cpap and apap not effictive

[robysue]

Ezil,

Thanks for all the data.

The overall picture of the night does show your pressure is increasing during time periods when it looks like you are stuck in sleep transition, unable to fully fall asleep, but your breathing is ragged enough that the machine thinks you're having hypopneas while asleep. In particular the pressure increases between 2:40--2:50, 6:10-6:20 and between 6:30-6:45 probably happened while you were tossing and turning and may have increased the tossing and turning.

It looks to me like you may have fallen asleep as early as around 23:35-23:40, but it might not have been until sometime between 23:50 and 0:05. If I had to guess, I'd say you probably were asleep by 23:40. The first couple of events may be sleep transitional. The events between 23:45-0:05 are really hard to interpret. If you had already started tossing and turning, they might be SWJ, but the breathing around them is pretty stable, so they may be real events. I'd lean towards saying they're real. It's probably too early for the first REM cycle.

The pressure increase in response to the events around 23:50-0:05 doesn't wake you up enough to make you turn the machine off and back on. So my guess is that you are indeed pretty sound asleep by 23:50. The snippet of zoomed in breathing for this time frame posted in https://1drv.ms/i/s!AgFs7hWqVGNflX-8HOhvTG--gg9f looks to me like its nice stable sleep breathing. There may be an arousal at 0:21:50, but its short lived and you return to nice stable sleep breathing. Breathing remains pretty stable (except for the scored events) throughout the rest of the first CPAP session. My guess is that you are in stable sleep pretty much all the way from around 23:35 until you wake up enough to turn the machine off around 2:05. That first CPAP session lasts for about 2 1/2 hours. That's more than enough time for a full sleep cycle. Maybe even enough for most of a second sleep cycle. It could be that the wake at 2:05 came after a second REM cycle that started a bit sooner than expected.

You reported that after the first wake the restlessness started. The next CPAP session is only 30 minutes long. You probably did doze off during this time, but you clearly didn't get into a stable sleep during this session. That's why I didn't ask you for any zoomed in snippets from this session.

The third CPAP session starts around 2:50. The breathing snippet in https://1drv.ms/i/s!AgFs7hWqVGNflgCg7cqvB-DLfr57 is pretty typical of sleep transition breathing. My guess is the CAs at 2:54 and 2:55 along with the H at 2:56 are all sleep transitional. I think you are asleep by 2:57.

Around 3:09:45 weird breathing sets up: You have a patch of 6 H's that are spaced at roughly 45 second intervals in a breathing pattern that gets flagged as periodic breathing. The funny breathing continues after the last H for another 6 minutes or so, although there is only one event scored during these 6 minutes (an OA at 3:16:40 that looks to me like it might be a "potential CA" that was mis-scored as an OA.) The breathing pretty much settles down by 3:19, although there's still a bit of periodicity that continues at least until 3:27. Perhaps you are tossing and turning and starting to drift in and out of sleep at the time the weird breathing pattern sets up around 3:16:40. Or your body had a bit of trouble regulating the the CO2 levels, but a full fledged CO2 undershoot/overshoot cycle did not materialize.

At any rate, the machine increases the pressure in response to those 6 Hs. Again, you don't seem to wake up enough to turn the machine off and back on, but given that there's a whole string of events that start by around 3:40 and continue until you turn the machine off and back on around 5:50, I wonder if you already are doing some serious tossing and turning by 3:40. Having said that, I'll add this: I don't think you were awake this whole time. I think there is some sort periods of real sleep mixed in with some SWJ breathing from tossing and turning. But unless I went through the whole session, I can't tell how much sleep is mixed in with SWJ. In other words, during this session, I think there is some evidence that you are having trouble staying soundly asleep. But the fact that you're not soundly sleeping here is probably enough to explain why the aerophagia was again a problem.

So where to go from here?

When you are willing to do an experiment with the trazadone, I think that's worth doing. If it makes it easier for you to stay asleep during the night instead of waking up tossing and turning, then you'll be able to figure out if controlling the restlessness is going to be a critical part of keeping the aerophagia under control. (How to keep the restlessness under control is another question given that you don't like taking the trazadone.)

[Ezil71]

Some interesting data from last night. I wanted to see if there was any difference in my breathing pattern during what looks like sleep when flex was turned completely off.

I used 6-12 apap, no flex, but only kept it on for the first half of the night.

Here are some overview charts and two zoomed in sections.

https://1drv.ms/i/s!AgFs7hWqVGNflgTQx-q9kDpLfSaK

https://1drv.ms/i/s!AgFs7hWqVGNflgUy0lUsYA4ogbc2

https://1drv.ms/i/s!AgFs7hWqVGNflgZ2OrAvdkRNC_lK

https://1drv.ms/i/s!AgFs7hWqVGNflgf-XXDh4IwJHNPe

What's interesting is that even though I had it set up to 12, unlike other nights my 95% was only 8 and didn't go shooting up to the max.

I'm wondering if running at 6-8 or 6-9 with flex off might get me closer to a short term solution (until I can get bipap). I did feel more air, but at least for the first half of the night it was tolerable.

