG. 2. Pretty sure that is exactly what Muffy suggests, hence why I am being encouraged to improve sleep hygiene and eliminate other waking mechanisms.

echo wrote:

SBD ISSUES: conjectures

The perfectionist in me would ask you to rank these in order of "likely" to "less likely"... and to group similar items together...if you go to your doctor with a "wild" list, the chances that they take you seriously are...don't shock them by "doing their job", you know?

Superb suggestions. Will do ASAP.

echo wrote:

WHAT NEEDS TO BE FIXED

Source of my OSA
Source of my arousals

Huh???? Is THAT what we are trying to fix? Shucks, source of OSA = bad genes, being overweight, facial structure. Throat closes, apnea happens.
Source of arousals = hm, how do we know you are having arousals?

I _think_ what we're actually trying to fix is a mixture of still not feeling well on the ASV, continued PLMs, as well as whatever your nightly pulse-ox is showing (heart rate, SP02).

Also , you are unsure of whether current ASV settings are optimal?

Oh whoops, I think there I went again and misinterpreted what you meant by "what needs to be fixed". So what we miss here is the "Thesis" of the whole story, what is the PROBLEM we are trying to solve. This can be a combination of how you feel (now, and/or versus before), your strange pulseox/BP measurements, and anything else out of the ordinary. What are the SYMPTOMS?

Fair comment, maybe I did miss the mark on "what I am trying to fix." 'Twas my best attempt first up. SDB Summaries 101...

echo wrote:

WHAT CAN BE MEASURED/CHANGED/TAKEN/IMPROVED

Again for this list, you need to make a priority list...Please don't take these comments as negative criticism

Good idea. Nay, very much appreciated comment. I have been involved in one or two heated scientific discussions in my time so hopefully I am well prepared for a good debate.

Cheers,

blizzardboy wrote: I never was one to chip out on the fairway, usually opting to try to thread the ball through the trees and then hook it around onto the green all in one go.

Aye, mate...

8 plus 2 equals...

blizzardboy wrote:Rough night last night. The migrating joint pain seems to have progressed to multi-joint pain. Feet, hands, wrist, groin/hip and neck painful last night. Kept me awake quite a bit. Also, my leg movements were strongly present when I woke up. Lots of toe curling and leg stretching. This joint pain is not something I have experienced in the past, only starting up mid-way through my S9 Autoset trial and now progressing while on the Adapt SV.

Your "toe curling and leg stretching" description of your movements sounds nearly textbook for PLMD, which is no surprise. And it is equally non-surprising that your movements would worsen as your xpap treatment improves, as that is a common pattern in PLMD. This could also account for your pain symptoms, as PLMD is not always limited to the legs. I am concerned that you will be on an extended search for obscure answers to something that is readily identifiable.

blizzardboy wrote:

dsm wrote:I am still wondering about EEP being 8 but that is worth exploring & am sure SWS will have some considerations re that value. You do have some leaking that on that brand & model of SV can cause issues. Otherwise it looks ok but I need to look at it in more depth.

Yes, -SWS has previously commented that maybe my OSA was being under-treated. Tonight I will set EPAP=10 on my VPAP Adapt SV Enhanced and see what the data looks like tomorrow.

I look forward to learn what you find in the depths.

blizzardboy

these are my impressions from another look at your data.

Your respiratory rate seems to fluctuate a lot and that is worth bringing up with your doc.
The apneas that occurred in that second group (5am) appear to be related to the large leak
as your respiratory rate leading into it seems quite normal.

Your tidal volume looks like it fluctuates a bit but the average seems around a 'low normal'

Overall the data (except for the leaking) seems ok.

Cheers

DSM

DreamDiver wrote: The pain waking you up sounds very familiar. I know it's already been suggested in this thread, but I don't remember - Blizzardboy, did you say you've already thoroughly ruled out hypothyroidism? I understand it can masquerade as fibromyalgia-like pain too.

-SWS - Here's a paper about alpha wave intrusion with FM. Interesting.

Muse-Inc wrote:

-SWS wrote:...fibromyalgia...

