cpap and apap not effictive

[Ezil71]

Hi Robysue, thanks for your input. I'm determined to figure this out and get some real sleep!

Here is last night's data, not good, but no surprise given the low pressures.

This is at 7/7 apap - but I turned flex completely off to see if that was any help.

It looks like I need to bump up more than a few cm since my ahi is still over 16. Even at 7 and only a few hours I can feel a bit of aerophasia, but not horrible at this level. Hard to say for sure since I didn't have it on all night.

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-


Should I keep going up by 1cm to 8/8? Or jump to 9 or 10 to see if my ahi comes down? When I've had a wider range in the past my 95% has been 10.5 to 11.8, up to 13.5 - but up until recently I had never tested above 14.

Thanks for the help - Ed

[Sleeprider]

Ed, I was thinking about your approach with the doctor who is reluctant to prescribe bilevel given your CPAP titration. No doubt that in a brief study in a clinical setting, 10 cm was found to be effective. I think you could replicate that yourself, by setting pressure to 10. I'm positive that for up to 1-1.5-hours you will be nearly apnea free. As your aerophagia progresses, you will start to have hypopnea as your volume capacity becomes diminished by your increasingly swollen belly, eventually leading to brief CA, where you stop breathing for 10-15 seconds at a time. This will continue until you wake up, belch and out-gas, then you can resume your sleep. This pattern seems repeatable. What your doctor needs to wrap his mind around is that the objective has become more complex than simply resolving obstructive sleep apnea; it is to compromise between resolving the OSA at as low a pressure as possible so as not to induce hypopnea and CA as well as discomfort from aerophagia.

We discussed before, you have all the documentation you need to prove you do not tolerate CPAP and do not receive the treatment you need at a constant pressure. No matter how long or how hard you try, you will continue to show this pattern. If he has a cure for the CPAP induced aerophagia, then you should welcome Ultthat as a miracle; otherwise, bilevel is your best answer, keeping EPAP as low as possible and using IPAP for Hypopnea.

You were doing best when using Flex which at least lowered pressure a bit. Based on the treatment summary, you seemed to have lower AHI at 10 cm than when we tried lower constant pressure. In any event, you need a few more data points at that pressure to satisfy your doctor you have given the titrated pressure a decent shot, and it seems better with Flex than without. You saw Robysue's settings of 4 EPAP and IPAP max 12. Not sure what her minimum and maximum pressure support (PS) are, but those are the kind of settings may be where you're heading. You don't seem to have apnea of any kind until after an hour on CPAP, then "Katy bar the door".

Tom

[Ezil71]

I'll give 10 cpap and cflex + at 3 a shot tonight.

I've been reading up on flex settings and it seems that cflex + might be better for me than cflex since it gives relief at the end of an inhale vs at the beginning of an exhale with cflex.

They really should rename the values from 1-3 to slow, medium and fast (if I am understanding how it really works, as a 2cm drop and a difference in speed).

[robysue]

It looks like I need to bump up more than a few cm since my ahi is still over 16. Even at 7 and only a few hours I can feel a bit of aerophasia, but not horrible at this level. Hard to say for sure since I didn't have it on all night.

Since you are still feeling the aerophagia at 7cm, I would be very reluctant to increase the pressure all the way up to 10cm and run the risk of the return of "horrible" aerophagia. Unless it is somehow part of a plan to get your doctor to advocate for a bilevel machine.

Unfortunately a lot of sleep docs minimize the problems some of us face with aerophagia. And if you wind up with really severe aerophagia, it can become a significant issue, even a deal breaker, when it comes to adjusting to PAP therapy.

Here's one thing you need to keep in mind about the aerophagia: There's a "chicken and egg" issue when it comes to aerophagia and arousals/wakes during the night. The aerophagia can trigger arousals and wakes, but lots of arousals and wakes can also trigger or aggravate the aerophagia because we often do swallow more when we're awake or semiawake than when we are asleep.

