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Complex Sleep Apnea
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Peter_C Offline

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Post: #11
RE: Complex Sleep Apnea
(12-16-2013 09:57 AM)robysue Wrote:  My comment:

1) Has a doctor seen any of your data? If so, what's the doc say about it?

2) As others have pointed out, you need to have more than one or two days worth of data before declaring something is a trend. In other words, if you give yourself more time at 16cm, those CA numbers may come down or they may not.

3) It's very premature to be talking about an ASV titration in my opinion. The first step is to see if your body adjusts and the CAs disappear on their own after a week or two of using 16cm. If the centrals remain about 5 at 16cm of pressure for a week or more and if the OAs and Hs are well controlled at 16cm, the next step (which is usually required by an insurance company) would be to see if an APAP or an ordinary bi-level (a Resmed VPAP or a PR BiPAP) might allow the OSA to be controlled without triggering the excessive number of centrals. An APAP would only increase the pressure when there is a need for additional pressure to control the OSA stuff, and since the pressure would not need to be as high as 16cm all the time, there may be far less of a tendency for the CAs to emerge. The advantage of the the bi-level over either a CPAP or APAP is that the overall pressure needs are reduced (even further) since there is one pressure for exhale (EPAP) and one pressure for inhale (IPAP). And the difference between them can be set to be farther than 3cm apart if need be. If the OSA is controlled by a bi-level and the centrals go away, then there's no need for the even more expensive ASV machine. If the centrals remain in clinically significant numbers after a switch to a bi-level machine, that's when the docs usually start thinking about doing an ASV titration.

AND, that's where I am right now. I have been on a bi-level for 5-7yrs now, and centrals are rising (may be due to meds). Once I get insurance, a new study is called for, and possibly an ASV machine. I bumped my PS by '1' point last night (trying to raise my O2 stats) and my nose really pitched a fit~! Closed up, and been sneezing since I woke - does that mean I should drop it back? Maybe, but not yet, gonna give it more time and see what both the data and my body say after a week or so at the new setting.

*I* am not a DOCTOR or any type of Health Care Professional. My thoughts/suggestions/ideas are strictly only my opinions.

"Only two defining forces have ever offered to die for you. Jesus Christ and the American Soldier. One died for your Soul, the other for your Freedom."
12-16-2013 11:44 AM
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Sauron Offline

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Post: #12
RE: Complex Sleep Apnea
Thanks for all the feedback.

I've dropped it back down to 15 in the meantime after talking to doctor and will leave it there for long enough to get a better of idea of what's happening.

Leak rates are low, - median 0.0, 95th percentile varies between 0.0 and 1.2

They don't seem to want to do an overnight study in the lab unless they absolutely have too, seem to prefer trial and error approach.

Doctor has seen data, he is surprised at the pressure I seem to require. But other than that hasn't said a lot.

I'm probably just over eager to get the optimal treatment, and don't want to wait!
12-16-2013 08:30 PM
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vsheline Offline

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Post: #13
RE: Complex Sleep Apnea
(12-15-2013 10:06 PM)Sauron Wrote:  While the overall numbers are a little lower on 16, I actually feel more tired the following day than on 14 and 15 - I'm not sure what that's about.

(12-16-2013 08:30 PM)Sauron Wrote:  I've dropped it back down to 15 in the meantime after talking to doctor and will leave it there for long enough to get a better of idea of what's happening.

Leak rates are low, - median 0.0, 95th percentile varies between 0.0 and 1.2

Hi Sauron,

After a couple weeks and your breathing muscles become accustomed to the higher pressure you may find your tiredness decreases when using high pressure settings like 15.

Obstructive Sleep Apnea is usually affected strongly by sleep position. One thing which is usually important if we want to lower our pressure needs is to keep from sleeping on our back (which is called the "supine" position). I wear a slightly snug teeshirt with a tennis ball in a pocket sewn right between the shoulder blades or higher, to keep me off my back while asleep. Works really well.

Congratulations on your low leak rate, especially at high pressures like 15. When the Unintentional Leak is below about 24 L/sec and steady (not jumping around a lot) the machine will more accurately recognise and prevent approaching obstructive events.

