Switched from APAP to BIPAP

[Geer1]

Should I do a max of 12cmH2O or 13cmH2O?

Lets try 12. You might actually feel better with pressure being kept low.

[AmirKas]

Sounds good, 

I'm still wondering, because I can use the ResMed Aircurve 10 as an APAP device, but might do better with pressure support instead of EPR, how would I go about replacing my Apap with a Bipap in the quickest amount of time as possible. The reason I think so is that even on days with low AHI numbers, I feel absolutely terrible. As well as that, according to my sleep study which excluded a lot of time periods during sleep, I have almost double the RDI than AHI and don't experience many desaturations over 4%. I want to feel somewhat decent before my next semester starts so that I can go back to doing what my potential allows me to do.

[AmirKas]

I've taken a closer look at my waveforms and notice that even though OSCAR doesn't report any flow limits for some periods of time, there are obvious deviations in my normal waveform despite the lack of recorded flow limits for the majority of the night. At EPR 2 / EPR 3, there are waveforms that correspond to the flow limited waveforms described at:

http://www.apneaboard.com/wiki/index.php...lasses.png


While I understand that EPR 3 seems to do more harm than good in regard to central apneas, I believe that my flow limitations, which are clearly prevalent throughout the night, pose a bigger indicator of why I feel so poor when waking up. Hence, I am suggesting that a Bipap machine might be better suited to my OSA archetype. To reiterate, my sleep study showed no indication of central/mixed apnea and that those issues are almost definitely treatment-emergent. 

Examples of unreported flow limits:

EPR 2 12 - 16 :

[attachment=33644]

EPR 3 12 - 16:

   

EPR 3 10 - 13:

[attachment=33647]





I don't want to succumb to the temptations of confirmation bias, but I'm simply trying to find out why I feel so terrible in a desperate time, despite a series of good results. Let me know what you guys think about my suggestion, observations, and how I should move forward. I've managed my expectations so far, but I need to start actually feeling better soon in light of securing a good future for me and my family. I am deviating a little bit from Geer's suggestion, and am going to sleep with a setting of 10cmH2O - 12cmH2O at EPR 3 tonight. I Will post my results tomorrow.

[Geer1]

A lot of those aren't real flow limitations. You do show some signs of restriction but so far everything in the data and in your comments about sleep quality has indicated worse sleep at EPR of 3. You keep saying you felt good the one night and you want to get back to that, that was a setting of 7-14 with EPR of 2 hence my recommendation to return to similar settings. You can keep trying to force yourself more air and pressure but if your body doesn't want it then it will hurt your treatment instead of helping.

The only way you will ever get a bilevel is to buy one out of pocket and so far everything indicates it would make your sleep quality worse. Until you are 100% sure that you are sleeping better with an EPR of 3 then there is absolutely no reason to consider it imo. Hoping your problem is as simple as you hope yours is doesn't make it true.

Your breathing issues aren't resolved, for example you are still breathing out of your mouth. CPAP can't fix that, you need to see the ENT to see if he can help and you need to try removing dairy from diet to see if that helps. Investigating these obvious issues will help more than continuing to adjust CPAP settings every night hoping to find one that magically solves everything.

[AmirKas]

Yeah, you're right. I'm honestly just trying to understand why my symptoms are still so severe. Instead of sleeping to recover from the day, I recover from my sleep during the day, only feeling normal once I've stayed up for longer than 14 hours. Even with decent AHI numbers and continuous use, I'm seeing no benefit whatsoever, feeling like I'm on a different planet for the first 2 hours after waking. And I don't think that gradually feeling better from waking up till I go to sleep is a result of a dairy intolerance (I will still attempt the elimination diet). 

-I'm also not sure why you don't consider those waveforms to be indicative of flow limitations. A lot of those waveforms have 2 -3 plateaus and flatter tops which supposedly indicate flow limitation.

If it's not an issue with flow limitation, then I don't know what the main issue is. I understand people say that you need to give the machine time to start reaping the benefits, but with 3 weeks and experiencing pretty severe symptoms, I'd think I'd notice some improvements with my numbers being pretty decent. 

I'll use settings of 8cmH2O - 12cmH2O but will attempt to use an EPR of 3 and see how I do at a lower pressure. Finger's crossed.

[Geer1]

If you have a dairy intolerance you will notice a difference in fatigue/energy levels. Another thing it could potentially do is improve your nasal congestion which will make it possible to breath through your nose which is far more efficient and will likely improve your sleep quality. If dairy is causing your congestion then removing it will do far more for your sleep breathing then CPAP settings will.

The first example you posted has too many odd shaped breaths indicative of an arousal occuring.

The second one has pretty good looking breaths and the one higher blip was probably a twitch or something. Nobody ever has perfect inspiratory flow curves all the time so it is normal to see the odd minor flow limited breath mixed in data, where it becomes an issue is when there are a lot of obvious flow limited breaths cumulating in arousal breathing.

