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New user, new diagnosis
#1
Hello,

I'm a new member and a new CPAP user (the OSA diagnosis is still pretty fresh).

I've had insomnia for about 15 years now - both trouble falling asleep and trouble staying asleep.  It's been managed with pills - until recently, it was Temazepam 30mg, Melatonin 10mg, Diphenhydramine HCl 50mg, Doxylamine Succinate 25mg.  

I've been working with a therapist on "Cognitive Behavioral Therapy for Insomnia".  It's helped quite a bit - my "sleep efficiency" is way up and I no longer take the Diphenhydramine nor the Doxylamine, and the Temazepam is down to 22.5mg.

Over the past year I've changed my diet and dropped 50 pounds.  As the wife pointed out, "you don't snore anymore".  

I get my healthcare through the VA.  During my last annual appointment, the doc referred me to the Sleep Medicine folks for a consult, just to rule out apnea.  They examined my throat and told me that it didn't look like the structures would be apnea-prone; perhaps I'd had more of an issue 50 pounds prior.  They still wanted to get me into an overnight study just to completely rule it out but it was not critical, so the appointment was well in the future.

(I'd thought to break into chunks so I could hit 4 posts quick but apparently it just appends to the initial post)

I did not enjoy the appointment. I am a stomach sleeper - have been since I was a teen; had severe road-rash on my back and had to learn not to sleep on it. Wasn't until after they wired me up that they told me I needed to sleep on my back or side; back just isn't restful and side makes my back hurt. Followed the directives, minimal sleep (it seemed like) - too much noise, bad positions, uncomfortable tiny bed.

They did not titrate me during the study.

The followup was a few days later and was about as detailed as "they determined you have sleep apnea, you'll be contacted for an appointment to come get a CPAP machine".

No questioning, no discussion. I'd have liked to know a lot of details that weren't provided.

Detailed report follows - pulled straight from my notes in the VA's system

Active Outpatient Medications (excluding Supplies):

Active Outpatient Medications Status
=========================================================================
1) TEMAZEPAM 7.5MG CAP TAKE THREE CAPSULES BY MOUTH AT ACTIVE
BEDTIME FOR SLEEP

Patient presents to the sleep lab for scheduled PSG. PSG procedure explained to
patient. Sleep sensors applied per sleep lab protocol. Lights out: 23:03,SAO2=
96%,P=70,EKG=(supine). Patient had some difficulty falling asleep and
maintaining sleep after lights out due to mild snores and hypopneas. Supine REM
sleep displayed mild to moderate snoring and obstructive OSA with mild oxygen
desats and arousals. Patient did not sleep lab criteria for emergency split-
night (RDI>40) study after two hours of sleep as his estimated RDI was 26.2.
Diagnostic PSG continued at 01:30. Lights on: 5:55. Sleep sensors removed from
patient. Patient provided shampoo and towels for clean-up. Patient completed
morning questionnaires and departed the sleep lab in apparent distress @ 6:45.
Preliminary staging and scoring completed.

POLYSOMNOGRAPHY REPORT
Patient Name:
Patient ID #:
Sex: Male Study Date:
D.O.B. Study Type: DIAGNOSTIC
Age: 47 years Referring Physician:
Height: 71.0 in. Interpreting Physician:
Weight: 208.6 lbs. Recording Technician:
B.M.I. 29.1 lb/in2 Scoring Technician:
Neck: 16.0 in. Epworth: 12/24
CPT Code: CPT Code Description: Attended Polysomnography 4
channels or more.

Medications: TEMAZEPAM

PROCEDURE:

Polysomnography was conducted on the night of 3/14/2017. The following
parameters were monitored: frontal, central and occipital EEG, electrooculogram
(EOG), submentalis EMG, nasal and oral airflow, anterior tibialis EMG, body
position and electrocardiogram. Additionally, thoracic and abdominal movements
were recorded by inductance plethysmography. Oxygen saturation (SpO2) was
monitored using a pulse oximeter. The tracing was scored using 30 second
epochs. Hypopneas were scored per AASM definition (4% desaturation).

SLEEP ARCHITECTURE
Lights off clock time: 11:03:10 PM
Lights on clock time: 5:55:58 AM

Total Recording Time (TRT): 423.9 minutes
Time In Bed (TIB): 412.8 minutes
Sleep Period Time (SPT): 407.8 minutes
Total Sleep Time (TST): 327.8 minutes
Sleep Efficiency: 79.4 %

Sleep Onset: 5.0 minutes
WASO: 80.0 minutes

REM Latency (from Sleep Onset): 126.5 minutes
REM Latency (from Lights Off): 131.5 minutes

Sleep Staging Duration % TST Latency (from LOFF)
N 1: 32.5 minutes 9.9 % N 1: 5.0 minutes
N 2: 211.8 minutes 64.6 % N 2: 11.5 minutes
N 3: 30.0 minutes 9.2 % N 3: 114.0 minutes
R: 53.5 minutes 16.3 % R: 131.5 minutes

*Above Index Values Based on Total Sleep Time ? Hypopneas scored based on 4% or
greater desaturation ? UH + CH +OH = Hypopnea Total