In my case the switch to bilevel took the edge off the aerophagia. But even now, six years into PAPing, if I have a restless night with a lot of wakes and arousals, I'm going to have more aerophagia to deal with. And that's in spite of cycling my machine off and back on at every wake to make sure my pressures go back to their minimum settings. So right now my sleep doc and I are working hard on figuring out ways to encourage me to both get soundly asleep and stay asleep during the night. PAP is not enough to do that for me, and if you're interested in what we're trying, just let me know and I'll write more about my PAP journey.

Here is last night's data, not good, but no surprise given the low pressures.

This is at 7/7 apap - but I turned flex completely off to see if that was any help.

It looks like I need to bump up more than a few cm since my ahi is still over 16.

Yes, the overall AHI is still too high at 7cm. But your events are clustered in three areas where the problem might be sleep instability, which can lead to "sleep-wake-junk" breathing which can artificially increase the AHI beyond what it really is. Mis-scored SWJ breathing can also lead to pressure increases if you are running in auto mode, which of course can then lead to more aerophagia.

In particular, there's a nasty cluster that starts around 0:05 and lasts until you turn the machine off at 0:18. My guess is that you woke up around 0:05 and tried to get back to sleep for about 15 minutes before deciding to turn the machine off. The timing of this cluster is a bit early for the first REM cycle, although it is possible that this cluster is REM-relateed rather than an arousal/wake followed by SWJ breathing causing the cluster.

Do you know if your REM AHI was much higher on your diagnostic sleep test than your non-REM AHI?

You turn the machine back on around 0:22, but your breathing doesn't really settle down into high quality sleep breathing until 1:10---right after the cluster of centrals and hypopneas. The close-up of the centrals you provide, along with the long stretch of no-event sleep breathing points to that 1:10 cluster being sleep transition related.

Do you remember being really restless for a long time after the wake where you turned the machine off and then back on?

If you do remember being really restless between 0:22 and 1:10, then most of those events may be sleep transition events or SWJ "non-events" or a combination of the two. My guess is that this cluster may have also been fed by some aerophagia as well as triggering additional aerophagia.

The last cluster of events starts around 2:05 and it starts with a few CAs. More pressure doesn't help treat CAs. Those CAs may represent arousal-related SWJ breathing, or they could be CAs, or they could be CPAP-related CAs (that usually resolve as you finally get used to therapy). But it's also possible that this cluster might be REM related, which again begs the question: Is your untreated OSA documented to be much worse in REM than non-REM?

And finally it appears that you "woke up" around 2:30 and took the mask off and then presumably went back to sleep without the PAP. I put quotes around the "woke up" because it is not clear to me if you actually woke up during the 2:05-2:15 cluster of events (making them SWJ events) and then gave up when you couldn't get back to sleep or if you actually were asleep during the 2:05-2:15 cluster and then woke up after that cluster was actually over.

Should I keep going up by 1cm to 8/8? Or jump to 9 or 10 to see if my ahi comes down?

My own sensitive stomach urges extreme caution in increasing the pressure as long as you are dealing with aerophagia AND you're not able to keep the mask on all night because of the aerophagia.

In other words, I would encourage you to work on increasing your comfort first in an effort to increase the usage time so that you can keep the mask on all night.

If you want to stick to fixed pressure, I'd use every setting (including the 7cm one) for several days before increasing the pressure. Sleep is a fickle thing and one bad night does not a trend make. If you have this kind of clustering for 3 or 4 nights in a row AND you're sure that you are asleep when the clusters are happening, then it's time to increase the pressure. But with the history of aerophagia, you have to go extremely slowly in increasing the pressure: A 2 or 3 cm jump in pressure is going to increase the aerophagia, and the increase in aerophagia may wind up increasing the AHI by triggering a lot of SWJ events.

When I've had a wider range in the past my 95% has been 10.5 to 11.8, up to 13.5 - but up until recently I had never tested above 14.

To help me help you:

At what pressure settings has the aerophagia been "horrible" where you get to define what "horrible" means to you?