Do you use Exhalation Pressure Relief (EPR)? For some patients a higher setting for EPR may improve sleep quality, like a bi-level machine does for some patients by making it much easier to exhale. For a minority of patients an increase in EPR will increase the number of their central events at least slightly.

A few short-lasting centrals per hour is nothing to be worried about. And centrals which occur just as we are falling asleep are common and are considered normal, but the machine will count these normal centrals also.

It is good to have a recording pulse oximeter to monitor O2 levels occasionally when sleeping. A wrist-mounted one will be more comfortable to wear all night or multiple nights, but some do not find the finger-mounted units objectionable to wear a whole night but often require adhesive tape lengthwise along only the sides (so as to keep unit from slipping off but also so as to not increase the pressure on your finger--not even the slightest amount).

I suspect central events are usually less stressful on the body than obstructive events. When in a central apnea or hypopnea, you start breathing again as soon as you try to. To end an obstructive apnea your body may need to give you a jolt of adrenalin, which tends to build up and stress the heart and other organs and increases risk of heart disease or stroke.

I think my doctor defines Complex Sleep Apnea as mixed central and obstructive sleep apnea where it was the PAP treatment that caused centrals to become dominant and remain dominant, even after a few weeks or months to get acclimated to treatment.

An increase in our number of Centrals might be caused not by a change in treatment pressure or in our prescriptions or over-the-counter meds but also by a change in diet or how much time before bedtime we eat or drink or take meds. Also,a prescription refill may have higher potency, or may be filled with older pills or pills which have been stored at a higher temperature and now have lower potency than the previous refill.

Take care,
Vaughn

Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
(This post was last modified: 12-17-2013 01:04 PM by vsheline.)
12-17-2013 12:54 PM
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Sauron Offline

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Post: #14
RE: Complex Sleep Apnea
(12-17-2013 12:54 PM)vsheline Wrote:  Obstructive Sleep Apnea is usually affected strongly by sleep position. One thing which is usually important if we want to lower our pressure needs is to keep from sleeping on our back (which is called the "supine" position)

I'm pretty sure I don't sleep on my back, I've always tended to sleep on my side or front. Front is essentially impossible now, so am staying on my side (as far as I am aware).

My AHI varies a lot from night to night on the same pressure settings. e.g last night AHI was 16.0 but the night before was 6.2 - both on pressure of 15.0 cmH2O.

EPR is set 3.0 cmH2O.

Question for the more experienced members:

AHI can vary considerably from night to night, but presumably the machine needs to be setup to handle your worst nights. While I have only had 3 nights on 15 cmH2O, the worst night had an AHI of 16.0 (9.0 obstructive, 1.2 central, 5.8 hypopnea). Is this enough to tell me that the pressure is insufficient, or can the apneas "settle down" once I become accustomed to the pressure settings?

I have an appointment to see the sleep technician today, but they apparently see a lot of people and don't spend a lot of time with you so want to be as prepared as possible. At this point should I be asking if an APAP device might be better, as I don't know that I want a constant 16 or 17 cmH2O inflating me all night long - or is it a bit early in the game?
12-17-2013 03:34 PM
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zonk Offline

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Post: #15
RE: Complex Sleep Apnea
(12-17-2013 03:34 PM)Sauron Wrote:  At this point should I be asking if an APAP device might be better, as I don't know that I want a constant 16 or 17 cmH2O inflating me all night long - or is it a bit early in the game?
Worth a try because you might only need that extra pressure for a short time and not all night long, also I would lower EPR level or turn off and see if that makes any difference. APAP adjust pressure in response to snoring and flow limitation which are early indicators to an obstructive event. If you look at detailed data graph, you see whether those apnea events are spaced out during the night or some are in clusters
12-17-2013 03:57 PM
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drmick3 Offline

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Post: #16
RE: Complex Sleep Apnea
(12-16-2013 12:21 AM)PaulaO2 Wrote:  First, that's just two nights of data. Not enough to form any opinion other than "well, that's different".