CHEYNE STOKES BREATHING: None Observed

RESPIRATORY
AHI: 20.3 RDI: 23.4

CA OA MA Apnea Hypop* A + H RERA Total
Number: 22 34 5 61 50 111 17 128
Total Dur(min): 5.8 11.3 1.4 18.5 19.4 37.9 7.2 45.0
Index(#/h TST): 4.0 6.2 0.9 11.2 9.2 20.3 3.1 23.4

AROUSALS
REM NREM Arousals Awakenings Ar+Aw Ar+Aw Index
Respiratory: 2 7 10 16 26 4.8
Leg Movement: 1 9 11 0 11 2.0
Snore: 0 0 0 0 0 0.0
Spontaneous: 2 17 20 3 23 4.2
Total: 5 33 41 19 60 11.0
Arousal Index: 5.6 7.2 7.5 3.5 11.0

LIMB MOVEMENTS
Count Index (#/h)
Total Leg Movement: 58 10.6
PLMS: 0 N/A
PLMS Arousals: 0 N/A

SNORING SUMMARY
Snoring Episodes: 0
Snoring Index: N/A
Total Time with Snoring: 0 min

OXYGEN
Mean SpO2: 93%
Low SpO2: 78%
High SpO2: 98%
<=88% (min): 10.5

CARDIAC SUMMARY

Average Pulse During Sleep(TST): 63.1 bpm Lowest Pulse During Sleep (TST):48 bpm
Highest Pulse During Sleep(TST):98 bpm Lowest Pulse During Recording (TIB):48bpm
Highest Pulse During Recording (TIB): 98 bpm

CARDIAC EVENT OBSERVATIONS
TYPE YES NO RATE / DURATION
Bradycardia: x Lowest HR Scored: N/A
Unclassified Tachycardia: x Highest HR Scored: N/A
Sinus Tachycardia During Sleep: x Highest HR Scored: N/A
Narrow Complex Tachycardia: x Highest HR Scored: N/A
Wide Complex Tachycardia: x Highest HR Scored: N/A
Asystole: x Longest Pause: N/A
Atrial Fibrillation: x Duration Longest Event: N/A

TECHNICIAN NOTES

PSG was performed to evaluate for sleep disordered breathing. The study was
notable for snoring and significant sleep related breathing events with an AHI
of 20/hr. Oxgen saturation nadir was 78%.

Impression:

Moderate Obstructive Sleep Apnea
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#2
Got the CPAP machine, intended to just leave it in the closet -- "even if I did have a bit of apnea on my back, that's not how I sleep", "Father-in-law has OSA and his CPAP machine sounds like a vacuum cleaner, can't have that", "how the heck would I be able to sleep with this thing on my face?"

Then the wife mentioned in the morning that she couldn't tell if I was breathing or not the night before. Sigh. CPAP out and set up, and time to start doing research. I've read a lot on your forums, learned quite a bit (I think); whether what I learned is correct or not is another story.

Apparently the issued CPAP is a really nice machine. The mask provided is also a ResMed but it was just in a plastic pouch and we removed and discarded those during the issuance.. so I don't know which Mirage it is.

So first usage was 12 April. I took the mask off around 4am, when I got up to use the bathroom. SleepyHead says AHI of 5.51 there.

13 April was the first night I left it on. It seemed to work well; felt decent in the morning and SH says my AHI was less than one.
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#3
Then there was last night (14 April).

I had alcohol last night, which is probably not relevant.

There were a few times I woke up and the pressure seemed to be most excessive - I am not sure where the mask was leaking but I could feel the breeze on my arm directly in front of my head, like the leak was coming straight out from the nose.

My assumption based on what I've learned so far is that the centrals from last night might be directly caused by the high pressure; I don't really get what sets it off on going full speed like that though. Wife says it had been churning away one of the previous nights (but I didn't notice)
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#4
So now I come to y'all, for help making sense of it.

My overall hope is that some/all of the insomnia can be helped by treating the apnea.
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#5
My SleepyHead charts are at h ttp://imgur.com/a/sOhFs
(still won't let me post links)
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#6
Welcome to the forum.

Thank you for posting your sleep study data in addition to your nightly graphs. Please make any further posts in this thread so we have a history.
What I see is that you are experiencing mostly Clear Airway events, not uncommon in new users. The CSR happened once so I'm not concerned about that unless it recurs.
To address the CA events I would like you to reduce your max to 9 cmH2O and set EPR to OFF (currently 3) so

5 - 9 with EPR Off.

This should lower your CA and hopefully not increase your obstructive events.

Fred
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#7
EDIT, while I was typing one showed up Smile
The clever guys will be along soon and help you dial in as best you can.
but you may have the wrong machine, I'd also take the results back to VA.
The machine you have treats the OA and hyponemia in the list, it doesn't treat the clear airway / cheyne stroke, where the high numbers are coming from.
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#8
Perfect, thank you; will report in tomorrow or Monday.
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#9
Just to be clear, I doubt you are having Central Apneas, None were indicated durin your sleep studies. I suspect the CA events you are having are pressure induced, the changes I've suggested will help determine that.

AJACK is correct in that if we don't manage the CA events we would recommend a different machine for treatment, but this first.
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#10
Hi derekf,
WELCOME! to the forum.!
I wish you good luck with your CPAP therapy, hang in there for more responses to your post.
trish6hundred
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