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New Member Looking for Help
#1
New Member Looking for Help
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Hi Everyone,

Been having a tough time with sleep and could really use some advice and help. I have recently re-started using an APAP and have tried several settings based upon research and recommendations in several posts. I have been doing a ton of research on this forum and a few others and have learned so much. What a great resource.
 
Some Background: In 2015 I had a home sleep test after complaining to my primary care Doc about waking up gasping for air and experiencing several symptoms associated with sleep apnea.  The test revealed that I had mild OSA and an APAP was provided. I wasn’t given a sleep study report or even told what my AHI was. The APAP provided was a Phillips System One. I was started out at a pressure rate of 4 min/20 max, but my remote DME changed settings over several months to 6.5 min/20 max. I never really had any issues adapting to treatment and for the most part it seemed to help.
 
After about 12 to 15 months (2015-2016) I had developed severe back issues that required 2 surgeries and subsequently lost 50 lbs. With the weight loss my previous symptoms of waking up gasping for air subsided to the point that I didn’t think I required the assistance of an APAP. I took myself off and all seemed fine. This continued until the past few years (2018–2020) when I experienced really poor sleep, waking up frequently (fragmented sleep) and short duration, perhaps 5 to 6 hours duration regularly. I have been able to keep my weight off however and still don’t have any sensation of not breathing or gasping for air.
 
I am a disabled Veteran and use the local VA for my Primary care now. I requested a sleep study from the VA back in early May, and it was conducted overnight in a Lab on 6/30. It took me two months to get the results after complaining regularly. Even though I hadn’t received the report from the VA yet, I knew that the study indicated I had sleep apnea since the Lab tech told me so. Given this, I pulled out my old System One and started using it again while waiting for the VA to provide my report and recommended course of treatment. The sleep report indicated moderate OSA, 1 obstructive, 1 central and 35 hypopneas for an AHI count of 7.2. It also indicated 56 arousals total, 9 respiratory and 11 leg movement (PLM) arousals.
 
I have tried various settings on my system one by pouring through the data and doing extensive research on this forum. I have increased the pressure from 6.5 slowly up to 10, played with AFLEX settings, 1 2 & 3, and while my AHI numbers were decent <3, I still had fragmented restless sleep and short duration.
 
While waiting for the VA to complete my study for two months, I came upon a great deal on a new ResMed AirSense 10 Autoset. The results were startling, AHI numbers consistently <1, however I am still experiencing restless and fragmented sleep, awakening several times a night. Over the past 6 weeks I experimented with the Autoset changing the minimum pressure and EPR settings and although in general I am sleeping deeper and better overall; my sleep is still fragmented with several awakenings. Given the lack of adequate sleep, I am constantly fatigued, frequently in a fog, tired, horrible mood and everything else that goes along with it.
 
Looking painstakingly at my data over the past several weeks, my flow rate seems to indicate several flow limitations at times (flat tops) which lead to arousal.  I could be wrong given my limited experience, but that’s what it looks like to me. Given this, and the fact that I can’t seem to get past the fragmented sleep no matter how I change my APAP settings I think I need pressure support due to the flow limitations and am thinking I may do better on an Aircurve VAuto. The VA is sending me a Phillips Dreamstation APAP and I know from personal experience with my System One, and this Forum that this is the wrong equipment for me. They also Titrated me at 5-10 which is way too low. I need 9-10 min with 20 max on a Phillips to keep my airway open.
 
Other info:
 
Meds: Synthroid & taking some supplements for the PLMS
Mask: Spent a small fortune over the past few months buying and trying several types of masks. Best set up for me with minimizing leaks has been the P10, taping mouth and using a chin strap (Bad mouth breather)
Sleep Position: Back and Sides
 
I have attached a copy of my recent sleep study and some Oscar charts from my System One and new Autoset.

I am sorry this is so long. I attempted to provide enough background and information to be useful. I am at my wits end trying to find a way to get better sleep, improve my quality of life and am turning to the experts on this forum for help. thank you in advance for any advice you can provide! I really appreciate it!


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#2
RE: New Member Looking for Help
your first screenshot had a 6.5 lower number and the 2nd one is 7.5 which is much better.  I would move to 8.5 for tonight and see how it works.
Apnea (80-100%) 10 seconds, Hypopnea (50-80%) 10 seconds, Flow Limits (0-50%) not timed 
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#3
RE: New Member Looking for Help
Hi SB!

Thank you for the quick reply! My first post was from my older Phillips System One and I was using it a a comparison to the newer ResMed Autoset. 6.5 is what my old DME had me on and was totally inadequate. I have since tried settings up to 10.0 and although it got a bit better, I still had the same issues. My 95% number on the System One ran about 9.5 average and frequently bumped up to 11 - 12 range during events. ResMed numbers are from the second attachment with the lower AHI. I have tried 6.5 up to 10 on the ResMed with different EPR settings as well and although it certainly is an improvement in over the System One in terms of AHI, I still suffer from fragmented sleep patterns and multiple awakenings no matter the settings. I started at 6.5 and went up to 10, then back down to 7.4 which is my mid average.
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#4
RE: New Member Looking for Help
Try 8.5 with epr at 3
Apnea (80-100%) 10 seconds, Hypopnea (50-80%) 10 seconds, Flow Limits (0-50%) not timed 
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#5
RE: New Member Looking for Help
Your report suggests that you are being very well treated, and I can't suggest anything.  When you have the very odd CA, the vertical line in purple in the top chart, your machine pulses up to a pressure which rewards it with your next breath. If you place your cursor over those coloured lines, it will tell you how long each of them lasted. If they're much longer than about 1-18 seconds, they're getting too long. Very often we hold our breath when we turn over, or when we partially awaken for some reason, and these are innocuous.