At what pressure settings has the aerophagia been "bad" but not "horrible"?

I've been reading up on flex settings and it seems that cflex + might be better for me than cflex since it gives relief at the end of an inhale vs at the beginning of an exhale with cflex.

I'm not sure the slight difference in timing of cflex vs. aflex/cflex+ will make a big difference. But then I have had to turn biflex totally OFF on my BiPAP because it was encouraging me to swallow when the pressure started to increase during my exhalations.

They really should rename the values from 1-3 to slow, medium and fast (if I am understanding how it really works, as a 2cm drop and a difference in speed).

The drop is also variable. Any one of the settings can cause a 2cm drop in pressure---on a forceful exhalation. But on a gentle exhalation, the drop in pressure may be as little as 0.5 or 1.0 cm.

What may help you the most is to figure out where in the exhalation the rise in pressure back up to full pressure feels most normal and triggers the least amount of air swallowing.

[rkl122]

..................
In particular, there's a nasty cluster that starts around 0:05 and lasts until you turn the machine off at 0:18. My guess is that you woke up around 0:05 and tried to get back to sleep for about 15 minutes before deciding to turn the machine off. The timing of this cluster is a bit early for the first REM cycle, although it is possible that this cluster is REM-relateed rather than an arousal/wake followed by SWJ breathing causing the cluster.........

I'd guess more likely the former than the latter, since the zoom shows the breathing to be regular. A display of the respiration rate chart could lend support for this.

.......Do you know if your REM AHI was much higher on your diagnostic sleep test than your non-REM AHI?

You turn the machine back on around 0:22, but your breathing doesn't really settle down into high quality sleep breathing until 1:10---right after the cluster of centrals and hypopneas. The close-up of the centrals you provide, along with the long stretch of no-event sleep breathing points to that 1:10 cluster being sleep transition related.....

Again, RR chart could be helpful, since respiration rate is frequently different awake than asleep, no?

..............
The last cluster of events starts around 2:05 and it starts with a few CAs. More pressure doesn't help treat CAs. Those CAs may represent arousal-related SWJ breathing, or they could be CAs, or they could be CPAP-related CAs (that usually resolve as you finally get used to therapy). But it's also possible that this cluster might be REM related, which again begs the question: Is your untreated OSA documented to be much worse in REM than non-REM?......

Same thought.

.........And finally it appears that you "woke up" around 2:30 and took the mask off and then presumably went back to sleep without the PAP. I put quotes around the "woke up" because it is not clear to me if you actually woke up during the 2:05-2:15 cluster of events (making them SWJ events) and then gave up when you couldn't get back to sleep or if you actually were asleep during the 2:05-2:15 cluster and then woke up after that cluster was actually over..............

Again, respiration graph could help clarify.

A clearer picture won't necessarily change the (good) advice here on therapy, but if we're going to engage in supposition, why not use all data available? Of course, that becomes more tedious when newbies are not encouraged to post tidal charts.

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?

-Ron

...............

[richb]

rkl122 wrote: "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?
Ron"

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. I agree that comfort is the first priority. If cpap is going to work it needs to be used for most of the night. In that regard I would suggest adjusting the pressures DOWN after trying them up. 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.

Rich

[Ezil71]

Lots of good info, thanks.

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. I don't usually have any problems falling back to sleep (except when I tried presssures above 12).

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).

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 had a bad cough and chest congestion last fall that took a few months to clear up (but did). I apparently have a small amount of lung damage from a long past illness in my upper left part of my lung, but nothing any of the docs have been concerned about, not sure if they should be.

I will post some more charts shortly.

[Ezil71]

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

[Sleeprider]

Not sure when you fall asleep, but you sure are consistent in developing events at 1-hour.

[richb]

Looks like a lot of sleep/wake junk is being recorded at a straight pressure of 7. What is interesting is that you have a couple of significant periods of sleep with normal breathing. See if you can get through a night using the machine at 7 cm H2O.

Rich