[CPAP] First days of CPAP/APAP, not feeling better.

[asm44]

Hi,

I recently had a sleep study where I was diagnosed with minor sleep apnea and UARS causing acid reflux into my throat. I had a pH manometry study that showed severe acid reflux into my throat, but it only occurs when I'm sleeping, and then had an in-lab sleep study where the sleep obstruction was diagnosed.

Some data I collected so far:

last night, APAP @4-12cm H20:
obstruction/cenetral event


two nights ago, using CPAP @ 8 cm H20:
obstruction event

central event


First night, APAP @ 4-12 cm H20:
central/RERA event 1



After this first few nights, I'm feeling awful. My sleep is worse than ever, I'm forced to sleep on my back because of the full face mask and I'm a stomach sleeper. And I'm waking up multiple times a night with the familiar sore throat from acid exposure. I feel depressed and have a hard time getting out of bed.

My throat is scarred from years of this. It would be fantastic to finally find a solution.... and if fixes my sleep too that would be a bonus.

Should I be asking for a BiPAP/ASV from the doctor? I am returning tomorrow and will ask for a nasal mask that will allow me to sleep on my stomach.

Besides this problem I'm otherwise healthy. I'm 29, male, 6'0, 205lbs with a thick neck. I realize my BMI is overweight, but I've done serious strength training for over a decade. I have dropped 20 lbs and do feel a bit better since then, but I'm fairly lean now and would to maintain strength so don't want to lose any more weight.


Thanks.

[Sleeprider]

For most people, a starting pressure of 4-cm is too low, and does not allow for the use of pressure relief which is what you need to resolve flow limitation, normally associated with UARS. Your charts are helpful, however OSCAR also supports the Prisma machines now and may offer additional therapy details we rely on. I recommend you add it and post some detail charts. What I see in your charts above:

In the first chart we see a normal respiratory rate with some flow limitation at 4-cm leading into a respiratory disturbance at 02:56:15 that leads to an apnea followed by a recovery breath and a hypopnea. There is a similar breathing disruption flagged as a snore at 03:32.

Second chart at 06:37 shows a strong flow disturbance followed by apnea. This looks like a position change or body movement where you hold your breath.

Third chart shows an arousal followed by a CA flagged pause in breathing. This is a fairly common event during arousal and is not an indication of a therapy problem.

I would like to see you increase your minimum pressure to 6.0 and use some pressure relief. I forget what the feature is called in the Prisma, but it should increase your comfort with the therapy. Please respond with thoughts on trying a higher minimum pressure and exhale pressure relief. Some of the respiratory disturbances you showed in the charts could be related to your reflux and a need for swallowing or related arousal. Do you also experience aerophagia (air swallowing)?

Let's talk about changing to a nasal pillows mask. It would make you more comfortable and get you off your back. I use the Resmed Airfit P10 which is a very minimal mask and allows sleep in any position.

[asm44]

Do you mean aerophagis from the CPAP? Not that I've noticed. I do experience a lot of burping, which is I think from constantly swallowing due to post nasal drip from the reflux.

Looking into Oscar now. The 2nd chart was in CPAP mode @ 8cm h2o.

Appreciate the guidance.

EDIT: According to the wiki Oscar 13.0 does not support prisma devices, and the 13.1 release notes don't mention prisma eitiher. I tried using it and it doesn't recognize the data on the SDcard.

[Sleeprider]

The post-nasal drip problem is one I have also had. I use fluticasone propionate nasal spray (Flonase) to help with nasal inflammation and post nasal drip, and that can be very effective, especially if you have allergies. When you swallow you take in air, so we want to be careful with too much pressure.

Is your CPAP auto-pressure or fixed? Do you have an exhale pressure relief option? I'd like to see you use auto CPAP mode with minimum pressure 6.0, maximum pressure 10.0 and exhale relief setting 2.

You are correct, the current support on Oscar is:
Löwenstein / Weinmann
Partly supported by Oscar; Somnobalance
Not supported by OSCAR: Prisma

[asm44]

It can do CPAP and APAP. I'll try the APAP at 6-10 tonight.

Is this the exhale pressure relief you were talking about? Isn't that what a BiPAP does?





what do you think about asking the doctor to give me a Bipap/ASV? I will also ask for flonase, I tried to get it already but it's prescription only where I live.

Thanks again for the help.

[SarcasticDave94]

That looks like the exhale relief mentioned. Try that at number 2.

Other machines? Unless you have a lot of Central Apnea on the diagnostic test then an ASV is not needed. What I see on that chart is perhaps treatment emergent Central Apnea. These will go away with time on PAP.

[asm44]

Cool, thanks. Everyone here is insanely helpful.

Regarding other machines -- I was reading a wiki page here that recommending BiPAP for UARS (which is the main diagnosis):

http://www.apneaboard.com/wiki/index.php..._and_BiPAP

[Sleeprider]

Using the Prisma SoftPap feature will give you a taste of bilevel pressure. I think you will like it. We can hold off on considering other therapy modes until we see if this brings you the comfort and relief you are looking for. We have seen many members benefit from the exhale pressure relief. The main symptom of UARS is restricted inspiratory flow or flow limitation. This can be visualized in the flow-rate charts as a flattening of the inspiratory peaks (flat-tops) as the flow rate plateaus due to airflow restriction. We have learned that bilevel pressure support and exhale pressure relief work the same way, and both can help with flow limitation by increasing pressure during the inhale phase. This wiki article I wrote explains it with graphs and images http://www.apneaboard.com/wiki/index.php...limitation

[Dormeo]

About the reflux: have you tried sleeping with the head of your bed a little higher than the foot? In the U.S. one can buy long shallow wedges to put under the mattress for this purpose. I'm sure you're also careful about your diet, staying upright after meals, and not eating close to bed-time.

Here's an interesting article suggesting that people with apnea who use their machines also see a reduction in GERD symptoms:

https://jcsm.aasm.org/doi/10.5664/jcsm.6126

It might also be worth talking with your doctor about a more aggressive approach to the GERD, trying some of the medications that could help. (Or perhaps you're already doing this.)

[asm44]

@Sleeprider -- great, thanks. Helpful to learn a little about the wave forms.

@Dormeo -- I have tried for many weeks to sleep on an elevated bed before I got the CPAP, and I didn't notice any benefit and my sleep got worse. Seems like the suction effect from the obstruction overcomes gravity. I eat pretty healthy, but I also do not reflux after eating. It is only in my sleep. Not eating before bed is the only thing that has helped.

The issue with taking medications like PPIs is that they are not so effective for supraesophageal reflux disease or LPR. I don't have GERD. The throat is much more sensitive than the esophagus (where I have no damage), so even a little bit of acid can cause problems, and with the acid, pepsin is also refluxed which binds to the throat and continues to digest it long after the acid is gone (not a problem with standard GERD since the pepsin doesn't bind to the esophagus). So sure, PPIs can reduce acid by up to 80%, but it doesn't really matter for LPR, it's sitll enough to damage and it still brings up pepsin. Also PPIs have some serious side effects, especially with long-term use. I have tried taking them in the past for a few weeks at a time and noticed no difference. The literature on this is pretty controversial too -- with some meta studies showing PPIs are no better than placebo for LPR, and some showing some effectiveness. I'd much rather stop the acid coming up altogether and am still hoping that a correctly configured CPAP is the answer.