Newbie

Not thinking about meds making OSA worse but meds maybe making general sleep quality worse.
I didn't see anything that stood out with the Crestor either.
Thinking about meds that might have these side effects
trouble getting to sleep...staying asleep
insomnia
nervousness
stuff like that which might be a culprit in your wake ups.

Regarding the UPPP...unfortunately everything that I have read about the procedure and people coming back to cpap therapy after a UPPP hasn't been good. Main thing was that people were having problems finding a pressure that would do the needed job.
And then IF found...feeling better even if the data reports were acceptable.
That's one of the reasons we discourage UPPP procedures so much here. The results aren't always good and when they are they don't seem to last and then people coming back to cpap have even a more difficult time getting issues sorted out.
Plus it seems like people need even more pressure to get the job done.

Before you go thinking about a newer machine I was hoping to find a sort of an optimal pressure...I would hate for you to get a cpap/apap machine and end up needing a bilevel pressure machine because of higher pressure needs and comfort.
I am not thinking so much about the bilevel ASV machines used for treating centrals either. I was thinking more on the lines of the "plain" bilevel machine like I use.
If you do start thinking about a newer model machine that flags those additional events that the M series machine doesn't....I would look at bilevel if it were me. You can always use it dumbed down if need be but we can't make the regular cpap/apap machines do the bilevel pressures.

If you are going to need pressures in the teens to hold the airway open then bilevel would likely be more comfortable and more comfort sure doesn't hurt the sleep quality.

First and foremost, Pugsy, I appreciate all your help. Thanks so much for making time for me.

My waking could just be part of getting used to CPAP or it could be more. I often sleep through the night without the mask so while it is possible that events are now waking me, it would be in combination with therapy. This is a lifestyle change. I am used to watching late night TV and eventually drifting off but once I hit that CPAP power button, brain begins the "must sleep now" routine. I tend to focus on my breathing and the fit of the mask. My mind races and I can get a little anxious. Sometimes I have to get up, scratch my nose, and suit-up again. This makes therapy further difficult especially when I wake abruptly and have to start over. In fact, staying on task with CPAP is becoming difficult since I feel more rested without it. We keep cranking up the pressure but events keep happening. An AHI of 60 at 8cm was especially concerning. That being said, I am committed to making it work. For my long term health and for my family. Bring it on.

One thing we have not discussed is the C-Flex mode. I have it at the highest setting (3 - least resistance). Could that have an impact on the events? I already set the range from 11cm to 14cm and ensured the data card is all the way in. I'll certainly post the results.

Thanks again.

- Flappy

CFlex setting shouldn't make all that big of a difference except in comfort. The amount of reduction is based more on your own force of breathing. It's not nearly the reduction that the ResMed machines offer with their exhale relief.
I don't really think that is your issue but it is something you could play with to see if you like the way the other settings might feel.
See here for how it works.
http://cflexplus.respironics.com/

Any particular reason you are running in APAP mode? I was one of those people who could not handle APAP - I would wake up every time the machine tried to adjust pressure. I've tried APAP on and off throughout the years and my brain just doesn't like it.

So you might want to trial a fixed pressure for a night or two, see if that helps.

echo wrote:Any particular reason you are running in APAP mode? I was one of those people who could not handle APAP - I would wake up every time the machine tried to adjust pressure. I've tried APAP on and off throughout the years and my brain just doesn't like it.

So you might want to trial a fixed pressure for a night or two, see if that helps.

I'm all for it if I can find a pressure that works. The APAP range prescribed from the sleep study was 6cm-16cm. I have yet to see a pressure where my AHI is controlled within normal limits.

Uncle Flapp wrote:I'm all for it if I can find a pressure that works. The APAP range prescribed from the sleep study was 6cm-16cm. I have yet to see a pressure where my AHI is controlled within normal limits.

Point taken. Your charts on the previous page suggest something in the range of 10-12. And assuming those OAs aren't CAs, then I'd pick whatever was the highest 90% or 95% pressure on average and start there.

But, in case they might be centrals, it is worth exploring... Did they flag any centrals during your first PSG or your titration?

In my case, for example, I get centrals at 11 and above (this was noted on my titatration results and my machine also scores CAs).

A word about the 90% pressure number.
It's a number where the machine says you spend 90 % if the time at OR BELOW. That's all it means. People often forget the OR BELOW part of the definition.
Now sometimes that will happen to be the pressure where if you to use straight cpap you might want to be around that pressure but I don't put much into that line of thinking until I see long term 90 % numbers because they are simply too easily skewed by things during the night that don't always happen every night.
See this thread as an example
viewtopic.php?f=1&t=39869&st=0&sk=t&sd=a
At first glance based on one report the 90 % pressure is 15 cm...but with optimal minimal pressure you can see it is only 11 cm.
There's no sense in using 15 cm all night when 11 cm would likely do a great job.