What do you think?

[robysue]

Ezil71,

Those breathing snippets look much more like normal sleep breathing than the others did. And the RR is now down to a normal range. I think this is pretty good evidence that your airway doesn't like Flex. A real BiPAP (like mine) does not increase the pressure until the start of the inhalation, so you don't get the same problem you were experiencing with Flex. And a real BiPAP can help quite a bit with the aerophagia.

There's also a lot less evidence of tossing and turning. (Of course, most of your tossing and turning seems to be in the second half of the night, and you only used the machine for half the night here.)

I think it is worth experimenting with running in 6-8 or 6-9 with no Flex for a few days. Yeah, your AHI will likely be higher than desired, but the goal at this point is to get you where you can comfortably use the machine while fighting for a BiPAP with your doc.

By the way, it helps to document the aerophagia. As in keep a journal every morning: Make a note of how bad the aerophagia was and whether it was a (possible) factor in your waking up adn whether it was a (possible) factor in choosing to not mask back up after a wake.

That's what got me my BiPAP: I kept complaining of waking up with serious bloating and the sleep doc's PA and I had tried a number of things to try to confront it. And at yet another "semi-emergency, can-you-squeeze-me-in" appointment roughly 2 months after starting PAP, the PA said to me, "The sleep doc and I have talked and we think it might be worth trying a BiPAP. Would you like to do a BiPAP titration study?" I was shocked when she suggested it. But I'm glad I said "Yes, I'm willing to try BiPAP."

[Ezil71]

I there any value it trying a lower min pressure below 6 based on my charts so far?

Like apap 4-9 with no flex?

[richb]

I think you need to find out if OAs start to increase and at what pressure CAs decrease.

[Ezil71]

I think you need to find out if OAs start to increase and at what pressure CAs decrease.

I'm pretty new to this but do I understand correctly that if the minimum is too low I would see more CA's?

[Sleeprider]

Minimum too low would be OA.

[robysue]

I there any value it trying a lower min pressure below 6 based on my charts so far?

Like apap 4-9 with no flex?

There are two things to consider:

1) On the one hand, when the starting pressure is too low, the machine has to play catch up once the events start. And that can lead to both a higher than expected AHI and the potential for aerophagia if your stomach is actually sensitive to increasing pressure.

2) On the other hand, if the pressure can stay in the 4-7cm range for 30-50% of the night, that might help on the aerophagia end of things.

It's worth a try. If you clearly need a lot more pressure than 4cm, you'll see in it in the data within a few nights of data.

[robysue]

I think you need to find out if OAs start to increase and at what pressure CAs decrease.

I'm pretty new to this but do I understand correctly that if the minimum is too low I would see more CA's?

Ezil,

Too low pressure lets more OAs, obstructive Hs, and snoring happen.

Too high (fixed) pressure encourages more CAs to happen in a select group of patients, including those with complex sleep apnea.

For most people, CAs are not a serious problem regardless of the pressure. For a few people, there is a pressure threshold that tends to cause CAs. The usual hypothesis is that PAP therapy can encourage CO2 washout in a few folks. Once too much CO2 has been blown off, the breathing slows because the CO2 trigger for "inhale NOW" has been messed up. So a central CA winds up occurring, and this, in turn, triggers a CO2 undershoot---not enough CO2 is being blown off. So the CO2 level in the blood increases and that over triggers the "inhale NOW" response, which in turn starts the next overshoot part of the cycle.

Don't worry about CAs unless you start seeing a boatload of them at a time when you *know* you are asleep.

[Ezil71]

Some updates since my last post...

I was able to get in to see my sleep doc today. It was a bit of a difficult appointment. I came armed with my laptop and all my sleepyhead data, and of course with my apap. He didn't want to look at the sleepyhead data - at all.

I explained the issue with flex on the dreamstation (only at most 2cm relief) and requested a bipap but he wouldn't issue one, despite my severe aerophasia.

I finally got a copy of my sleep studies, which was rather perplexing to be honest. My initial evaluation study showed an AHI of 22, nearly all central and the majority when on my back. Just a little OSA.

The frustrating part was that my titration study was nothing like my normal night. It showed few events, all cleared by 9.5 to 10cm, and no RLS (which I know I get because I wake up to them). Looking at the data when my machine is set to 10cm cpap, it doesn't even come close to clearing up my events on a normal night, at least not in REM.

The good news is that since my last posts I've found that for the first part of the night/non REM I can clear my events with between 7 and 7.5 cm (with flex turned off). Anything above 8 or 8.5 and the aerophasia gets bad, so I don't know where, if ever, my REM sleep would get cleared up.

I pointed my doc to this thread, so hopefully he will take a look at the feedback from others.

I'm beyond desperate for real sleep.

He did agree to at least change my machine. He is suggesting that at Resmed Airsense might be enough given that it gives more true exhale relief than the dreamstation flex.

I'm not really sure why he was so insistent that a bipap wasn't needed. I don't see the harm in trying it.

At this point all I can do is try out the Resmed and go from there.