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cpap and apap not effictive
#51
(10-20-2016, 07:53 PM)Sleeprider Wrote: Not sure when you fall asleep, but you sure are consistent in developing events at 1-hour.

I can fall asleep almost instantly. It is very rare for me to be awake for more than a few minutes, at least when first going to bed.

I wake up once every night to go to the bathroom and most nights can fall asleep pretty quickly. Sometimes I do take a bit, or I'll wake up early (4-5 or so) and can't get back to sleep.

Given that I fall asleep quickly, is that a REM cycle at one hour? Or is that later?

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#52
Hi Ezil71. I'm looking at the chart you just posted. Something went on at about 1 hour but you woke up just after those events. You had some more erratic breathing when you went back to sleep and another brief period soon after that. You had another bunch of events prior to waking and discontinuing use of the machine. I think that some of the events are sleep/wake junk and some may be related to rem sleep. I would like to see your flow chart for those groupings of events. I think you may have had some episodes of aerophagia during those event groupings. I would try to get through an entire night using the machine at your current settings. Then look at your flow patterns and your respiration patterns. The next thing to figure out is why you are swallowing air during specific periods and not others. Something that just crossed my mind is to try a nasal mask instead of a FFM. My thought is that you might swallow less air and also be able to burp more freely.

Rich
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#53
First some comments in getting response to some things said by various people after my last post.

rkl122 makes some comments about using the respiratory rate to tease out sleep vs. wake breathing. In general I find the granulation of RR graphs not particularly useful in my own data for teasing apart wake vs. sleep. The shape of the zoomed in flow rate is a better indicator for my breathing. But it is true that most people's RR goes down when they fall asleep. (My hubby's tends to go up slightly, however.) And the RR is usually much more stable in sleep than in wake, but the RR also usually is much less stable in REM sleep than in non-REM sleep. I've read that REM-sleep breathing can look somewhat like wake breathing, but I don't have a source handy to back that claim up right now.

And then there is another thing about RR graphs: If you are indeed in the middle of a long, significant cluster of sleep apnea events, the RR graph is going to have a lot of variation in it, particularly if some of the events are central in nature and there is a bit of a CO2 overshoot/undershoot cycle developing. So the RR graph may not be particularly useful in teasing apart a real cluster from SWJ in some people's data.


rkl122 also brings up the OP's tidal volume:
Quote:Note also that the OP's tidal volume is on the low side and respiration rate on the high side. This gives a normal minute volume, but perhaps is another clue to help explain his sleep architecture? For example, is reduced lung capacity a risk factor for aerophagia?
First, the OP's median tidal volume is listed as 520 mL, which according to a quick google search is pretty close to the average tidal volume in a young, healthy male. (Most sources report the average tidal volume in an adult male as being between 500 and 600 mL.) Moreover, tidal volume does depend on the size of the person. For example, I'm a 5'1" female who weighs about 110 lbs. And my median tidal volume in SH is usually reported as around 300 mL, which has never been "flagged" by any tests as being too low for my size.

Next I've never run across anything in my reading that ties either tidal volume or minute volume to sleep architecture. If you've seen something in the literature that indicates a connection, can you provide a citation?

Finally I've never hear or read anything about reduced lung capacity being a risk for aerophagia. The usual risk factors for aerophagia that are cited are issues with GERD-related problems since the usual hypothesis about aerophagia is that a weak lower esophageal sphincter is to blame for letting the air get into the stomach. However there are people without GERD who have problems with aerophagia and there are also people with GERD who don't have problems with aerophagia.

So again, if you have a source that indicates that low tidal volume might be correlated with a higher risk of aerophagia, can you provide a citation?

richb writes:
(10-20-2016, 03:00 PM)richb Wrote: I think that the aerophagia is limiting Ezil71's lung capacity. The cut off tops of his inhalation waveforms indicate to me that he has a severely limited lung capacity due to his diaphragm being impeded by his stomach full of air. Respiration is on the high side because of limited lung capacity. The higher respiration rate could also be contributing to CO2 washout. I also think that he gets so full of air that he is suffering full apnea events.
Pardon my saying it, but where are you getting this idea?

