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Greetings & Happy New Year! [CA and H concerns]
#1
Greetings & Happy New Year! [CA and H concerns]
Hello!

I've been on APAP just under two months now, have been reading everything I can find on this subject.  Search results started picking up posts on this forum, in which I could find posts on almost any subject I can think of, by people who've been down this path (and as I've discovered, the many branches of it).  You folks are awesome - the Apnea Board is now a go-to-source of info for me, so I figured it was time to introduce myself.

A nasty bout with endocarditis in my early thirties left me with a deficient mitral valve.  The docs all expected I'd be needing a heart valve replacement before too long, and started doing annual echocardiograms to monitor how things were progressing.  Twenty-five years later, nothing much has changed in either the periodic study results (in which LVE is actually normal), or the consensus opinion.  I feel good, and had a great day skiing yesterday.

Which would be the end of the story, except that my cardiologist referred me to a sleep doc after a blood test came back suggestive of low oxygen effects. A simple oximetry test confirmed dips into the 80s at night.  The doc explained the difference between obstructive & central apnea,  and the additional challenge we fact of living at altitude (I'm at 7000 feet above sea level)  We then did an overnight home sleep study came back with a sleep apnea diagnosis, an AHI of 16, with an "overwhelming majority" of them being obstructive in nature.

Ok then.  Doc put me on a DreamStation with a pressure range of 5-20.  And I found SleepyHead.  And because my primary objective is to "fix" the O2 problem, I bought an overnight O2 monitor (Lokeee) to keep an eye on that.  It was fascinating to look at the SleepyHead graphs & back at the O2 record, and I could see the clear relation between events and O2 drops. 

The biggest issue at first was just getting used to CPAP - I started with a nasal pillow, it wouldn't stay put and irritated my nose. We keep the house cold at night and it felt like trying to sleep with an ice cube under my nose.  I bought a heated tube and switched to a full face mask - just in time as I had a nasty code through which it would have been impossible to breath through my nose.  The "pressure pulses" shoved air down my esophagus, making me burp and waking me up.  And in the full face mask at starting pressure, I felt like I couldn't breath. 

Over the next few weeks, I noticed that SleepyHead was showing not an "overwhelming majority of OA's, but rather an overwhelming majority of CA's - OA's were rare, CA's often at the same level as H's or higher.   Which all seemed rather odd given the initial study.  Reading the board here,  I learned that this is fairly common, and that it sometimes goes away in a few months...  and in fact, the CA's started tapering off perhaps a month in, but are still there, just at lower levels, along with mostly H's.  The other thing I found, charting exported data from SleepyHead, was that the "pressure pulses" had dramatically decreased over time, to where there's just a handful a night now.  The H's and periodical breathing (averaging some 6%) are about where they started at.   I noticed that about 1/2 the H's follow a big breath, and the other half are in the troughs of periodic breathing (which is where many of the former CA's would appear).

I sense these as well, frequently: realizing I haven't been breathing in awhile.. and consciously resuming.. occurring just as I'm about to drift off to sleep, or before waking.  Or feeling like my breathing is confused, not knowing whether to breath in or out.  The only "obstructive" awareness I've had is occasionally when yawning under pressure.   My gut feel is that I have very little obstructive stuff going on, whereas I seem to have a persistent problem with a lack of urge to breathe at times.  And I'm guessing this is probably related to living at 7,000 feet (20% less oxygen up here - I had some really great nights traveling to sea level, btw) and the cycles of O2 / CO2 underlying the periodic breathing messing with that urge to breathe.

I checked in with the doc about the mix of stuff still going on, and he's wanting me to do an in-lab sleep study now to find out what's really happening (he doesn't particularly trust the home sleep study or the cpap machine results).  I also asked for some relief to the feeling of rebreathing at 5.  He raised the minimum pressure to 7, and I figured out the A-FLEX, which was enabled, was dropping the exhale pressure further to 4..  and after reading in the forum here that turning it off my be a good idea to deal with central issues anyway, I turned it off.  My AHI has been dropping over the last month, this change didn't seem to affect it, though the machine is reporting more OA's, with flow rate patterns that look to me like the old CA's, just with the flat line replaced with a slight wiggle.  Other than breathing easier at the initial pressure, I don't sense any change myself. 

