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Altitude, dehydration, and centrals
#1
Altitude, dehydration, and centrals
First off, a big thanks to Technopauper for the details of his journey, and his recent update to “Chart Envy”: reading through it seems to have lit up a lightbulb or two with me.

I’ve had my machine for a few months past a year, and have had “mixed success” with getting the numbers as low as I’d like. Ignoring a several-month period of eye surgeries and recovery (which really jacked with my numbers), I’ve had some mild successes, but never seemed to get things below 3.0 or so for any length of time. Also, annoyingly, there would be spikes in nightly AHIs every now and then - up to 8 - 10 or so - that have had me chasing my tail trying to figure out. 

In past OSCAR data, it seems that on “bad nights” OA events increase somewhat, but CAs always seem to be what suddenly went from “not much” to often “dominating”. I’ve always chalked these up to “not figuring things out yet”, or “temporary adjustments” - which is why I generally posted only “good nights” OSCAR examples. 

Reading through Technopauper’s story, I noticed a very similar trend (although thankfully with much smaller peak AHIs). The big commonality is altitude: I currently live at around 5,300 feet. Every time I have traveled east, I’ve dropped 4,000 feet or so: the first night and definitely the second usually showed a solid AHI improvement. Likewise, when I travelled back home, the first night and definitely the second usually showed a spike that took a night or two to normalize back to old (home) values. For at least the next couple of years, sleeping at altitude will continue to be a basic fact of life for me. 

It’s also pretty dry here year-round. I’ve found that during the last two times that I got pretty dehydrated (which is really easy to do), my AHIs would get much worse (12 - 18 at times) for at least a couple of days while I corrected the problem.

One of the commonalities between shifting-altitude effects and dehydration is that not only do my AHIs (definitely CAs) increase, but even without events the breathing waveform has segments that look decidedly periodic. These are sometimes being flagged as such by OSCAR on really bad nights, sometimes not. 

My new game plan is to stop trying different masks, chin straps / collars, mouth taping, and the like, hold with what has been “best” so far, and see what fluctuations happen on their own. I’ll then likely post both the good and the bad nights, to get feedback on what really may be going on. 

Past experience has shown that how I felt and functioned mentally the next day when I was at or below 2 AHI were dramatically better than after a night of 3.5+.  My goal (hopefully taking less than another year to reach) is to get my nights down closer to that < 2 AHI level on an on-going basis. We’ll see how this plays out.

Also a really big thanks to the Apnea Board forum admins and contributors as well. I’ve been dealing with apnea treatment for at least a decade, first using an oral appliance and now APAP. Over the years, I have found my sleep-related medical professionals to run the gamut from very helpful and insightful to absolute bozos. Self education is so crucial when dealing with apnea, and the knowledge found on on-line forums (Apnea Board being a strong one) have been a key part of that.
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#2
RE: Altitude, dehydration, and centrals
A relevant current thread for you may be the one by sosotired where he was concerned about Cheyne-Stokes, which was really just the periodic breathing you talk about above, and that was a component with Technopauper. http://www.apneaboard.com/forums/Thread-...kes--29354 His discoveries in that thread may be worth reading and following.
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#3
RE: Altitude, dehydration, and centrals
Hi Sleeprider - 

Thanks for the reference - I looked through the thread by sosotired (who is located all of 40 miles away - very similar conditions), and see a lot of similar patterns as well. (Really makes me glad that I didn't move to somewhere higher, like Leadville...)

It appears that sosotired is using a bilevel, whereas I just have an APAP. Some of the additional terms (and ResMed's parallel terms) are kind of unclear to me, but it seems that sosotired's primary issue was around (exhalation?) pressure support exacerbating the oscillations during the periodic breathing episodes. I don't have a bilevel, but I do have EPR set to 3 ... which I think is related to the condition mentioned. 

Could reducing my EPR to 2 or 1 result in a similar behavior, or is EPR completely different?

For some additional backstory, I will say that some time ago when I moved out here, I needed to take a few weeks run of Diamox. My doctor (back east) was initially skeptical that I'd need that prescription, since usually folks don't need that for altitude until they hit 8K feet or so. I had significant daytime symptoms during a previous visit, so Diamox happened. I was able to come off the prescription in a few weeks, and a few months later was regularly hiking above 10K without issue. However, it makes me wonder if I'm somehow more "sensitive" to the altitude than most, possibly in combination with dehydration, and if this is somehow related.
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#4
RE: Altitude, dehydration, and centrals
Yes EPR is the same as pressure support and sst found he had to turn it off and use a fixed CPAP pressure which either an Aircurve bilevel or Airsense Autoset can do. I’m thinking the same approach, turning EPR down or off will give you similar benefits.

BTW don’t hesitate to crosstalk in his thread. You guys have a lot in common
Sleeprider
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#5
RE: Altitude, dehydration, and centrals
Well, score another one for the negative interactions between altitude and EPR / PS. 