We don't even have a 6 or 7 hour continual time frame to evaluate much of anything for you at the moment. So the 90% pressure number is based on a extremely short time frame and thus we can't put a lot of faith in it being the holy grail of numbers.
If we had 30 nights with 6 plus hours each night...then yes, that 30 night average 90% pressure would likely be more important.
I have nights where my 90 % pressure might be 18 cm...maybe once or twice a week but long term over 6 months it is only 12 cm.
It's just a number that sometimes might be what you would use if using straight cpap and sometimes it might not.....

All of the discussion about central vs obstructive apnea prompted me to take another look at the sleep study done just 5 weeks ago. All of this data is without CPAP therapy. Hopefully this will help.

Technical Data
Total Sleep Time 328.8 min
N1 Sleep 29.5 min (9.0%)
N2 Sleep 259.5 min (78.9%)
N3 Sleep 4.5 min (1.4%)
R Sleep 35.3 min (10.7%)

189 Arousals, Arousal Index 34.5
Moderate snoring
EKG demonstrated normal sinus rhythm

Positional Summary
Left: 214 min (65.3%)
Right: 71 min (21.6%)
Supine: 43 min (13.1%)

Arousal Summary
Respiratory Events: 196 (Index 35.8 )
Snore: 8 (Index 1.5)
Spontaneous: 1 (Index 0.2)

Respiratory Events Summary
Obstructive Apnea: 95
Mixed Apnea: 36
Central Apnea: 70
Total Apnea: 201
Central Hypopneas: 1
Obstructive Hypopneas: 255
Total Hypopneas: 256

Respiratory Event Durations
Apnea, NREM: 22.4 avg, 51.3 max
Hypopnea, NREM: 25.2 avg, 51.3 max
RERA, NREM: 15.7 avg, 23.4 max
Apnea, REM: 34.3 avg, 57.6 max
Hypopnea, REM 41.7 avg, 57.6 max
RERA, REM: 0 avg, 0 max

Well crap...70 centrals in not quite 5.5 hours of sleep is almost 13 per hour.
While not horribly horrible...sure isn't low enough to slide under the radar either.

You don't happen to know if you had very many way back when you were originally given the M series machine do you?

Does this recent study show an overall AHI or hourly index? Like around 80 to 84 or there abouts?
Edit: never mind this question...you answered it in your first post. I had to close the write area to be able to get back to it.
AHI 84.

326 minutes of sleep time is 5.43 hours of sleep...take your events divided by hours of sleep to get hourly index/average.

Since you already had a machine at home from past cpap trial/use you opted for trying the titration at home with the machine...is that correct?

After some morning coffee and a little bit of thinking...what was the doctor's recommendation after the recent sleep study results were in? Was the doctor who ordered the sleep study a special sleep doctor or just your PCP or GP who might not know about centrals?

There's a good chance that the 10 to 12 AHI we are getting off the M series machine now is primarily those centrals that you had during the diagnostic study with no machine and we would expect to see those since we don't treat centrals with this type of machine that you have now. Probably explains why we aren't seeing any Flow limitation and snores now..the current pressures are preventing them along with the OAs and what's left is likely centrals.
Impossible to know for sure with this machine.
Problem is...I don't know that I would recommend buying a machine like I am using even though it flags centrals just to make sure because with that many centrals you might end up needing the high dollar bilevel machine...ASV type.

On the plus side it doesn't look like the increase in pressures we have been trying is making the centrals worse.

Self titrating works decently as long as there are no complicating factors...and the centrals complicate things.
When things get complicated like this...always best to defer to the professionals in this situation.

You don't by chance happen to have an overnight recording pulse oximeter where you could again check your oxygen levels while attempting to use the M series machine do you? To see if you are still having significant desats????
Do you still have a working relationship with a DME who might let you have one for an overnight testing??? Often they will have one available and supply it at minimal to no cost for evaluation of the effectiveness of the therapy.

Since you are having huge issues with staying asleep long enough to get decent reports and with the diagnostic sleep study central count so high..alarms are going off all over the place.

Ah, coffee. What a wonderful idea. I don't usually drink it - makes me a bit squirrely but today I might just grab a mocha on the way into the office (everything is better with chocolate).
Another night of CPAP and another 90 minutes of uninterrupted sleep. Granted, the new high(er) settings were tougher to get used to - felt like inflating a beach ball for one of my kids. Anyhoo, here are the results:

P11 - 68.3%, OA 2.4, AHI 2.4
P12 - 34.4%, OA 13.5, AHI 13.5
P13 - 1.4%, OA 0, AHI 0

And again, there was a little cluster at the end of the timeline that probable woke me.

Pugsy wrote:Probably explains why we aren't seeing any Flow limitation and snores now.

I don't see any flow limitations for the duration under any pressure. Is there a setting to turn that statistic on? Also, last night's data was a bit goofy - the time stamp was off. I can't find a setting for the clock to ensure it is correct. As far as the oximeter, I was looking for one on Amazon but didn't have any luck finding anything with continuous readings.

The M series I have was actually my father's - he passed two years ago from cancer. I had the machine sitting in a closet. I got here on my own accord.