"Cut off tops" of the inhalation wave forms are typical of flow limitations which indicate an airway that is in danger of collapsing. And in the two snippets of wave form data the OP posted, there is only minor evidence of flow limitations.

And what exactly are you basing your claim that the OP has a RR on the "high side", particularly high enough to trigger CO2 washout? SH reports the 95% RR as 13.2, which is not at all on the "high side." The max RR is 17.29, which is not exceptionally high, but may be elevated. We don't have any direct evidence of what the OP's RR or tidal volume is during the snippets of wave form that has been presented, and it seems unreasonable to me to speculate that either the TV or the RR is somehow out of whack here.

Finally I'll add something from my own six years of experience dealing with aerophagia: In general my worst nights for aerophagia are tied to overall restlessness, not my AHI. I've had nights where my AHI is much higher than normal, but because I was not particularly restless, I did not have any serious aerophagia in the morning. I've also had nights where my AHI has been under 0.5 where I've had severe aerophagia; these are also nights where I've had a large number of wakes and arousals. I have been told by a PSG tech that I trust that many people have a tendency to swallow when they wake up or arouse. And aerophagia itself can cause arousals. So there is a feedback loop that can get started with aerophagia on a bad night: More arousals leads to more swallowing that leads to more aerophagia that leads to more arousals that leads to more swallowing ... The AHI is irrelevant in this feedback loop.


Quote: Another thing to consider is that Ezil71 might be suffering from aerophagia without cpap. If this is the case he (you) might be experiencing apneaic events resulting from aerophagia. A visit to a GI specialist might be helpful in any event.
GERD and aerophagia are not the same thing, but they can be related.

Without CPAP, you don't get aerophagia, but you may have GERD. With CPAP, there is an excess amount of air being blown into your upper airway. If the esophageal sphincters are weak enough, that air can be forced into the stomach. Or if you are doing a lot of swallowing, there is more air (since it is pressurized) available to be swallowed.

A GI specialist is unlikely to know anything at all about CPAP or CPAP-related aerophagia issues. However if GERD is a possibility then it may be worthwhile to talk to your PCP about it. Sometimes treating the GERD will relieve the aerophagia.

But it's just as important to note that untreated OSA can aggravate untreated GERD. The repeated gasping involved in opening the collapsed airway can cause enough negative pressure in the esophagus to pull acid up from the stomach.
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#54
(10-20-2016, 06:10 PM)Ezil71 Wrote: RobySue - I woke up once to use the bathroom and thought I fell back to sleep fairly quickly, but not restfully and did end up just turning it off when I woke again.
So you do you mean that when you woke up again you were feeling unrested? Or do you mean that you were aware you were tossing and turning and sleeping very lightly before deciding that since you were awake anyway that you might as well turn the machine off?

It's really important to figure out which is more accurate. If you were tossing and turning and vaguely aware that you weren't sleeping very well for this whole period, then that large cluster of events is most likely either SWJ or possibly sleep transitional events that kept you from getting soundly asleep. Either way, the restlessness may have aggravated any aerophagia you were dealing with at the time.



Quote:To that, anything 9 or less and I don't notice much air, but enough to be aware of it, mainly in the morning. 9-11 and I'm feeling it in the morning for sure and sometimes during the night. I have been able to get 7+ hours on the machine at up to 11.5.

Anything above 12 and I have trouble falling asleep and/or am semi awakened by massive burps or gas (and have a harder time falling back to sleep).
If I were you, I would concentrate for the next week or two on sorting out what you need to do to minimize the discomfort from the aerophagia so that you are less likely
to just take the mask off in the middle of the night because you don't feel like you are sleeping very well.

I'd suggest that you consider using a pressure range of 7-11 for a while. That's not a huge range, but it should allow the pressure to stay below 9 for most of the night, but still allow it to go up to 11 when you are dealing with clusters of events. I'd also suggest that you turn the machine off and then back on whenever you wake up feeling like the pressure is noticeable and/or bothering you. That will reset the pressure back down to 7cm, and that may allow you to get all the way to a sound sleep instead of getting stuck in sleep transition with a bunch of events that may or may not be "real" but will increase the pressure.