When I posted, my previous night's OSCAR display showed an AHI of 5.96, with lots of periodic breathing. This was "improved" over a few previous nights at or above 10, and with areas bad enough to be flagged as CSR. This was with EPR full-time at 3.

Reduced EPR to 2, and got AHI of 3.11 with much improved periodic breathing.

Reduced EPR to 1, and got AHI of 2.48, with even more periodic breathing reductions and significant reduction of CAs as well.

Turned off EPR entirely, and haven't had a night above 2 AHI. Just for comfort's sake, I shifted EPR back to 2, but ramp-up only.

Having said that, I'm now fighting an issue with mouth leaks. While none of my leaks have been in the LL category, what happens at least a couple times a night (a few more that I don't remember, looking at the graphs) is that the sensation of the leak briefly wakes me up. Attaching last night's charts...

Looking for ideas here. I've tried mouth taping before, and although it seemed to have a positive effect before - granted, while all of the other stuff was still going on - I ended up getting sort of lower bronchial infection, caused by saliva inhalation as far as I can tell, that took a doctor's visit to clear up. Although I'm open to improved taping suggestions, given what's been going on since March, I'd probably wait for a while on taping: I don't need to cause myself grief by having to go to the doctor with "breathing issues". 

I use a chin strap, which has been helpful in keeping my jaw closed and (usually) forward. I've tried three different types of soft collar: regular (although possibly a bit too tall), Releaf, and Eliminator. All seemed to result in worse leaks and AHIs than the chin strap - or even used in conjunction with it, and the first two had comfort and effectiveness issues with side sleeping. (I have significant tongue obstruction, due to a large tongue.) 

I could also try using the F20 again, with the new EPR settings in place. I've had more issues with mask leakage in the past when using the F20 instead of the P10, although this may have been exacerbated by the apneas causing me to toss more than usual. 

For all I know, the conditions causing the mouth leaks may have always been present, but just never been as much of a factor with all of the shifting and tossing related to the other events going on.

   
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#6
RE: Altitude, dehydration, and centrals
Let's limit maximum pressure at 9.0 We may or may not need to add to that, but your pressure is rising on flow limitation with few actual obstructive events. Leaks should stabilize with less pressure fluctuation. Your leaks are mostly disruptive to your sleep, and are not large leaks. Increase your Ramp minimum pressure to 6.0 and you will actually feel the EPR. By starting at 4.0 you don't get enough air, and the machine can only produce fixed pressure at 4.0.
Sleeprider
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____________________________________________
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#7
RE: Altitude, dehydration, and centrals
Okay, after one night's trial at the new settings: the bumping of the ramp-up pressure to 6 was definitely nice - less "trying to suck air through a tube" - and I don't recall waking up from mouth leaks this time (although leaks did happen from time-to-time, maybe not as protracted as before). 

The flat-topping of the pressure did seem to increase the number of events, mainly in clusters. 

   

Just so I understand: is the idea to "sneak up" on the proper max pressure, to be able to handle the obstructions while keeping the machine from "going nuts" and overcompensating, which causes the mouth leak arousals?
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#8
RE: Altitude, dehydration, and centrals
I agree with your summary of the path forward. We want comfort and efficacy so increasing max pressure should help  reduce obstruction. Watch for clustering of obstructive events that might be an indication of positional apnea. Read the Soft Cervical Collar wiki in my signature links.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#9
RE: Altitude, dehydration, and centrals
I also live in CO (western slope - Palisade). My sleep doctor - now retired - told me that the higher altitude increased centrals. We lived in our motor home full time for 11 years but came back to CO a couple of times a year and while here my centrals always went up.
My average AHI is about 2.4. I have been using CPAP since 2005 and have always had occasional AHI spikes of up to 8 or so, Maybe once every 2 or 3 months. My sleep doctor and now my PA don't know why.
I am no longer concerned about it.
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#10
RE: Altitude, dehydration, and centrals
Clay, another technique I have seen used to control centrals is to take low prophylactic doses of Acetazolamide (Diamox). It slightly acidifies the blood and avoids the loop gain effect of CO2 sensitivity. You are probably aware of the use of the drug in high altitude acclimation and treatment of high altitude pulmonary edema (HAPE) and cerebral edema (HACE). These are more acute effects and are also treated with acetazolamide. Anyway, low doses seem effective in treating the CA events that occur, as people live and move around at higher altitudes.

We have a lot of members from Colorado that have arrived to the forum with the mystery altitude related central events, that normalize at lower elevations. Particularly residents in Summit county and similar higher locations where altitudes of 7-9k feet are common. One of the challenges these people have is being tested for sleep apnea at an elevation that resembles where they live. Testing someone at 4-5000 feet, who lives at 8000 feet can result in not identifying the high rates of CA when they return home. In rare cases ASV is needed to control the CA events, and in others like yours, a careful titraton of pressure seems to suffice.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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