Dr John Lowe is a fibro and hypo researcher; he belives fibro is a subset of hypo symptoms. All his fibro folks improve when put on the right dose of thyroid.

That's very interesting, DD and Muse...! Thanks for that information!

My sister received a fibro diagnosis from Mayo years ago. Last time I saw her she was starting a fibro flareup. When I asked if she had kept up with any of the research or advances in fibro over the years her answer was no. So I think I'll forward both of those potentially helpful pieces of fibro information her way.

blizzardboy wrote: Fybromyalgia seems to be fairly poorly understood at present given what Google has fed me. Fair call?

I think that's a very fair call. Unfortunately I think that same fair call applies to Complex Sleep Apnea, which isn't even in the ICSD yet...

blizzardboy wrote:No I haven't. However I pressed my thumb into the spots on my body that are used to indicate FM and they are all sore for me. Surely, though, FM is a symptom of my CPAP treatment rather than the cause of my SDB as I only developed sore joints only recently. BTW, the pain I feel is sharp and acute, not dull. Reminds me of some of my football joint injuries e.g. groin pull.

Well, I took a quick peek at a fibro search link only to see a claim that fibro onset is typically between the ages of 25 and 45. Earlier in the thread I wondered if your 25s cycling of highly non-uniform breathing might be epiphenomenal of something else going on in physiology---such as cycling pain signals...

Anecdotally, some SDB patients report on the message boards complete remission of their fibro symptoms when SDB is properly addressed. However, I think most do not. Additionally, most fibro patients do not seem to suffer SDB at all. So I believe it's entirely possible that you might have concomitant fibro and SBD. And, at least theoretically, I believe those two conditions can exacerbate each other. Were a fair number of your central apneas post-arousal, for instance? If so, then fibromyalgia alpha wave intrusions and/or pain might be more causal regarding your central component then other more commonly discussed loop gain issues.

blizzardboy wrote:However I pressed my thumb into the spots on my body that are used to indicate FM and they are all sore for me.

Well, if you had fibro, you just might gain sleep and perhaps even SDB benefits by optimally managing your fibro symptoms. Those 12 pressure points are diagnostically employed because they entail a certain specificity for fibro. PLMD, for instance, should not cause that---even if PLMD is known to be present.

One additional comment I want to add is to be aware that different brand ASVs deliver the pressure differently to the mask.

Because the Vpap Adapt SV has a proximal pressure sensing line, it very accurately detects the pressure at your mask. I have checked this with a dial manometer & what the data says matches what the manometer says.

But when you used that Bipap Auto SV, it measure the pressure at the machine end of the hose & makes an allowance for losses that naturally occur when air flows down a tube (vs is static in a tube). When I put a dial manometer on a Bipap SV, the pressure at the mask tends to be approx 1 CMs less than what the machine & data from the machine report.

So when you were using the Bipap Auto SV it is quite probable that your Epap was really 7 CMs but when using the Vpap SV it was 8 CMs. Now look closely at your pattern of apneas between the two machines & you can see a notable difference on AI events reported between them. This is telling me that you were possibly doing better when Epap was increased (just by switching from the Bipap SV to the Vpap SV). So if you went to 9 CM (EEP on the Vpap SV) that should show an even better AI result & may lessen the aerophagia which may get worse if you set EEP to 10.

On my machines I tend to set the Bipap settings up by 1 CMs to compensate for the measured difference.

Also,

I used to notice more leg & foot cramps when I was on my Vpap SV than when I was on my Bipap SV. I strongly suspect what you are describing may be CO2 related. Raise this issue with your doc & see what he says. I have come to believe that CO2 retention/loss can be impacted by the gap set between Epap & Ipap (the pressure support (PS)). I have done some experiments where I was able to reduce the cramps when using my Vpap SV by adjusting carefully this PS. Of course there is nothing to say that the cramps I experience are related to what you are describing. But I do think it can be related to CO2 levels in the blood.

DSM

PS I am not a medical person or any expert on cpap therapy, just a very inquisitive user.