Quote:As far as lung function - I did have a breathing/capacity test (in the chamber device). That was almost a year ago and it showed 'normal'.
I don't think your problems are related to your tidal volume.


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#55
(10-20-2016, 07:51 AM)Ezil71 Wrote: Some screenshots:

https://1drv.ms/i/s!AgFs7hWqVGNflWsVGoNav95Id0Xd

https://1drv.ms/i/s!AgFs7hWqVGNflWzKdN5sVfLDbrnp

https://1drv.ms/i/s!AgFs7hWqVGNflW4rTc11-KBYfDTx

https://1drv.ms/i/s!AgFs7hWqVGNflW2XrzQPPi-QaX5-

(10-20-2016, 06:16 PM)Ezil71 Wrote: I'm not sure exactly what to post but here are a few:

https://1drv.ms/i/s!AgFs7hWqVGNflW-zCYZUlC6TT-6F

https://1drv.ms/i/s!AgFs7hWqVGNflXGyMS5kmEs_Xx3w

https://1drv.ms/i/s!AgFs7hWqVGNflXCkJ4m4YiAQ7D7d

These are all the same night of data, right?

I still think that the cluster of events before the wake at around 0:15 are likely SWJ. My guess is that you woke up first, possibly because of the growing leak, and events are scored after you are awake.

You said you fell asleep quickly after coming back to bed, but it sure looks like you didn't fall deeply and soundly asleep after coming back to bed. That first hour after you came back to bed is really ugly. The most likely explanation in my opinion is that you are drifting in and out of sleep or perhaps you're "stuck" in sleep transition. Some of these events might be real, some might be "false" (in the sense of not being scored on a PSG), but it's hard to tell for sure. What does seem important is that you seem to be stuck in a place between being really awake (you think you were asleep after all) and being really, soundly asleep with good, regular breathing (which kicks in around 1:10). It's also worth noting that there probably is some sleep mixed in (between 0:27 and 0:35 as well as between 0:40 and 0:50) with this hour long cluster that appears to be mainly SWJ.

One question to ask yourself: Is this kind of stuff happening all the time, or only now and then?

If it's only now and then, it may be best to not over analyze what's going on. If it's all the time, that's a different story.
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#56
robysue. Maybe I should have said that Ezil71 has LES disfunction rather than outright aerophagia without cpap. I still feel that Ezil71's apneaic episodes are mostly related to bloating. i also think that Ezil71's inhalation is cut off by the bloating. We need more data such as a full nights use of cpap to figure out what is going on here. A full night at 7 will give us a baseline. Another night at 5 and an additional at 9 will show the relationship between OSA cpap pressure and hypopneas/CAs. A visit with a GI specialist would be in order to check out LES function as well.
Ezil71 does not seem to be a textbook case.

Rich
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#57
Well last night was pretty bad. I don't know that I would take much out of analyzing it because it was not that typical. I was tossing and turning way more than usual, was waking up too hot a lot and just generally had a crap night.

I did try using my nasal pillows rather than the full face, but I don't think that was too much of the problem. I don't have nights this restless very often, but my back was bothering me and it felt like a night where I'd had too much caffeine or alcohol, even though I didn't (and don't very often). I've learned over the years that any caffeine after about 11am messes with me (oddly, about 12 hours later) and alcohol always has me tossing and turning so I rarely have any.

robysue - for the other night, yes those are all from the same night. I didn't feel restless and thought I went back to sleep but obviously not very soundly. That night was fairly typical. Even without any cpap my pattern is to fall asleep quickly, wake up once, and at least 'feel' like I fall back to sleep, most of the time, very quickly.

For what its worth i never feel like I sleep deeply, ever. Over the last many months of trying to use cpap I have had about half a dozen 2-3 hour periods where I have woken up after just a few hours and felt like I slept a week, but otherwise am always more tired in the mornings.