Back in September, my wife was worried about my apnea so I finally decided to do something about it. I scheduled a visit with an ENT to see why the UPPP wasn't working, and a visit with my PCP for my annual. I saw my PCP first and asked that he order a sleep study. I saw the ENT a week later - he identified restricted airway and recommended another surgery. The UPPP I had 7 or so years ago was such a painful recovery that there was no freakin' way I would do it all over again. I told the ENT that I would rather try CPAP. He too ordered a sleep study.

A couple of weeks after the study, I received a call from an RT. Her affiliated medical supply store wanted to issue a ResMed S9 Escape Auto. With a copay of $300, I asked her if the M series was compatible. The attending physician at the sleep study was not specific in the machine - he merely prescribed an APAP 6cm-16cm.

I am sure the $300 deal is still on the table and I am not opposed to paying the money if it will help but it sounds like I should be pushing for a BiPAP, correct?

Whatever you do...don't get a machine with the word "Escape" in the model name...even the S9 Escape Auto because while it will give you an AHI number it won't give you any breakdown as to event categories and with the history of centrals...you want the central category identified. The S9 Escape Auto will give you less information than your M series machine.

Thanks for the history on the M series...I understand.

Uncle Flapp wrote:felt like inflating a beach ball

Yeah, with the higher pressures you get to understand what aerophagia means. I haven't had it often but when I have had it...not pleasant at all so I do sympathize with you.

Uncle Flapp wrote:The attending physician at the sleep study was not specific in the machine - he merely prescribed an APAP 6cm-16cm.

Well I guess with that recommendation he wasn't overly alarmed about the presence of the centrals....doesn't totally quell my concerns though.

Uncle Flapp wrote:it sounds like I should be pushing for a BiPAP, correct?

Yeah..maybe but I am not sure which BiPap....the BiPap like I use or the fancy high end BiPap that is used for troublesome centrals as well as treating the obstructives.
The DME won't dispense a Bipap (bilevel pressure) machine without RX being specific to that type of machine. Can't buy it online with out bipap RX either.

Oh...the Flow limitation thing...it is already turned on...if you were having FLs they would be flagged.
If you were to use straight cpap mode then it would be turned off. That's why I usually suggest APAP mode ...even if we used the minimum pressure to equal maximum pressure which effectively makes the machine work like a cpap machine...we still have the FLs turned on and would see them if they happened. Hence the tiny range I suggested that you try...to see if we limited the varying pressure if it would help with your wake ups...it didn't. I doubt that little change was the cause of the wake up.
FLs will drive the pressure up..that and snores and other indications of the airway tissues collapsing.
Centrals by themselves won't drive the pressure up...the machine will ignore them and any associated pressure increases around the time of a maybe central are just a coincidence likely from some sort of FL or snore or other obstructive event warning sign.

Right now my main concern is whether those OAs that we are seeing are obstructive or just centrals getting dumped in the OA basket because the machine has no where else to put them.
We need a machine that flags centrals separately so that we know for sure...and then we need to figure out which bipap you might need...like mine or the high end fancy machine.
This is really where the sleep doctor is supposed to earn his fees.
Often people do have to jump through several hoops (insurance requirements) before insurance will pay for that high end bilevel machine...they aren't cheap.
Go from cpap to bipap to high end bipap...but that's when people don't normally have centrals to start with...the fact that you had around 13 centrals per hour even without a machine...really muddies up the usual progression and your history of the UPPP muddies things even more.

I have a sort of half assed idea...will send you a PM in a bit.

I finally got in for CPAP Titration on 12/27 but had a horrible night. The tech insisted on starting me out on standard CPAP with pressure at a mere 5cm. I slept only 30 minutes before arousing and wanting to throw the mask across the room. She changed the mode to APAP, the pressure went up a bit, and I was able to sleep for about an hour. Again, events woke me as I struggled for air. Then, finally, she put be on BiPAP mode and I slept for 3.5 hours. It was a beautiful thing. For the last hour of the study the tech wanted me to try ASV but I was unable to tolerate it. I had enough. At 3:30am I was supposed to be able to try something new and relax enough to fall asleep? Seems unrealistic. I found myself fighting with the machine trying to regulate each breath. The machine was trying to force air while I was trying to exhale. The breathing pattern was too fast and I could not keep up. After struggling for about 10 minutes, I told the tech I was done. Had enough. Get me the heck out of there. I signed my early termination form and went home.

This afternoon, I got a call from the physician. He acknowledged that I had a difficult night but explained to me that the BiPAP yielded positive results. Although not perfect, my AHI went from 84 to 11 so he will be prescribing a BiPAP. When inquiring about the ASV for my centrals, he told me that the tech shouldn't have tried the ASV for the last hour and that this is a process. "We'll start with the BiPAP, monitor results, and go from there." I look forward to getting a copy of the actual study.

EDIT: DME just called. Rx does not specify which model BiPAP but they prefer Respironics. Any advice as to which model will give the appropriate reporting? Differentiating between central and obstructive events would be ideal.