The third example could potentially be flow limitation of some sort although again breath shapes are a bit odd and may be being influenced by something else such as rem sleep. The small amplitude breaths on the right could potentially be central in nature in which case if you try to fight the potential flow limitations to the left you may exaggerate central breaths to the right.

CPAP settings are a game of compromise and when there are other issues like not being able to breath through your nose it becomes a lot more difficult to ever find full relief/ideal settings because CPAP can only do so much. Many guys fall into the trap of continuously trying different settings and wanting to try different machines etc, I call it going down the PAP rabbit hole. Some guys do this for years without finding settings that work. My recommendation to settle on what appears to be a good enough CPAP machine isn't to give up on the matter it is to adopt that these settings appear to be best for you at this time (at least until your body adapts further) while focusing on other potential treatments/health issues that could be playing a larger role.

I will be curious if you feel better at lower pressures again now that you have tried higher ones. My recent sleep study told me they had to go up to 11 cm to treat my breathing and I have been playing with higher pressures for a while and maybe it helps for a bit of the night but overall it made my treatment worse and I have now reduced back to lower pressures again. You can't treat every breathing issue with CPAP and sometimes trying to do so makes things worse.

[AmirKas]

After hearing how long my friend has to wait to do his septoplasty / turbinate reduction, I'm not confident that I'll fix that issue in the near future. Congestion isn't too much of an issue unless it's allergy season, in which I normally take allergy medication to alleviate anyways. I'm not expecting to feel like I can literally conquer the world, but if I could explain the extent of my symptoms, you'd have to understand that I can definitely feel better than this. I personally don't think dairy could cause this level of severity since I actually did essentially do an elimination diet when I was around 16 years old and found the diet to not produce any significant results - asked my mom for her observations as well and she agreed. Not sure if an intolerance can become this much worse during the course of just a few years, but I really do think my symptoms are largely a result of sleep-disordered breathing (always feel better the longer I stay awake with symptoms being its worst upon waking)


I'm pretty desperate to feel like myself again... I really don't want to drop out of college (nor can I because they provide my insurance) because of a recently debilitating disorder. I know I can contribute a lot to society if I were to regain my gift, but right now I genuinely feel like a shell of my former self in all aspects of being.

... I just know there's something out there that'll really make a difference and that's why I'm on here posting every single day.

Also...
I'd like to ask, could the Aircurve 10 act as the auto set if need be? I understand EPR (PS rather) would be at 3 but I genuinely feel like a more advanced machine could potentially make therapy more effective.

[Geer1]

If you can't breath through your nose there is obviously an issue there and it is likely due to congestion of some sort. Not only is mouth breathing an issue on its own but using CPAP with a FFM can also make apnea/restriction worse in some people. That is why I said I would be interested to see results on a nasal mask but if you can't breath through nose it probably won't help. If your nose has structural issues then they may need to be fixed before you can get full benefits of CPAP, you are correct that process may take time I had to wait a year for my surgery thanks to our great medical system in Canada. Life doesn't end, you figure out how to get by, manage your stress, treat the symptoms and keep chugging along.

A vauto can do little more than supply higher EPR. When operated at PS of 3 or lower it is effectively the same machine with some very minor extra capabilities to shift pressure waveform slightly. In rare cases this has proven to be beneficial but it would be a long shot. If you want to spend $1000 to buy a used one then feel free to try, you won't be able to get one through a doctor or insurance because there is nothing medically that supports bilevel use.

[cathyf]

AK -- I'm intrigued because your SDB looks a lit like mine does, but it's not having nearly as ugly effects on me.

I'm going to suggest that you go to this site [/url]https://www.hypersomniafoundation.org/classification/  [url=https://www.hypersomniafoundation.org/classification/]and see if this looks familiar. Narcolepsy as shown in the movies looks really dramatic (movies are supposed to be dramatic, LOL) but that's just NT1. NT2 and IH look different.

[AmirKas]

Hi Cathy, 

I definitely don't have narcolepsy, I'm quite certain of that. Rather than daytime sleepiness, my worse symptoms primarily consist of mental and physical fatigue (brain fog), irritability, anxiety, and the corresponding difficulty to respond to intrusive thoughts. These symptoms were not noticeably prevalent a few years ago but during high school, my fatigue levels were becoming a problem. The brain fog is quite debilitating and I can even feel the physical feeling of fog. I suspected ADHD, but my ADHD-PI symptoms weren't prevalent as a child, and I failed my stimulant trials because they made me feel overwhelmingly agitated. 

Hence, why with an RDI of 9.4 (20 during REM) according to a sleep study that ended up excluding 50% of the night, I suspect UARS and flow limited breathing to be my main issue. While OSCAR doesn't fully record all my flow limitations, I can see that my flow waveform shows consistent irregularities during the night. 

Maybe it's a case where SDB severity doesn't correspond well to symptoms, or that my biggest fear is coming to the realization, and I'm descending into schizophrenic psychosis (no family history whatsoever)