I did go see someone about my upper GI because my doc was suspecting gerd. None of the gerd medicines helped, they made me feel worse and the GI doc blew me off saying that at 44 I was too young to have an upper GI scope based on what he was seeing. I have an appointment with my primary soon and will push to look more deeply at that issue.

I'll post a few charts from last night, not sure which to zoom in on, let me know if there are specific areas that might be useful.

Thanks, Ed

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#58
Here is last night. cpap at 10 aflex 3 with nasal pillows vs full face on the others:

https://1drv.ms/i/s!AgFs7hWqVGNflXIU_RaIJd_Zen9P

https://1drv.ms/i/s!AgFs7hWqVGNflXRP3Za8tN9O5zHb

https://1drv.ms/i/s!AgFs7hWqVGNflXOOLhX6yrdSt1Jf

I would agree robysue, I think going to 7-11 apap is about my best range for now, or maybe 8-12. Considering I had over 4 hours last night, I don't feel that bloated today, so 12 on the nasal pillows with aflex 3 might be tolerable.

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#59
(10-20-2016, 09:54 PM)robysue Wrote: rkl122 also brings up the OP's tidal volume:
Quote:Note also that the OP's tidal volume is on the low side and respiration rate on the high side. This gives a normal minute volume, but perhaps is another clue to help explain his sleep architecture? For example, is reduced lung capacity a risk factor for aerophagia?
First, the OP's median tidal volume is listed as 520 mL, which according to a quick google search is pretty close to the average tidal volume in a young, healthy male. (Most sources report the average tidal volume in an adult male as being between 500 and 600 mL.) Moreover, tidal volume does depend on the size of the person. For example, I'm a 5'1" female who weighs about 110 lbs. And my median tidal volume in SH is usually reported as around 300 mL, which has never been "flagged" by any tests as being too low for my size.

Next I've never run across anything in my reading that ties either tidal volume or minute volume to sleep architecture. If you've seen something in the literature that indicates a connection, can you provide a citation?

Finally I've never hear or read anything about reduced lung capacity being a risk for aerophagia. The usual risk factors for aerophagia that are cited are issues with GERD-related problems since the usual hypothesis about aerophagia is that a weak lower esophageal sphincter is to blame for letting the air get into the stomach. However there are people without GERD who have problems with aerophagia and there are also people with GERD who don't have problems with aerophagia.

So again, if you have a source that indicates that low tidal volume might be correlated with a higher risk of aerophagia, can you provide a citation?
Well I am humbled and embarrassed. I misread the OP's TV as 320, and I don't know what I was thinking to call the RR high. I apologize for the mis-statements. And particular apologies to EZIL71 if I caused any additional concern. These data are NOT indicative of a pulmonary issue. (RobySue, agreed, your low TV probably reflects smaller than average lungs Smile ) And, no, I've not found a citation connecting TV with aerophagia. I was more asking whether there is a connection. As to overall sleep architecture, I feel it's of interest to at least take note of any data that exceeds normal extremes (NOT the case here), but again, I was more inquiring about potential interpretations. No known relevant research.

Quote:In general I find the granulation of RR graphs not particularly useful in my own data for teasing apart wake vs. sleep. The shape of the zoomed in flow rate is a better indicator for my breathing. But it is true that most people's RR goes down when they fall asleep. (My hubby's tends to go up slightly, however.) And the RR is usually much more stable in sleep than in wake, but the RR also usually is much less stable in REM sleep than in non-REM sleep. I've read that REM-sleep breathing can look somewhat like wake breathing, but I don't have a source handy to back that claim up right now.
Here, I've seen references also. They support your description. I've read that sleep RR can be lower, higher, or the same as wakeful RR, and that REM RR usually averages higher, and yes, more erratic. I've also read that apneic event frequency is generally higher during REM. Where I'm coming from on this is that my own nightly RR graph has a particular personality. I don't want to divert this thread further, so won't display an image here, but my RR profile is one of the few aspects of my architecture that shows a repeating pattern: noticeably lower (not higher!) RR during wakefulness, very noticeably raised RR during periods of intense dreaming. Before I started getting my AHI below 5, frequently I had dense clusters of apneic events around the REM bumps, but not in the REM bumps. This was contrary to expectations. I wondered about it for months. A supposition evolved: basically that those surrounding events were not true apneas, but post arousal SWJ themselves. Then it would make sense that they wouldn't occur during REM, because there's evidence that our musculature is largely paralyzed during REM. (I'll look for the reference if you want.) True, I can't say for sure this is what's happening, and I'm not clear how it'd affect therapy if I could, but it's my working hypothesis. I'd sure like to see more pappers posting the RR chart.