I think your tidal volume is a bit stingy, but I'm far away from being a schooled critic of such things.  I think you should wait for bonjour or Sleeprider to look in and offer their opinions.
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#6
RE: New Member Looking for Help
Can you continue to use the AutoSet? ResMed's EPR is therapeutically the same as Pressure Support of 1,2,3. This is what can help with the Flow Limits.
The PR has bad Flow Limitations and I suspected more with a zoomed view which you confirmed. I would increase the EPR with the AutoSet and set the min Pressure no lower than 7 (higher is ok)
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#7
RE: New Member Looking for Help
Will do, thank you!

(09-08-2020, 05:15 PM)mesenteria Wrote: Your report suggests that you are being very well treated, and I can't suggest anything.  When you have the very odd CA, the vertical line in purple in the top chart, your machine pulses up to a pressure which rewards it with your next breath.  If you place your cursor over those coloured lines, it will tell you how long each of them lasted.  If they're much longer than about 1-18 seconds, they're getting too long.  Very often we hold our breath when we turn over, or when we partially awaken for some reason, and these are innocuous.

I think your tidal volume is a bit stingy, but I'm far away from being a schooled critic of such things.  I think you should wait for bonjour or Sleeprider to look in and offer their opinions.

Yes, you are correct, the CA's last 10 to 18 seconds. I do in fact note that I hold my breath when I turn over.

Thank you

(09-08-2020, 06:00 PM)bonjour Wrote: Can you continue to use the AutoSet?  ResMed's EPR is therapeutically the same as Pressure Support of 1,2,3.  This is what can help with the Flow Limits.  
The PR has bad Flow Limitations and I suspected more with a zoomed view which you confirmed.  I would increase the EPR with the AutoSet and set the min Pressure no lower than 7 (higher is ok)

Thank you. I will continue with the Autoset, set the EPR at 3 and push to 8.5 tonight.
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#8
RE: New Member Looking for Help
"I am constantly fatigued, frequently in a fog, tired, horrible mood and everything else that goes along with it."

if your disordered breathing is well treated you have to look elsewhere for feeling this way. it is quite possible plm is the culprit. pap doesn't help plm & resmed machines can actually cause additional sleep disturbances (on top of plm arousals) as they ineffectively raise pressure against plm induced flow limitations. best to get plm treated, not easy to do. otherwise the trick is to limit max ipap to avoid problems with runaway pressure. pressure will not overcome non-passive flow limitations, which is my respiratory response to plm, maybe yours too.
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#9
RE: New Member Looking for Help
(09-08-2020, 08:12 PM)sheepless Wrote: "I am constantly fatigued, frequently in a fog, tired, horrible mood and everything else that goes along with it."

if your disordered breathing is well treated you have to look elsewhere for feeling this way. it is quite possible plm is the culprit. pap doesn't help plm & resmed machines can actually cause additional sleep disturbances (on top of plm arousals) as they ineffectively raise pressure against plm induced flow limitations. best to get plm treated, not easy to do.  otherwise the trick is to limit max ipap to avoid problems with runaway pressure. pressure will not overcome non-passive flow limitations, which is my respiratory response to plm, maybe yours too.

I think what you are saying makes total sense. My Primary care Doc didn't say anything when I asked him about the PLM results from the sleep study. I had more arousal's from PLM than I did for respiratory arousal's. I had already been on Gabapentin for 3 years due to extensive nerve pain following back surgery and got off of it about 8 months ago. I had to keep increasing the dose and didn't think it really did anything any longer. I did some research and am trying some supplements for RLS, however since I don't have any indications of normal RLS symptoms and don't know or recall any leg movements during sleep I don't know if they help. I did used to get some horrific leg, calf and foot muscle spasms, but those have been greatly reduced to very rarely now that I take magnesium. Do you recommend I seek out a neurologist for the PLM?
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#10
RE: New Member Looking for Help
       
   
So I changed settings to 8.6 with EPR at 3. The settings seemed very comfortable.

The early CA and Hypopnea and last two CA's were junk as I was awake. The next CA looks real and shortly after that event my flow rates transform from nicely structured wave flow peaks to flat tops indicating flow limits. The second Hypopnea looks real as well.

I seemed to wake up quite a bit last night. I remember awakening at 12:30, 1:30, got out of bed once and took a bathroom break and then awoke several times after that until getting out of bed shortly before 4:30. I actually was awoken during the night with a sharp leg/foot pain and movement of my leg, a first for me that I can recall. I am beginning to think, especially from some of the input received and from the results of my sleep test that these interruptions and fragmented sleep are due to PLM and not respiratory events as those are being treated adequately with the APAP.
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