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[Treatment] Tonkachonk's therapy thread
#1
Tonkachonk's therapy thread
It has been a week with my CPAP, so I figured it appropriate to begin posting here. In my sleep study, I scored an AHI of 63.3, almost all of which were hypopneas. I had 2.5 for Central Apnea, and 1.5 for Obstructive Apnea, the rest are hypopneas.  Very interestingly, I only scored an AHI of 3.7 in my home sleep test. Just an odd thing I thought I would share as that was a pretty big difference.

Right now I am hovering around an AHI of 10 most nights, with most of my events being Clear Airway (CA). They are often occurring in clusters, and there is always a large cluster right after I fall asleep. I have read elsewhere these might resolve on their own with more time in therapy. I turned off the ramp feature, though that didn't seem to help.

I had some trouble with mouth leakage, I was waking up with my mouth open and air rushing out of it and seeing large leaks in my reports. I seem to have fixed that with mouth taping, but am also going to try a full face mask (Resmed F30i) which should arrive today or tomorrow. I don't really like mouth taping as I don't like how my mouth feels in the morning, and I also usually have had to reapply the tape during the night because my drooling caused it to loose its stickiness.

I have attached my OSCAR results from the other night which are pretty typical. I am going to hold off on changing any settings until I have been with the full face mask for about a week but would appreciate anyone's input and if anyone else has had to deal with all these CA events. Also, if anyone else had a similar experience of false negative in their home sleep test that would be interesting to know.

EDIT: Also, just want to add that although my AHI is still higher than desired, I am noticing changes in my life, primarily that I feel a lot more clear headed and don't have many problems with focus or brain fog that I have been having. I attribute this to probably actually getting some amount of deep N3 phase sleep and some amount of REM sleep, both sleep stages that I barely got any of in my sleep study (30 minutes of N3, only 10 minutes of REM with a terrible REM latency of 299 minutes!)


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#2
RE: Tonkachonk's therapy thread
You seem to be experiencing a significant therapy onset central sleep apnea problem. This is unusual, but not rare. It seems to come from the improved ventilation of CPAP driving down CO2 resulting in changes in respiratory drive. It gets too complicated to get into all the feedback mechanisms involved in the respiratory drive, but we can see a delayed feedback loop in your graphs that the ventilation is resulting in alternately hyperventilation and hypoventilation or central apnea. Given your clinical results, the hypopnea may have been central all along, and with the increased ventilation have morphed into central apnea which is a short cessation of breathing, rather than just a reduction in breathing volume.

I think we need to modify your current CPAP settings to limit the range of pressure. You don't need higher pressure to deal with obstructive events, so instead of minimum 7.0 and maximum 15.0 pressure, I'd like to see you set the minimum and maximum at 8.0. This fixed pressure should be less disruptive and may avoid some of the central apnea. Your machine also allows for expiratory pressure reduction (EPR), but that acts like bilevel and can actually make CA worse in some people by increasing ventilation (tidal volume), so for now, we will leave that off. We may eventually want to use it to address flow limitation, but for now, a fixed low pressure should improve your results.

Before masking up for the night, I want you to settle and relax until you feel a normal respiratory volume. If you look at your flow rate graph posted above, it is clear you have a very high breathing rate indicated by the height of the flow rate graph. Settle down, and mask up when you feel more relaxed. This may help you avoid getting into that initial hyper/hypo ventilation loop.
Sleeprider
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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: Tonkachonk's therapy thread
I decided to not change any pressure settings just yet as I am getting used to the new mask (Resmed F30i). Although not nearly comfortable as the P30i, I am getting used to it and able to fall asleep just fine. I do wake up with a really dry throat, and my humidifer is set to the maximum value I can have it before I get rain out. Probably need to switch to a heated hose soon.

Anyway, I have been having AHI 1-2 which is fantastic. I find it really easy to breath with the mask on once I get settled. I almost hate taking it off in the morning! And I took your suggestions of making sure I get into a good breathing rhythm and be relaxed before I mask up which I think has helped a lot.