So Ezil71, thanx for publishing the RR graph. (More on that below.*) I would interpret it pretty much in accord with RobySue's observations. I would surmise that the dip at the beginning is wakefulness - which would probably mean it took you longer to fall asleep than you think. The bumps around 00:50 and 02:20 (do you remember dreaming just before waking?) I would speculate are REM periods. Notice how the clusters seem to thin out during the bumps. I am hypothesizing that this supports the supposition that the clusters themselves are SWJ and not true apneas.

As noted, the Flow Rate trace is very important at the breath by breath level, and zooms on my "clusters" indicated compatibility with the notion that most of my clustered events were SWJ.

Ezil71, this is all supposition, and nothing I'm saying impinges on RobySue's therapeutic suggestions. I'd simply add the suggestion that you be mindful of the RR trace over time - like weeks. Look for repeating patterns and decide for yourself whether they fit with inferences drawn from the rest of the data. In the meantime, listen to RobySue Smile

*Ezil71, re. your tidal graphs, I know I implied tidal data is of interest, but perhaps only to dataphiles like me. (You have what's called an inverted I:E ratio, but that's of no concern.) Would suggest you stick with the recommended order for now with the exception of substituting the RR graph for the Snores. For P Resperonics machines, the latter is redundant in the sense that the VS2 channel in Events contains the same data. I would also suggest adding the average line overlay to the RR graph (right click to left of graph), and thickening it (File=>Preferences=>Appearance) so it is legible. You may also want to hide the pie chart (File=>Preferences=>Appearance) . For zooms, ~three minute windows containing apneas in the FR graph would be helpful. As RobySue implies, valuable inferences may be drawn from the shape of individual breaths.

Again apologies for my misleading statements. Ezil71, you are in good hands. Good luck.

-Ron
.................

We are such stuff
As dreams are made on, and our little life
Is rounded with a sleep.
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#60
Ezil71,

Last night's AHI has a large number of CAs in the last 2 hours of the night. More pressure would not have prevented them. And it looks like the first 3 hours of the night were not really all that bad, even if they felt bad. The wake at 1:10 looks like it could be a post REM wake; the timing is right for a post REM wake. It looks to me like you got a solid 60-90 minutes of 23:30 and 1:10 and it also looks to me like you got another solid 60 minutes of sleep from shortly after 1:15 to 2:15. But everything after 2:15 looks pretty crappy. Any chance the tossing and turning and repeatedly waking up too hot was mainly confined to the 2:15-4:30 time frame? Given the CAs and your report of the night being "bad", it's possible this is evidence that you're getting stuck in some kind of sleep transition problem after a mini-wake or arousal that you may or may not clearly remember.

I don't think I'd be worried about the CAs yet. They may just be part of your overall "can't get to sleep soundly" problem. However, the CAs are worth keeping an eye on.

I have a question and an idea: Do you have a FitBit or similar device that can measure movement during the night? In other words a fitness monitor that claims to distinguish sleep from wake based on movement?

If you have a FitBit or are willing to get one, it would be interesting to correlate whether the FitBit shows you as being in "Deep Sleep" or "Light Sleep/Wake" during the worst of your long event clusters. The cheaper FitBit data is not anywhere close to being 100% accurate and it doesn't claim to make an effort to reliably detect sleep stages. But if a cheep FitBit is set to "Sensitive" for "Sleep Detection", it will mark any period with significant body movement as "Restless, Light Sleep, Wake" And it is true that in both REM and Stage 3 sleep, body movement is at a minimum. So if there's a correlation between when the FitBit data says you're restless and when the CPAP data says there's a lot of events going on, you'll have another data point to use to infer whether the event clusters are likely to be SWJ and/or sleep transitional vs a real cluster that is potentially tied to REM sleep.

