[Treatment] Waking reflexes, cannot fall asleep

[norbert80]

Below I have attached two recordings from the pure obstructive diagnosis two years ago that I got from the doctor.

   
   

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Just to be sure we understand: you were not asleep during the periods of time shown on the Oscar chart?  It'll be good to see what happens with the revised settings Sleeprider has recommended.  When you post the next chart, could you indicate the periods of time, if any, during which you were asleep?

Yes, NO sleep periods in OSCAR chart.

I will try.

[Sleeprider]

If we can get a good view of your sleep, I suspect that your events are indeed mainly obstructive and EPR will be helpful. We need to watch for periodic leg movement which seems prevalent in your test, and I'm nearly certain you will have positional (chin-tucking) issues which may be the best explanation of your startling awake http://www.apneaboard.com/wiki/index.php...onal_Apnea

[Dormeo]

In the U.S., "PLM" would mean "periodic leg movement." Do you know whether that's what it means here? Did your doctor discuss leg movements with you?

[sheepless]

the second screenshot of your sleep test clearly shows quite a bit of periodic limb movement. in a nice touch I haven't seen before, it shows respiration or flow rate whose pattern is a/the signature of plm. this will complicate treatment because no pap mode I'm aware of will help it. even when you get your ahi down, plm will continue to disturb sleep. it may even be the source of some of your central events.

be aware that resmed machines increase pressure (ineffectively) in the presence of (plm induced) flow limitations potentially causing leaks and awakenings.

my experience has been that sleep docs tell us plm is nothing to worry about. I strongly disagree. best to ask for medication that will reduce it. finding the right med seems to take a bit of trial and error. you can monitor effectiveness of plm treatment by looking for flow rate patterns similar to the one at the left of the video box in your second screenshot.

my experience is similar to yours; diagnosed with central apnea in my early 30's. 30 years later I retested with something like 208 obstructive and 196 central events and they still diagnosed me with obstructive apnea and prescribed an apap which doesn't treat central events. makes no sense to me but at least in the U.S. it's rare anyone is diagnosed with anything other than obstructive apnea. we have to complain and fight to get the proper pap modality (asv).

[jammer521]

try setting an alarm for a hour, wake up and put the mask on, and trying falling back asleep with it, that's what worked for me initially to get used to it

[norbert80]

If we can get a good view of your sleep, I suspect that your events are indeed mainly obstructive and EPR will be helpful. We need to watch for periodic leg movement which seems prevalent in your test, and I'm nearly certain you will have positional (chin-tucking) issues which may be the best explanation of your startling awake http://www.apneaboard.com/wiki/index.php...onal_Apnea

Never heard about PLM.

[norbert80]

try setting an alarm for a hour, wake up and put the mask on, and trying falling back asleep with it, that's what worked for me initially to get used to it

Thanks for this tip. I will give it a try.

[norbert80]

The Airsense 10 reacts to flow limitation, and yours is extremely high at .04, .34 and 0.50 (median, 95% and maximum).  The algorithm is designed to increase pressure for flow limitation to reduce the inspiratory flow resistance or obstruction.  If you look very closely at the flow rate graph, you will see very distorted and flattened peaks. This happens because as inspiration progresses, resistance becomes higher and the flow rate slows. Normally with an unobstructed airway, the flow rate to the point where flow slows ahead of expiration because the lungs are full.  

The best way to treat this with your machine is to turn on EPR (exhale pressure relief) and increase maximum pressure.  The settings should be minimum pressure 7.0, maximum pressure 12.0 or higher with EPR on full-time at 3.  This will result in bilevel pressure with inhale/exhale pressure of 7.0/4.0 to 12.0/9.0.  The use of bilevel pressure supports inspiratory effort and reduces flow limitation.  

Your chart shows a lot of central or clear-airway apnea events in the second half. I suspect these events are false, or when you are awake.  EPR may make that worse, however, it is worth trying to see what happens.  If EPR does increase CA events, you will likely need a different form of therapy.  Did you have any central apnea in your diagnostic study?

To change your profile just click on the UserCP in the upper right corner of this page http://www.apneaboard.com/forums/usercp.php

Hello Sleeprider and all other participants,

I have now tested the settings you suggested twice. This makes the therapy feel much better overall. Now I really have the feeling of getting enough air.

Unfortunately, I did not succeed in falling asleep with it either. The first night with it (January 3), at the moment of falling asleep, I had the feeling that my chin would drop a little and, above all, air would flow out of my mouth. This was then a new kind of wake-up reflex for me.

The second night (January 5) I also could not fall asleep. However, this time I did not have the feeling that air was coming out of my mouth.

Attached are the two screenshots from OSCAR. Please note the following. This applies to both screenshots:
- The one on the left is a general attempt to get used to the ResMed device in bed while I was still reading something. No efforts to fall asleep at this time.
- The right part after the break then shows the time during the unsuccessful efforts to fall asleep.

   
   


For the time being, however, I will keep these settings unless you have other recommendations. Overall, I feel comfortable with it. I will now try to get used to it in a disciplined way and also to go to bed earlier overall again in order to achieve an appropriate sleep rhythm.
I will also try this thing with the alarm clock.

At this point, thanks again for your great advice. It helps me a lot.

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try setting an alarm for a hour, wake up and put the mask on, and trying falling back asleep with it, that's what worked for me initially to get used to it

Thanks. I will try it.

[Sleeprider]

I think the biggest obstacle you face at this point is to get sustained therapy for a longer period of time. The CA events may be related to sleep disruption or arousal, or may be real. With only 98 minutes of therapy time, it's premature to make a judgement. I agree with your decision to maintain settings for now.

[Dormeo]

It's very good you're more comfortable with the treatment. As you say, the next step is to be able to fall asleep with it.

I would suggest that you do your "practice" sessions outside your bedroom. This is in line with the recommendations that experts make about getting better sleep:

• Keep a consistent sleep schedule. Get up at the same time every day, even on weekends or during vacations.
• Set a bedtime that is early enough for you to get at least 7 hours of sleep.
• Don’t go to bed unless you are sleepy.
• If you don’t fall asleep after 20 minutes, get out of bed.
• Establish a relaxing bedtime routine.
• Use your bed only for sleep and sex.
• Make your bedroom quiet and relaxing. Keep the room at a comfortable, cool temperature.
• Limit exposure to bright light in the evenings.
• Turn off electronic devices at least 30 minutes before bedtime.
• Don’t eat a large meal before bedtime. If you are hungry at night, eat a light, healthy snack.
• Exercise regularly and maintain a healthy diet.
• Avoid consuming caffeine in the late afternoon or evening.
• Avoid consuming alcohol before bedtime.
• Reduce your fluid intake before bedtime.

The purpose of the recommendation to use your bed only for sleep and sex is to avoid setting up mental associations between being in bed and trying but failing to sleep.

Keep us posted, would you?