Just got overdue titration results, can people give their opinions?

[sventory]

The sad part is about this study, is I felt well more rested than I normally sleep. And the techs said I slept most the whole time, which is true, but it's clearly sh**ty quality interrupted sleep.

My previous posts on my current CPAP usage outside of this titration: http://www.apneaboard.com/forums/Thread-...piralogist

I've attached the new report anonymized. Please take a look. Overall sleep time doesn't look that bad as well as quick sleep onset, but 160 arousals that they claim were not respiratory related, but I'm just sitting here wondering what the hell could cause someone to raise from deep sleep or REM sleep otherwise? Even if it was anxiety or something, that should make falling to sleep difficult, or getting back to sleep hard, I seem to have neither problem, just TONS of arousals.

I tried asking what happens to events under 9 seconds and why they don't count, and other than saying "this is the gold standard" or other non-explanations, no one could explain it. I tried asking the techs what is the criteria for a "respiratory arousal" and they couldn't answer, they don't score RDI and RERA anymore, but they note I had none in the paragraphs. They also put my pressure super low and the tech manually adjusts it if they see breathing difficulties. So my normal pressure is around 12-15, but they put me at 6/7. I also asked, why does my Auto PAP then constantly shoot my pressure up even when I drop to something like 10? Why is it doing that if I am fine at 6? They couldn't answer. Also to note at some point early in the night after awakening, I took a mirtazpine because it really helps me sleep, just so they could get some data. Subjectively I thought I slept better than normal, but the 14 min of deep sleep broken across like 8 chunks says otherwise. So my normal is even worse than this.

I have another appointment to go over the raw data from the study with my doctor, but as I expected, they were of no help and said the only solution at this point is pills. Despite sleeping 21 years of my life perfectly, I now for some unexplained reason not breathing related arouse a billion times a night.

Trying to be concise here I have:

• Narrow airway with small chin confirmed by Jaw Surgeon, ceph revealed 39mm cubed min aximal airway volume, normal average is >100.
  
• My Autopap at home will shoot up the pressure when I put the min at 8-10 to around 12. Yet they said I was fine on 6-7. 
  
• My breath curve on any pressure on sleepyhead is not smooth. Inspiration is rough and jagged. I have low total inspiratory volume (high 20s max).
  
• Tons of "spontaneous arousals" during sleep, barley any deep sleep, with no explanation.
  

Can anyone give me some ideas on what I can do here based on all the above and the attached sleep study?

[Gideon]

I saw no mention of Flow Limits.
Your Dr is going to recommend CPAP at 6 or 7 cmw.  Per the sleep study you do not have apnea at those pressures.

I suggest that you set a range of 6-7 and post expanded 2 min charts of the flow and flow limit as well as the full night to provide context.
Let's see if they may be a problem at these pressures.  If the sleep study used flex/epr add that in too.

In your previous post both I and Sleeprider saw significant Flow Limits.  Flow limits will drive your pressures higher if allowed to.

[Sleeprider]

Typical sleep study proving you are medically treated, with the caviat of chronic low SpO2. The study shows CPAP is effective and you don't qualify for supplemental oxygen. If you want to resolve the disruptive flow limits, it will be on your own dime. There was never a question about AHI efficacy. Did your doctor just ignore your input, or not get it? I assume you showed him the charts, and discussed flow limits and low tidal volume. There is a reason for low SpO2, and This study was not designed to diagnose or treat it.

[sventory]

But I don’t even have low SpO2 do I? Lowest was 93 for the night. That’s fine right?

I mean is it possible the flow limits are causing the arousals? I know you said you had a similar experience aleeprider untl getting bipap, did you have tons of arousals befor too?

[Sleeprider]

Page 1, sentence 2 " and low oxygen saturation of 92%." I misread this as the average. Normal is above 95%, and 92% was your minimum. So it checks out. Your flow limits are still apparent in previous data, so I guess if that or your comfort is something you want to address, you may be on your own.

[sventory]

I see, I am just trying to assess if this still could be an issue. Do you think it could be possible that I'm just sensitive and my body is arousing because of constant flow limitations? If so, then I guess I'll have a Bipap. And did you experience anything similar before you switched to Bipap? 