Second, complex apnea diagnosis would be if the central events had been high to begin with and had changed at all with treatment. They stayed relatively low the entire time until you hit 16. This is common. And I can tell you why it happened.

Look at the time you spent at each pressure.

15 nights
7 nights
2 nights
1 night
2 nights

Those last three were too many changes over too small a time frame. The first two were fine. Lots of time to gather data, look for trends and averages. You can't go by one or two nights and call it done. Too many things go into it. Add in that all you have to go by is a CPAP machine and you are really shooting in the dark. At least the single night of sleep study includes other factors such as oximetry, chest belt, limb movement, etc.

You say you made the move from 15 to 16 so I am assuming the others were made by the doc. They may have looked at your data and saw a pattern we can't see. So when you didn't drop low enough in those two days (which is really too short a time span) they raised it a single digit. But then you raised it one more. Your body and brain went all "hey, wait a minute" and the central events increased. This happens to a lot of us. What they may do is if they decide that 16 is your treatment pressure, is they may lower it back to 14 for a few weeks then raise it to 15 for a few weeks then go to 16 for a few weeks and monitor your data. Or they could give you an autoPAP and avoid all this mess.

Really, an autoPAP would have done what they've done here in much less time anyway. But I'm sure they had their reasons.

I seem to have become an example of what Paula02 said in her comments that I boldfaced above. I just went over the sleep study's doctor's report with my primary care doctor who originally suspected sleep apnea and sent me for a sleep study.

The doctor from the sleep study diagnosed me with OSA, chronic, severe and recommended a home auto titration device set between 5 and 20, since he could not determine the optional pressure setting. He found a number of central and complex apneas with 0% time spent in REM sleep and only 85 minutes of total sleep time.

I did have a miserable night sleeping with a bad back and not being able to rollover because of the wires attached to my legs, which were always coming off. Plus, my back was hurting from sitting on a hard chair with no back support while the tech wired me up, so I was hurting even before I got into the bed.

The sleep doctor recommended a second sleep study if the trial on the AutoSelect did not take care of the central and complex apneas he found in the sleep study.

I have been following this thread initiated by Sauron who was setting her own optimal pressure setting and reviewing her data. However, I was told by my primary care doc that the DME would follow my data with the 5-20 auto setting.

In talking with the DME they said I should use the 5-20 AutoSelect settings for one month and then give the SD card to them to download. They would then send the download to either my primary care doctor or the sleep study doc, depending on who I chose.

The DME explained that the docs wanted 30 days before looking at any data, since the first two weeks or so could very well be a chaotic adjustment as far as the data was concerned. Once I'd settled in to a stable pattern, that's the data they wanted to see before any other decisions were made in regard to treatment or further sleep studies..

I'd like comments from the Board veterans if this seems like a reasonable way to go.

In addition, I'd like some discussion of the pros and cons of me, myself, looking at the data.

I'm anticipating that I would not want to change the pressure settings since this is as much, or more, a diagnostic process as a treatment program and something needs to remain unchanged in order to get a clean look at my sleep in the home without all the wires, with the right kind of mask, etc.Help
12-17-2013 06:26 PM
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Tez62 Offline

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Post: #17
RE: Complex Sleep Apnea
(12-17-2013 06:26 PM)drmick3 Wrote:  The sleep doctor recommended a second sleep study if the trial on the AutoSelect did not take care of the central and complex apneas he found in the sleep study.

I have been following this thread initiated by Sauron who was setting her own optimal pressure setting and reviewing her data. However, I was told by my primary care doc that the DME would follow my data with the 5-20 auto setting.

In talking with the DME they said I should use the 5-20 AutoSelect settings for one month and then give the SD card to them to download. They would then send the download to either my primary care doctor or the sleep study doc, depending on who I chose.

The DME explained that the docs wanted 30 days before looking at any data, since the first two weeks or so could very well be a chaotic adjustment as far as the data was concerned. Once I'd settled in to a stable pattern, that's the data they wanted to see before any other decisions were made in regard to treatment or further sleep studies..