(10-21-2016, 08:47 AM)Ezil71 Wrote: I did try using my nasal pillows rather than the full face, but I don't think that was too much of the problem. I don't have nights this restless very often, but my back was bothering me and it felt like a night where I'd had too much caffeine or alcohol, even though I didn't (and don't very often). I've learned over the years that any caffeine after about 11am messes with me (oddly, about 12 hours later) and alcohol always has me tossing and turning so I rarely have any.
Even though caffeine and alcohol may not have had a role in why this night's so bad, it's worth tracking their affect on your sleep in the future.

Quote:Even without any cpap my pattern is to fall asleep quickly, wake up once, and at least 'feel' like I fall back to sleep, most of the time, very quickly.
The question that needs to be addressed is whether you *stay* fully asleep for any length of time after you fall asleep.

In several of my multiple sleep tests, I actually fell asleep within 20 minutes or so of "lights out", but I woke back up maybe 10 minutes later and then started tossing and turning for over an hour. In some of the tests I didn't remember falling asleep at all, but in at least one test I thought I'd been asleep for well over an hour before waking up and starting the tossing and turning.

Quote:For what its worth i never feel like I sleep deeply, ever. Over the last many months of trying to use cpap I have had about half a dozen 2-3 hour periods where I have woken up after just a few hours and felt like I slept a week, but otherwise am always more tired in the mornings.
How often have you used the CPAP for the first part of the night and then woke up and took the mask off before going back to bed?

For example, on this night, you went to bed at 11:20pm and you took the mask off for good at 4:20pm. That's only 5 hours of (not great) sleep. If you usually wear the mask for about 5 hours and then return to bed to get another couple of hours of sleep without the CPAP, that could be a factor in why you are still not sleeping well with the CPAP.

Quote:I did go see someone about my upper GI because my doc was suspecting gerd. None of the gerd medicines helped, they made me feel worse and the GI doc blew me off saying that at 44 I was too young to have an upper GI scope based on what he was seeing. I have an appointment with my primary soon and will push to look more deeply at that issue.
Rather than using GERD meds, which can have a lot of side effects, have you ever tried the usual non-med GERD-guidelines? Does eating late aggravate things? Does avoiding things like tomatoes and tomato sauce and greasy fried things help? Does sleeping with your head elevated help? Does sleeping on your LEFT side feel better than sleeping on your RIGHT side or sleeping on your back?

Quote:I'll post a few charts from last night, not sure which to zoom in on, let me know if there are specific areas that might be useful.
There are some areas that I'd like to see a zoom of:

The 15-20 minutes between 0:50 and that first wake.
The first 10 minutes after you turn the machine back on at around 1:15
The 10 minutes between 2:10 and 2:20
The 10 minutes between 3:07ish and 3:17ish

Zooming in this close will let us see the actual shape of your inhalations at some critical points during the night.

I'd like the following graphs, preferably in one screenshot:
1) the event chart
2) the flow wave graph
3) the respiratory rate graph
4) the tidal volume graph

Turn all the other graphs off to get these graphs to show up in one screen shot. If you don't know how to turn the graphs off then make two screen shots. The graph that I'm most interested in is the flow wave graph, but others seem to think the RR and tidal volume graphs are useful.

(10-21-2016, 08:54 AM)Ezil71 Wrote: I would agree robysue, I think going to 7-11 apap is about my best range for now, or maybe 8-12. Considering I had over 4 hours last night, I don't feel that bloated today, so 12 on the nasal pillows with aflex 3 might be tolerable.
I'd keep it at 7-11 with Aflex=3 if I were you. There's no point in running the risk of triggering the bloating when over half your events are CAs.

I'll end by asking some questions that I've asked before, but I need to be reminded about:

1) What was your usual sleep time pre-CPAP?
2) Are you going back to bed after turning the CPAP off at 4:30 or 5:30ish? Or are you getting up for the day at that time?


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