It just seems weird, from my limited knowledge, if I have a narrow airway and on Auto, the PAP ramps pressure throughout the night to say definitively I have no breathing issues. Because mentally I am not anxious or something, so I have no explanation for these arousals besides breathing related.

[Sleeprider]

Without the details, it's not possible to know the source of the arousals. Based on your history of flow limitation, it's logical that they may be respiratory event related. My own experience may not relate to yours, however, bilevel pressure support eliminated RERA and increased my tidal volume. I did not have the same level of flow limitation you have. I did acquire my first BiPAP through Craigslist, and I have no idea how I could have reasonably been approved for bilevel without that initiative, but my second bilevel was fully paid by insurance. You won't know until you have bilevel experience, and the cheapest, easiest way to make that happen is to buy used. Whether you should do so is your decision to make based on how you feel and your informed knowledge of how bilevel works and addresses flow limitation and tidal volume.

[holden4th]

I"ll back up SR on getting a BiLevel. Using a Respironics 560 Auto APAP I had issues with RERAs that I could not fully resolve. Occasionally, I had good nights with RERA readings but they were the exception rather than the norm. I kept researching and asking questions on this forum because I did not feel as good as the low AHI readings said I should.

I eventually decided that I should move to BiPAP and SR supported this choice based on his own experience. I got the Respironics PR760 auto and within a month or two my RERAs had dropped significantly. Changing to the Resmed VAuto brought even better results. The residual fatigue I still had when using APAP has gone and while there are days where I feel tired, it's more a result of my lifestyle than my Apnea. (Part of my job is coaching swimming and the constant early morning starts will wear anybody down - especially and old fart like me!)

As an Australian, the concept of getting all my treatment via insurance is a non-starter as OSA is not seen as a serious illness here. This is despite that fact that wherever you drive on the outback roads and main arterial highways there are signs all along warning of driver fatigue. Driver fatigue is one of the major causes of fatal accidents here in Australia but the idiots in government just can't seem to link that with OSA. I have private health insurance but they will not contribute anything towards my therapy. Most of the other health schemes are the same.

So, having to buy my own equipment, I found that Supplier #2 has great prices - especially for an Australian.

At this point in time:

The Respironics 760 BiPAP Auto is $619
The Respironcs DSX700H11 Dreamstation BiPAP is $799
The Resmed S9 VAuto BiLevel is $699
The Resmed S10 Aircurve VAuto is $799 - a bargain for this machine IMO

These are what Supplier #2 calls 'gently used' machines and having bought four machine from them over the last few years I can vouch for what they sell and their customer service. The alternative, as SR mentioned, is Craigslist but I like the idea of a company that will back their product as opposed to buying from a private vendor.

The caveat for all of this is that while BiPAP/BiLevel worked for me to reduce RERAs, it may not necessarily work for you. That said, the extra comfort levels of variable Pressure Support you can get from BiPAP are a major plus.

[sventory]

Thanks for contributing, question for you though. Did the machine's sleepyhead results say you are getting RERAs? I thought the machines are quite bad at it because there's no EEG to determine sleep transitions? Also, is your breathing curve fairly normal on sleepyhead? I kinda fixate on that because mine is not normal. So I am hoping to find others like me, or at least were like me before BiPap.

I purchased the Aircurve VAuto from supplier 2. Really it's my only hope left to explain all these "non respiratory-related" arousals. If the qualm is I am arousing before 10 seconds, so nothing is being marked as an event. I really only have BiPap or MMA surgery left. The scariest thought to me is if the doctors are right and it's not breathing related, I have no solution or explanation for my 160 arousals other than take neuroleptic pills =(.

[Sleeprider]

I went from a PRS1 560 to a PRS1 760 BiPAP. Both measure RERA and in my case it went from 2 to 4 per hour with CPAP to less than 0.5/hr on BiPAP. Results further improved with the Resmed, but it doesn't report RERA. I think you can recognize the RERA pattern from your old results, and it is more important how you feel. I'm sure you won't regret the decision. In your case try keeping EPAP pressure in a narrow range, and use PS to fine tune flow limits and comfort.