Now my problem is, the better AHI I have, the more tired I feel, the harder it is to wake up, I just have so much brain fog and fatigue right when I wake up. I have heard this may just be a process of my body healing itself from years of sleep deprivation? After all, my sleep study AHI was 63.

I do feel better once I have had my coffee, but it is causing problems with me making it to morning appointments because it makes me sleep in even more than I used to and feel so groggy when I wake up.

I am showing an OSCAR of last night which is my best AHI so far, however pretty typical for me since I started the new mask. Tell me if I need to zoom in anywhere.


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#4
RE: Tonkachonk's therapy thread
Wow - what a dramatic decrease in centrals! AHI is great. Now would be a good time to implement Sleeprider's suggestion of changing the max pressure to 8.
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#5
RE: Tonkachonk's therapy thread
It's great to see your changes have eliminated the apnea events. With the new mask, I think it may be interesting to put back EPR 1 and see if the CA returns or if it was a temporary therapy onset problem that may have passed. My hope is this can help with fatigue.
Sleeprider
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____________________________________________
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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: Tonkachonk's therapy thread
I haven't actually tried EPR yet at all. My concern right now is also random flow limit problems that seem to be happening. Last, I still kept the same settings and a few times had issues that look like this. All of the sudden, a lot of flow limitation that requires a large increase in pressure, and is usually associated with OA or at least hypopnea. I am wondering if this is a chin tuck related issue, and if I could stop the chin tucking this might not be an issue. I am 50/50 on my back and on my side, this might be associated to when I onto my back again as you can see in both last night and the night before, there is a bit more bumpiness in the flow and more flow limitation at certain times (which results in need for more pressure).

Should I still limit my max pressure even though the APAP seems to be needing it at these times? And last night I had more CA, but I am still interesting in turning on EPR, seeing as especially right when I am going to sleep I feel discomfort in exhalation.

One thing is, I actually fell asleep with two pillows last night, which might have caused an increase in chin tucking. Usually, I just use one pillow that is also a "anti-snore" pillow (didn't stop me snoring at all without a CPAP Oh-jeez ) but it is shaped in a way to have chin further back both on back or side sleeping.


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#7
RE: Tonkachonk's therapy thread
Interesting charts! This suggests you have intermittent positional obstruction ending in a RERA and recovery breathing that then leads to a pause in breathing (CA) due to the hyperventilation. The root cause is chin-tucking and flow obstruction. The centrals appear to be induced by hyperventilation which arises from obstructed, flow-limited breathing. This explains the pressure increases, long inspiration times and the spikes in inspiratory volume. http://www.apneaboard.com/wiki/index.php...onal_Apnea
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


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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#8
RE: Tonkachonk's therapy thread
The future SCC is in stock at my CVS, so I'm gonna go pick one up and see if that helps the positional apnea. From there, I will adjust max pressure down as needed.

If I try the collar tonight, is it to much of a change to also adjust EPR up to level 1? I do think I might benefit as I really do feel a bit uncomfortable exhaling especially right when I am trying to fall asleep
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#9
RE: Tonkachonk's therapy thread
Any time flow limitation is like you display above, is a good excuse for EPR. We can sort out the details later.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


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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#10
RE: Tonkachonk's therapy thread
OK, so a couple things from the past 2 nights.

1. Not sure if the SCC helps...but I don't have big periods of flow limitation anymore so I guess it does?
2. EPR was a bad idea - although I find it somewhat more comfortable when starting out, I get the big clusters of CA and had a lot more OA than I had without it so that is going off for now.

I have one question - under the clinical settings I see a "soft" vs "standard" response, what does this do and would soft be recommended? I am noticing a pattern of flow limitation, followed by pressure increase, followed by CA. Would a softer response maybe make this not happen so much.

So for now, I am going to try a more narrow pressure range. I don't think I will do constant 8, because I am worried about getting flow restriction that the machine wouldn't be able to fix, but I am going to set the max somewhere between 10-12, and the min at 8, because below 8 doesn't seem to do well for me and I have actually noticed I always feel like I need more pressure when I put the mask on at first. Should I try a "soft" response?


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