Brazen Therapy Thread

[Gideon]

Difference in pressure, get a glass of water and a straw, insert straw 4 cm deep and blow bubbles. The pressure is about .05 psi or 4 cmw.

IMHO your flow limitations/ restricted breathing are, cause me, crap. Your breathing is compromised at a pressure of 4. While there is no official threshold at a min we like to see the 95% value at or below 0.10, preferably 0.03.

Flow limits are like untimed hypopneas and represent restricted breathing.

Why did lowering your pressure decrease your AHI? I'd like to see your 7-9 charts but my best guess ( no data) is that your AHI events were converted into flow limitations.

Chronic fatigue from sleep apnea takes time to resolve. You likely had sleep apnea for years so don't expect your body to recover I. A short period.

[DaveCar]

A 1.68 to a 2.05 isnt really much to compare. Its typical to get those differences from night to night.
If we were looking at 1.68 to 12, then that would be something to chase.
Its also possible that the mask seal was leaking a bit at the slightly higher pressure.

Also, you may already be aware but, EPR doesnt do anything when you set to 4cm. 4cm is like the "floor" pressure.
Maybe something like 6-10 with EPR-2 ?

[Brazen]

Gideon - thank you, I do appreciate your input.

Should I be looking at flow limit instead of AHI? Why?

Should I not be expecting improvement after four months? How can that be the case? At what point should I feel improvement?
Isn't AHI under 5 considered controlled/treated OSA? Four months below that threshold is quite a while.


There are so many possible reasons for chronic fatigue that are not related to OSA.
I'm headed to yet another primary doc later this month since the last one wouldn't look past OSA.

I'm just really struggling.
I used to sleep so well and have the best dreams.
I just want my dreams back.

[Gideon]

AHI vs Flow Limits: Look at both

High flow limits, as with high AHi, means your body is stressed resulting from the extra effort required for breathing. US AHI standard is 5, in the EU it's 15. Here on Apnea Board it's between 2 and 3, and lower of it comes easily.
High flow limits can also indicate a form of sleep apnea called UARS which is typically under reported because it can have an AHI of zero. These are best treated with EPR ot Pressure Support which is the difference between inhale and exhale pressures.


How long to feel relief, very few feel relief on day 1, that's me,. Most take time to feel relief and that time is very variable with some taking a year or even more. This is after your therapy is optimized.

[Brazen]

Thank you Gideon,

I went back to pressure 7-9, with EPR 3.

I looked back at my data and 95% flow limit was near 0 when I had it set 7-9 before last week.
When I compare 95% flow limit on 4 vs 7-9 there is definitely a difference. 

So, all the different types of sleep apnea I've seen mentioned here...  my sleep specialists have not mentioned anything more specific than OSA.
Nor have they looked at anything other than use compliance and AHI.
Why aren't the docs looking at it more closely?

A year?!! Seriously?
How can the improvement even be attributed to the cpap at that point?
And what makes folks wear it that long with no improvement?

Sigh.

[Gideon]

Speed and dollars is my guess.
Very few doctors look at the detailed data. Most are interested in AHI under 5 and compliance because insurance cares, at least that is what it looks like.
It typically takes months to get an appointment with a sleep doctor, just from reading the posts.


Length of time, as you noted fatigue can come from many sources, low oxygen is one. What were your O2 levels on your titration study? Were they low on your diagnostic study?

Also look at sleep Hygiene as a possible source of fatigue.

IMHO your initial settings, even your titration sleep study matters little. A simple question, should your setting be based on just a few minutes of a sleep study, or how you sleep for an entire night? Any way, after night one the detailed results should be read and evaluate. Why? The machine being used is rarely the the same and in the lab you are wired, watched, and taped, you need help if you need to use the toilet. The bed, pillow, lighting, covers, etc. Are what you use at home. That can't be normal. Let's not forget the fact that most sleep labs seem to rubber-stamp OSA as the diagnosis. Example, extreme one, an AHI of 60 receiving the diagnosis of OSA when only one event, not 1 per hour, a single event was identified as Obstructive with the remaining being central apneas per the details. I certainly do not have the education and certification to diagnose someone but come on. Not everyone is that bad but....some are.

