[Treatment] ASV settings for treatment of complex sleep apnea

[Geer1]

Thanks for this Geer1. Very insightful. I guess technically an ASV device could detect such heavy breathing and limit that to control the hyperventilation. Ever heard of a device that can do that? ASV really helps me a lot but it is far from perfect.

There is no device that I know of that will treat hyperventilation. If it was a PAP type device it would have to act in the opposite way and create a vacuum to try and counteract spontaneous respiratory effort, such a process would be counter intuitive/productive to the underlying reason for using PAP to begin with.

How I believe ASV helps this situation is by forcing you to breath when your body doesn't want to(via backup rate and maintaining ventilation). It removes the central apnea and associated hypercapnia which avoids triggering the hyperventilation process. This doesn't treat the hyperpnea/hyperventilation but rather helps to try and avoid it. 

Joey, regarding oral anatomy all I can recommend is trying to get an appointment with a knowledgeable and experience ENT that specializes in this stuff. I wouldn't try to convince him that your anatomy is an issue, I would ask his opinion as to whether it may or may not be affecting your sleep breathing/quality and if there is anything that could be done to help (and of course the risks associated with such a surgery).

[JoeyWallaby]

I've seen one ENT and he wasn't very helpful, didn't appear to have much training in airway-related disorders. With surgeries, I think ENTs mainly do soft-tissue surgeries which has very low effectiveness in treating OSA/UARS. I'm thinking of seeing an orthodontist.

Sleep endoscopy would be interesting.

Didn't use CPAP last night and dreamt of cracking my teeth and spitting them out...

[sheepless]

I used to have the crumbling teeth dream ALL the time. rarely since I retired though so I attribute it to stress.

[Geer1]

Whether it is an ENT, Orthodontist or whatever the key is that it needs to be a specialist in this field. Not all ENT's or Orthodontists will have the knowledge or experience about this because there are a wide range of issues these doctors treat. If you see and ENT that specializes in apnea he will know a lot more than one that specializes in hearing issues.

Edit: Was that actually a dream or is your bruxism worse without PAP? SDB is a cause of arousal, more arousal's mean more bruxism in a lot of people that have both.

[JoeyWallaby]

Bruxism is worse without CPAP, not just dreams.

Doctor appointment booked. Will be asking for sleep study and gastroscopy.

Don’t think any ENTs here are specialised in airways. I’ll ask my doctor and search online later.

If I was to get a surgery, it wouldn’t be a soft tissue surgery. If clinically indicated, I’d get palate expansion with a MSE device. Side-effects and complications are usually minimal, biggest issue is the cost and time. You sometimes have to get braces beforehand, and always need braces afterwards.

Biggest benefit for airways is increased oral space and nasal space. Because the palate is the base of the airways, expanding the palate then increases airway space.

[Ratchick]

I used to have that dream too - the teeth thing? Also about grinding my teeth so hard one pops out and then all the others would come with like they were unzipping almost, like the roots were linked to something... Horrible dreams. It's very disturbing to see myself clenching my jaw in my sleep and equally frustrating that I had dentists arguing with me about it. Insisting I would wake up before I broke a tooth. Yeah. No. That happened at least four times.

Stress definitely made it worse but so did having a godawful crossbite and, no doubt, the sleep apnea (considering I haven't had one of those dreams OR woken myself up clenching my jaw, making my teeth hurt, biting my lip/cheek or the cracking/grinding of teeth since I started PAP).

Good luck.

[Geer1]

Joey,

I just had a 2nd sleep study (clinic agreed to one at a reduced cost because of couple issues and lack of data in the first one). I went in a bit more prepared knowing what to expect and even got a sleeping pill from doctor in case I needed it (and did end up taking it).

Started the first bit out like my first study. I didn't even think I was falling asleep, I kept having the hypnic jerk type thing going on when trying to fall asleep. I called sleep tech in to say I would like to use the sleeping pill and when she came in she said that I was having bruxism arousals again and the off RERA and that I was drifting in and out of sleep but barely. Soon as she said RERA I made up my mind and told her I want to use CPAP. We put it on and I was able to get a bit more sleep but I woke up a bit later and had some issues with some aerophagia and was having trouble falling back to sleep because of noisy venting of mask (they only had N20 with old style elbows). I am pretty sure this is because she was running straight pressure (confirmed this morning that didn't use flex or PS, it was a PR machine). I did end up getting back to sleep after I believe she dropped pressure back down and then I slept for a good chunk and was able to get the rem sleep data I was hoping for.

I believe she now thinks my bruxism is caused by very minor breathing disturbances and that she noticed definite improvement on the CPAP. It was a bit worse during REM during which she had to increase to 12 cm of pressure to avoid arousals. I guess I might be in the UARS club after all. My question now is if it is because of restricted airways or because of an overly sensitive nervous system.

Now the question is if my current settings treat this (I believe they do at least partially) and how much is remaining untreated. Unfortunately there is no way to easily know without further titration tests to be able to see the arousals. I can pick through my OSCAR data to see arousal breathing and can record sleep to see if there is obvious bruxism etc but still difficult to know if ideally treated without EEG data.

Anyways thought you might be interested. PSG is the holy grail because it gives all the data necessary to diagnose these sleep issues. Unfortunately sleep techs are a pain (I had mentioned I used EPR of 3, why was no pressure support used) and finding a good one/clinic to do tests and be willing to do ASV titration for you would be the hard part.

I've also confirmed some reactions on my tongue related to ingestion of both dairy and gluten (ingestion of either causes geographic tongue in my case). I am starting to wonder if my scalloped tongue is/was due to being swollen from some sort of allergy/autoimmune reaction. If so that would also explain why my breathing used to be much worse and why my original home sleep study indicated moderate level hypopneas. I still think a whole lot of this stuff is all intertwined (gut health, "nonallergic" rhinitis, lpr, bruxism, apnea/UARS), the question is what is the main driving force and how to treat/fix.

[JoeyWallaby]

Thanks Geer1, I have an appointment in November with a sleep doctor. Hopefully I'll be referred for a sleep study.

I'm going to ask my doctor for another B12 and Vitamin D test.

Any feedback on my recent CPAP data?

[SarcasticDave94]

As best as I can make out the OSCAR charts, your AHI is more than low enough. What's the scoop on comfort, being well rested, and such like?

[Geer1]

I don't see anything new in the data.

Still waiting for my sleep study results, talk about painfully slow.... I tried higher pressure for a while since tech had commented on it helping but I feel like I sleep worse. Tried a nasal mask again and don't think that helps either.

I started doing physio for TMJ issues. Been doing weekly intramuscular stimulation and facial muscles have started loosening up for the first time in who knows how long. Potentially caused by the bruxism or maybe a side effect of what is also causing the bruxism. My teeth/gums don't feel as sore now so I think the IMS is helping a bit but not sure how long results will last for. I am thinking of trying Botox treatments if muscles just tighten up again.

You ever do anything more for bruxism other than the mouth guard? I believe my sleep quality is mostly poor for reasons other then apnea but so hard to get any answers or find improvement. I feel you are in a similar boat.