Which brings things up to date.  I'm looking forward to the sleep study, in the meantime here's my latest chart.
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#2
RE: Greetings & Happy New Year!
Let's try attaching that chart again...
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#3
RE: Greetings & Happy New Year!
Your central events are fine. Your obstructive events are being treated. Your main problem is the hypopneas. My guess is it is because your machine is set to "wide open". As you can tell from your chart, you barely crest 10. If the sleep test is going to cost you money, forget about it. Set your machine to 8-12 and gather data for at lest ten days.

If it is not going to cost you money, go ahead with the sleep test. If nothing else, it will put you at ease.

As far as living at that elevation, the machine compensates for it. And if you've lived there a while, it should have no bearing on your sleep apnea. What it can do, is make the O2 drops worse than if you were at sea level. But since you are treating your sleep apnea, you should be good.

And yes, central events can happen when first starting treatment. If too high, the treatment pressure can be set lower than necessary then increased over time. Many of us have central events lower than 5. If your CI gets to be higher than 5 consistently, then there is something to be concerned about. In addition to the CPAP itself, other things can contribute to the CI. Medications, alcohol, etc.
PaulaO

Take a deep breath and count to zen.




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#4
RE: Greetings & Happy New Year! [CA and H concerns]
I agree with your doctor's recommendation to do a clinical PSG, but it's important that it be done at a similar altitude to where you live. Your results on Sleepyhead appear to be mixed or complex apnea, but it's hard to draw firm conclusions from the CPAP data. Overwhelmingly your AHI is from hypopnea events, that this suggests a need for bilevel therapy. Instead of a simple diagnostic test, I would suggest your doctor bump this to a CPAP/BiPAP titration so that the relative effectiveness of bilevel can be evaluated. While I agree with Paula in general, I think the problem is not so much the wide-open settings, but a lack of pressure support (difference between inhale and exhale pressure). It would be pretty easy to bump your minimum pressure to 10.0 and verify whether you need simply higher pressure, or to consider bilevel. I think that is a pretty good first move.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
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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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#5
RE: Greetings & Happy New Year! [CA and H concerns]
I second Sleeprider's advise be sure to get the sleep study done at as close to your elevation as possible. My family also lives at about 7,000 feet. My teenage son has had multiple sleep studies at different elevations. My son's AHI and O2 sats were significantly better in the sleep study that was done at a lower elevation than they were at altitude. Like you when we travel to a lower elevation my son's APAP machine shows a much lower AHI, and when we go up in elevation my son's AHI climbs significantly. Because of my son's low oxygen saturations and a mixture of obstructive and central events finding the right treatment wasn't straightforward or easy. For my son having an in lab titration at elevation was extremely helpful.
Good luck!
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#6
RE: Greetings & Happy New Year! [CA and H concerns]
Thanks all!  I think I'm sleeping better just knowing I have a support group on this!  (last two nights under 5, with solid O2 throughout).

The change to 7-20 was relatively recent, so I'm starting with PaulaO2's suggestion of going at least 10 days before changing things.  I like the idea of being able to look back to see how a 10 day record of some adjustment or experiment went.

My share of the sleep study wouldn't cost much, I checked their elevation (similar, thanks for that tip ColoradoMom!), and called them up to find out more about what I can expect out of it.  SleepRider, you suggested the H's might require bi-level therapy, and that reminded me that the doc also said I may need a different machine.. so I asked about this and titration and was told that they would be trying "several different" machines on me to figure out what's going on & what would best help... and confirmed that I could expect new prescription levels coming out of it.  So I booked a night in early February to do that.

Which gives me three 10 day periods to try adjustments / run experiments in before that study.

The CA's & OA's are nearly gone, leaving all the H's... SleepRider, could you elaborate on how bi-level helps with H's?  The initial settings on my machine were 5-20, with pressure relief of "2" (A-FLEX setting of 2 on the Dreamstation, which lowers exhale pressure) - and H's were just as high even at the end of that after a month and a half.  I noticed that the change in pressure didn't occur until you *started* to breath the other way (in or out), but was not pro-active (i.e. timed or something to try and get you to breathe) - a least with the APAP A-FLEX. I am wondering if I should run a 10 day stretch with exhale pressure relief set to the max on this machine of "3"  (though that would require also increasing pressure as I start feeling like I'm rebreathing if exhale pressure gets below about 5.5).  ... or whether that isn't the direction you were thinking of (i.e. an actual bi-level machine with more advanced options is required to even test that).  I turned off A-FLEX trying to get the CA's down.  They are down now.  But that might have just been the passage of time, getting used to APAP in general.  Seems worth testing to see if reintroducing it brings back CA's or not.