Thus you have advocates of self care such as this forum.

There is one thing that sets this forum apart from most others and that is the use of data on which to base a suggestion, detailed daily data, not the summary data the doctors look at, the breath by breath data. I can tell if you are tucking your chin at night, your doc can only see high AHI and increase your pressure which BTW will not work.

It is easy to see that your body is doing better with CPAP than without it. As a nurse you take vitals. Would you rather have good vitals or bad vitals. Do all your patients with good vitals feel they don't need to be in a hospital? Same thing for Sleep Apnea.

[SleepyHenry2]

Braden;
The “problem” with Flow limitations is that there is no universally accepted definition of what they are and how many are necessary to cause symptoms.
On the other hand, we know they are responsible for a lot of our Upper Airway Resistance syndrome symptoms!
 Earlier this spring, I went to see my Sleep Doc. All it took was for me was to show him several OSCAR's Flow Rate charts plus confirmation with some OSCAR's Flow Limitations graphs, and he agreed I needed a BiPAP device....However, Medicare only allows a change every 5 years, and I am not yet is schedule for a replacement.

This reminds me of the famous characterization of pornography by Supreme Court justice Potter Stewart: "I know it when I see it" (Jacobellis v. Ohio, 1964).

It seems we can say the same of Flow limitations!    

[Gideon]

Sleepy,
If your doctor changes your prescription and provides a needs case you should be able to get the new device since acBiLevel is a different product code

[Brazen]

Thank you both!

Gideon - how is it easy to see my body is doing better on CPAP?  Please explain how to evaluate the data to see that.
I don't know how to see that in the data so I'm just going off how I feel....  so far I feel no better, some days even a tad worse, with CPAP than without.

I didn't have a titration study.  It was supposed to happen the last half of my diagnostic study night but I didn't have any apnea events until after 3am (when they suggested I sleep on my back - which I rarely do at home) so they didn't put me on cpap at the clinic. It wasn't until someone from the DME called me 4 weeks later and told me my CPAP machine was there waiting for me that I found out the doc had diagnosed OSA. Doc wrote the pressure 5-15 and sent me on my way.
During the diagnostic study my O2 was above 90% except for one 3 minute dip to 85% (in over 8 hours).
I have Raynaud's disease so it isn't uncommon for my finger pulse ox to read low, or not at all, at times so I even take that with a big grain of salt. 

I have since met with a sleep NP once... she didn't review/discuss the CPAP report at all. I reported my continued fatigue and explained my frustration to her. She gave me a different mask (awful nasal thing) and a list of dentists in the area that do MA Devices as an alternative to CPAP.

I do all the sleep hygiene things. No electronics, no big meals, limit caffeine, no booze, no naps, cool and cozy room...
Without the CPAP I sleep like a rock. Takes two minutes to fall asleep and I wake up 8-12hours later in the same side position I fell asleep.
I just never feel rested.

I'm attaching last night's data. Settings: 7-9cmw, EPR 3, no ramp.
I was annoyed by mask leak and threw the thing off a couple hours before I woke up for the day.

Attached is also one of the nights with pressure set to 4 for easy comparison. Explanation of how one is better for my body than the other would be awesome.

[Gideon]

Between those two charts your resistance to breathing is much better at 7-9, EPR=3. That is an obvious improvement. Officially both are equally good to your doctor.
By any chance can you get and post the results of your diagnostic study so we can see the difference before and with CPAP.

Diabetes. A patient has an untreated A1C of 9 and a treated one of 5.5. Should be stop treatment, the meds because he doesn't feel the difference? Of course not. While sleep apnea may or may not be the cause of your fatigue, it is helping your body.
Same thing for smoker vs nonsmoker, or at healthy eight vs 100+ pounds over. Does losing weight or stopping smoking help them long term?