I'd like comments from the Board veterans if this seems like a reasonable way to go.

drmick3, it sounds reasonable to me, then after the 30 days they can adjust your pressures to a smaller range i.e. 4-14 or 5-15.
You can still view your data daily or weekly without changing the settings using sleepyhead.
You may want to update your Machine type in your profile, I assume it is a Resmed S9 Autoset, the model name is next to the power button on the CPAP.
(This post was last modified: 12-17-2013 06:36 PM by Tez62.)
12-17-2013 06:35 PM
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Peter_C Offline

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Post: #18
RE: Complex Sleep Apnea
drmick3 - the only real downside I see, is if you need a higher pressure all the time, the machine will start you out every night at the lowest available pressure (5) and slowly work it's way up to whatever pressure you seem to need most of the time (I bounce between 14-16, with jumps a bit higher now and then) - so using myself as an example, it's clearly to my benefit to start at least at '13' as I never go lower - but it's only for a month or so, and who knows, you may only need a pressure of 6-7, right?

While you can learn how to adjust it yourself, I'd try hard not to 'tinker' - as it's true, your body needs time just to get used to the machine, and then time to fine-tune the pressure.

*I* am not a DOCTOR or any type of Health Care Professional. My thoughts/suggestions/ideas are strictly only my opinions.

"Only two defining forces have ever offered to die for you. Jesus Christ and the American Soldier. One died for your Soul, the other for your Freedom."
12-17-2013 07:35 PM
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Sauron Offline

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Post: #19
RE: Complex Sleep Apnea
(12-17-2013 06:26 PM)drmick3 Wrote:  I have been following this thread initiated by Sauron who was setting her own optimal pressure setting and reviewing her data.

I'm a BOY!!!!

And to clarify, only the adjustment from 15 to 16 was done by me; all other adjustments were done by, or at the suggestion of, the sleep technician.

I have been reviewing my own data as I like to know what is going on, plus I generally don't take for gospel what any one person tells me (even if they are the expert). For example, I mentioned my belief that I had sleep apnea many times to my GP and was always dismissed because I never actually fell asleep during the day and aren't obese. When I finally dug my heels in and insisted on a sleep study (just a take home overnight oximetry test) it showed I have severe sleep apnea.
(This post was last modified: 12-17-2013 07:49 PM by Sauron.)
12-17-2013 07:47 PM
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drmick3 Offline

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Post: #20
RE: Complex Sleep Apnea
(12-17-2013 07:47 PM)Sauron Wrote:  
(12-17-2013 06:26 PM)drmick3 Wrote:  I have been following this thread initiated by Sauron who was setting her own optimal pressure setting and reviewing her data.

I'm a BOY!!!!

And to clarify, only the adjustment from 15 to 16 was done by me; all other adjustments were done by, or at the suggestion of, the sleep technician.

I have been reviewing my own data as I like to know what is going on, plus I generally don't take for gospel what any one person tells me (even if they are the expert). For example, I mentioned my belief that I had sleep apnea many times to my GP and was always dismissed because I never actually fell asleep during the day and aren't obese. When I finally dug my heels in and insisted on a sleep study (just a take home overnight oximetry test) it showed I have severe sleep apnea.
Oh-jeez

Boy, did I screw up, or what! Guess my minds fuzzier than I thought during the day.

Forgive me for the gender mistake.

I recall reading Paula02's comments about whether some of the pressure settings were yours or a docs, but I thought it was still up in the air. Sorry again.

We think alike though, I also like to check out the experts and even had an arrogant cardiologist tell me of course I didn't have sleep apnea since I didn't snore, disagreeing with my primary care doc. My kidney doc said the primary care doc was right and that if I did have sleep apnea, it would go a long way toward fixing a number of problems with one fix.

i can overdo the analysis at times. Not often, but I can do it.

In this case it seems like the sleep doc recommended the AutoSelect since he couldn't determine my optimarl pressure setting, which is fine with me because I wanted the ResMed AutoSelect anyway even before I got his auto recommendation. Now, I won't have to pay the extra money since he order it for me. Sleep-well
12-17-2013 08:39 PM
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