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Help a newbie, please?
#1
Help a newbie, please?
I was recently diagnosed with severe OSA (with centrals as well), and have had my Dreamstation CPAP Pro (insurance wouldn't authorize auto or ASV, yet) for a week and a half. I was also Rx'd 6LPM oxygen titrated through the CPAP, which I only used for 2 days last week, and it made me feel worse, so I took a break from it while I tried to adapt to the CPAP therapy generally, which has been a struggle. When I did use the O2 for those 2 days, periodic breathing showed up on my sleepyhead data, but only for the days I used O2.  I will admit to being resistant to using the O2. I'm a backpacker with dreams of long distance thru-hiking in the next few years and can't be lugging O2 on the trail, so don't want to develop a "dependence" on it in the interim. I will use it if I must, but would rather not. My doctor's office is not at all helpful (won't make any appointments or have any discussions about the DX until 6 weeks after CPAP therapy initiation).

I was initially using the Respironics DreamWear nasal mask until two days ago, but just couldn't adjust to it, and just switched to a ResMed Airfit N20, which I've only used for the last two days. I suspect that I need a Small and the DME gave me a Med. I'll admit that I am struggling with wearing the mask still; I will wear it for a few hours while/after I fall asleep, and then, at some point after that, in my sleep, or groggily frustrated, end up taking it off until the early mornings when I put it back on for a few hours. While I am finding the Airfit easier to deal with (nothing pushing up against my nostrils), I still feel what I'm guessing is air hunger? I basically feel like I can't breathe, like I can't draw a deep breath. I do have seasonal allergies and mild asthma (though it's typically only exercise-induced, so I haven't tried using an inhaler before bed, but maybe that would help?). Now, I do feel this way mildly during the day (like I can't draw a deep breath), which I chalk up to my allergies, but I don't notice it often; at night, however, it feels almost constant since starting the CPAP (I don't remember experiencing it before starting CPAP therapy). Now, I think it may be just acclimating to the CPAP, to having forced pressure constantly fed into my nose, but I'm not sure. I was Rx'd a pressure of 8, and they initially set it up with Smart Ramp of 20 minutes starting at 4, humidifier at 3. Between the DreamWear mask and the Smart Ramp, I spent most of the nights feeling like I was suffocating, and I ended up turning on the Auto Trial for 30 days, turning Smart Ramp off, and setting the APAP range to 7.0-12.0 in the hopes of finding a pressure that will eliminate the OSA and the centrals and hypopneas that I'm experiencing. I suppose now that I've got a mask that works better for me, I could just set it back to 8, and see how that works? 

With the CPAP, my AHI has been all over the place, but generally bad (ranging from 6.1-17.6). Last night it was 13.49 with a usage of 4:15. According to DreamMapper and Sleepyhead, my centrals and hypopneas almost always outnumber obstructive events. I'm guessing that is why I was also Rx'd the oxygen, though my doctor's office is not at all helpful, and the sleep tech, my primary care doc, and the DME techs have all been surprised that I was Rx'd with such a high volume of O2. I'm a small guy (5'1, 124#), 43 yo, side sleeper, if that helps, and I have lost 15# since my initial sleep study, lowering my BMI from 27 to 24, so far. While I was using the DreamWear mask, I felt like my sleep was worse than it's ever been, but since using the Airfit N20, it feels like it may be getting better, though I'm still so freaking exhausted... 

Some more details:

Initial sleep study (wt 143): 
-prolonged sleep latency 
-REM latency at 225 minutes, and REM sleep at 6%
-AHI and RDI 37.6/hour
-Oxygen sat decreased to nadir of 82%

Titration study (wt 130): 
-sleep latency normal
-REM latency @ 225 minutes, and REM sleep at 5%
-CPAP pressures of 4 to 8 used and 8 cm of water "appeared to be the optimal pressure"
-6LPM O2 fed into CPAP line
-Total Sleep time with O2 Saturations <89%: 4.8 min

So, with all of that, what would you recommend? And, has anyone else experienced the REM latency and low REM sleep %?  Is that just from years of sleep deprivation and will it improve, or could it be symptomatic of a larger problem?

Thanks for any/all suggestions!


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#2
RE: Help a newbie, please?
dadtojma,
Welcome to Apnea Board!

It looks like you have complex sleep apnea.  

You need higher pressure to combat the Obstructives, but a higher pressure may cause more Clear Airway events.  So sometimes a lower straight pressure setting is recommended.  With Complex SA, insurance will require that you "fail" at Cpap, before being titrated for an ASV machine...which is what you may need.  

I would go back to the pressure of 8cm and turn off the Flex setting.  After a couple weeks, touch base with your doctor if the Clear Airway events are not lowered to see what his game plan is.

I can't comment on Oxygen as I don't use it.

I'm sure others will be along with some advice.
OpalRose
Apnea Board Administrator
http://www.ApneaBoard.com


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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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#3
RE: Help a newbie, please?
The REM latency and low percentage of REM could have been due to 'first night affect'.
You can read about it here:


https://www.google.com/url?q=https://www...p8C1lCtxk9
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#4
RE: Help a newbie, please?
To help you get used to it would be wear it while watching tv or reading a book before sleeping.
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#5
RE: Help a newbie, please?
That "insurance wouldn't approve auto" is probably a story by the supplier (DME). The same billing code is almost universally used for CPAP whether it is fixed or auto. At least you have the data. I would like to put everyone on a Resmed Airsense 10 Autoset because it offers such diverse and effective treatment options. I agree it's kind of early to pull the trigger on ASV, but you might be able to persuade your doctor to specify Auto CPAP in light of your poor results so far. If he goes for it, ask for the Airsense 10 Autoset.

I think it would be useful to request a copy of your diagnostic and titration studies. The titration study in particular would show the event rates and types of events at pressures. The types of apnea are also important to know from the initial diagnostic study. These reports are yours under Federal law (HIPAA). We can point you to your rights, or just google patient rights under HIPAA.

This is a very high event rate, and you will fail CPAP sooner than later if this continues. That is not a bad thing, and would trigger the BiPAP / ASV study. You do however have to stick with it to get there, and that can be hard. Just remember the events are not your fault and your efforts to find therapeutic settings that work are completely okay as long as you gave the prescription a decent try. The extent of your central events is not something your CPAP can treat. The obstructive events will either respond to higher pressure or a positional therapy. I think a soft cervical collar may help with the strong obstructive clusters.

Try this: relax in a chair and really relax. Let your chin drop towards your chest, just as it might if you fell asleep or if your pillow was too high in bed. If you feel you can't breathe through that posture or it causes resistance or snoring, that is a positional apnea. If it has no affect, then let me know, but if you feel the resistance to airflow, that is a pretty good indication that a soft collar that prevents your chin from dropping may help a lot.

Don't lose sight of the big picture. We might help you solve the problem with your current CPAP or we might help you to talk to your doctor about your intractable problem, and get you to the next level of treatment, which may be bilevel or ASV.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

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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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#6
RE: Help a newbie, please?
You were diagnoses with severe OSA which often means higher treatment pressure.
The fact that some CA were observed means nothing - some CA are normal.

Your sleepyhead data shows that your OSA is not adequately treated which means you need more pressure. Increase the min to 10 as a start. Increase max to 15. Ignore CA events until OSA is properly treated as often the CA events are false and will likely fade away.

After defeating the OSA (OA, H), then you can worry about a CA problem if one exists.
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