The thought to "try higher pressure" makes sense, but I'm really hoping that's not the issue - even 7 is getting near the level at which air starts getting forced into my esophagus, which keeps me awake burping it back out.  My worst CA's (a couple of 40 seconders) occurred at P12, but that was just three weeks in.  Which is just to say I'm hesitant to go there - I have no doubt the sleep study folks WILL go there, and will tell me if that's what's required Smile
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#7
RE: Greetings & Happy New Year! [CA and H concerns]
First, let me be clear, the AFlex or CFlex on your Philps machine is not a bilevel pressure like you would get on a Resmed CPAP. Increasing the Flex setting is very unlikely to help your therapy and does not get you 3-cm of pressure relief, it just changes when the pressure drops amd resumes (pressure relief) during he cycle.  As I pointed out before, your machine doesn't do a good job of predicting your respiration timing and that is not going to change.

Hypopnea is often a result of severe flow limitation, and bilevel pressure is the best way to resolve that problem.  With bilevel, the EPAP pressure is set to keep the airway patent and prevent obstructive apnea, then IPAP is used to support your respiration and overcome any upper airway resistance. This makes breathing easier (less physical effort) and boosts the inspiratory flow rate. It is the limited inspiratory flow during inhale that causes hypopnea to occur, and bilevel is a direct treatment of that problem. It's not just higher pressure, it is low expiratory pressure followed by supportive higher inspiratory pressure.  The difference between IPAP and EPAP is called Pressure Support (PS).  A high enough PS can actually do all the work of respiration, but you only need an assist, not a ventilator. Read this wiki http://www.apneaboard.com/wiki/index.php..._and_BiPAP

To understand how bilevel (VPAP/BiPAP) titration works, read the chart below. This is for fixed bilevel, but the same principle works for automatic bilevel. Ultimately I'd like to see you using something like the machine I use, Resmed Aircurve 10 Vauto. The point is, EPAP is used to prevent obstructive sleep apnea, and IPAP is used to eliminate hypopnea. Remember IPAP-EPAP=PS.

[Image: attachment.php?aid=4203]
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: Greetings & Happy New Year! [CA and H concerns]
SleepRider, thanks for the info about bl-level.  I did a little bit of daytime experimentation, and found that even an aflex setting of 1 on my DreamStation felt rather unnatural to me, causing the mask to jump oddly making inhale / exhale transitions.  As this is apparently not representative of bi-level I'm thinking I'll just leave "flex" off until the sleep study, and see if they come back with a bi-level recommendation or not.

Since my last post, I completed 10 days of apap at a minimum pressure of 7 (flex off), with an average AHI of 5.45, and charts looking a lot like that first one that I posted above.  One other observation is that my O2 levels overnight were improved (over the minimum pressure of 5).

I then gave some thought as to what to try next, after re-reading the responses here, eyeing my charts and thinking about how much more pressure I thought I could take in one step, I ended up setting the apap to a minimum of 8.5 and maximum of 12.5.  The first night's results were so impressive I thought I'd give it a few more days to see if it'd hold up... I'm now four days in, and the average AHI for those 4 days is... 1.77 !  O2 levels kicked up a bit, and "drops" lowered, too. 

Apparently, I did need more pressure! You folks are awesome.

I'll give it a few more nights and then post the most "typical" chart of the new settings - "stoked"
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#9
RE: Greetings & Happy New Year! [CA and H concerns]
Ok, a week at the new variable 8.5 to 12.5 setting yielded an average AHI of 2.20.  The H's are down and the CA's did *not* return with the higher pressure.  Oxygen saturation charts were all quite good, as good or better then at the minimum pressure of 7 - all in all a huge success.


Here's a fairly "typical" chart, though periodic breathing is on the high side, it was all over the place for the week (I had two nights like this around 10, four nights < 2, and one in between).

I'll finish out the 10 days, then think about making an adjustment... perhaps just nudging up the pressure.
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#10
RE: Greetings & Happy New Year! [CA and H concerns]
A minimum of 9.0 is looking better. Nice to hear the improvement.
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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