Still Having Clear and Obstructive Apneas - Help

[Gator5000e]

Morning all. It's been a few weeks since I posted here and the suggestions made have helped greatly. Folks suggested some pressure changes. Plus I added the new Dreamwear full facemask and it appears to be helping with my AHI readings. However, when I saw my provider's PA on Monday, she was concerned with the amount of clear airway apneas and obstructive apneas I was still having. For instance, last night the Dreamwear app showed the following data for the past few nights. Sorry if this isn't helpful info. If not just let me know and I wont post these anymore.

The PA says I need to do two things. First she want me to be titrated in a sleep study. Originally my insurnace company did not approve the second part of the study and put me straight to the Dreamstation Auto CPAP machine. So she wants the second part of the study completed. She also says I need a Bi-PAP machine since she is concerned about the clear airway and obstructive apneas I am still having. I am not losing confidence but would like to hear what the experts in this forum say.

I will add a couple of additional factors in the mix. First I underwent a facial CT scan which shows I have a severe bony nasal septum to the left along with a 7mm left sided bony spur expending between the left middle and inferior turbinate which contacts the lateral nasal wall. Apparently I also have severely inflamed turbinates. An ENT i went to was wishy washy about doing septum surgery, basically saying it was up to me. I do not know if this is in any way contributing to my sleep issues. Any thoughts would be appreciated.

Finally, as I am 62 yeas old, I am taking Flomax for some assistance in that regard. I am, I believe, experiencing one of the side effects of congestion. I am sure that is not helping my issues, but again, I don't know if it is a factor or now.

Any thoughts from the group would be appreciated. Thank you in advance.

Here are some of the DreamMapper results. Earlier than May 26th, some of the number are on par with the May 26th readings below.

5/26 - Total Clear Airway Apneas - 36 Total Obstructive Apneas - 33 Total Hypopneas - 13 AHI - 9.5
5/27 - Total Clear Airway Apneas - 11 Total Obstructive Apneas - 16 Total Hypopneas - 5 AHI - 5.8
5/28 - Total Clear Airway Apneas - 5 Total Obstructive Apneas - 17 Total Hypopneas - 6 AHI - 5.1
5/29 - Total Clear Airway Apneas - 15 Total Obstructive Apneas - 29 Total Hypopneas - 10 AHI - 8
5/30 - Total Clear Airway Apneas - 21 Total Obstructive Apneas - 21 Total Hypopneas - 11 AHI - 7.8
5/31 - Total Clear Airway Apneas - 13 Total Obstructive Apneas - 14 Total Hypopneas - 8 AHI - 5.3
6/1 - Total Clear Airway Apneas - 11 Total Obstructive Apneas - 11 Total Hypopneas - 8 AHI - 4.6
6/2 - Total Clear Airway Apneas - 4 Total Obstructive Apneas - 8 Total Hypopneas - 10 AHI - 2.8
6/3 - Total Clear Airway Apneas - 8 Total Obstructive Apneas - 13 Total Hypopneas - 5 AHI - 4
6/4 - Total Clear Airway Apneas - 10 Total Obstructive Apneas - 18 Total Hypopneas - 10 AHI - 5.3
6/5 - Total Clear Airway Apneas - 11 Total Obstructive Apneas - 9 Total Hypopneas - 11 AHI - 4.8

I've also attached the SH data from last night and from my worst night recently

[Pugsy]

Have you tried turning Flex off?

Approximately how many times to you waken during the night?

Do you spend much time awake with the mask and machine on?

Your June 2 report...how many hours of sleep? Can you post an image of it?

[Gator5000e]

Pugsy, thank you for your prompt reply. I do not believe I have adjusted the Flex setting on the machine. Not sure what it does or doesn't do. But I will check it when I get home.

I usually wake up (that I am aware of) once, maybe twice a night. I forgot to add that I have major issues falling asleep so I use Ambien (i generally take half of a 10mg tablet) to assist me in falling asleep.

I usually do not wear the mask until I am ready to go to sleep. I usually read for an hour or so before bed without the mask or machine on. I only put it on when I am ready to go to sleep. I do run the machine in the morning for a bout 15 minutes to dry everything out. But no, I do not spend anytime at all awake with the mask and machine on.

Here is the image of the June 2nd report. I can't recall why it shows 1 hours of sleep and 9 hours awake if that is what you were concerned with.

[Pugsy]

I can't recall why it shows 1 hours of sleep and 9 hours awake if that is what you were concerned with.

Sleep is the time you turned the machine on and wake is the time you turned it off.
I wasn't so much concerned as I was wondering why the AHI was so good that night and not so good some of the other nights.
I was wondering maybe if it was a really short night or something and just didn't have time to have much happen but you got nearly 8 hours on the machine.

If you spent much time awake on the machine then we might think some of those events are awake breathing irregularities getting flagged by mistake.

Flex is exhale relief. Looks like it is set to maybe 2 or 3. Turning off Flex effectively increases your overall average pressure a bit so that it doesn't drop. Sometimes that dropping during exhale can trigger central apneas and while I doubt that your centrals are because of the drop...might try turning it off just to see if it changes anything.

Your centrals might be more post arousal centrals if the obstructive stuff is maybe causing an arousal that you may or may not remember. It wouldn't be impossible if you used a little more pressure to better deal with the obstructive stuff that if those centrals are more related to the arousal that if the obstructive stuff were better reduced that the central stuff might reduce.

Have you looked at those centrals/CAs up close to see if it looks like you had an arousal right before the central flag?
If not, you might learn how to do it.
See this page and watch the videos especially the last one.
http://freecpapadvice.com/sleepyhead-free-software

[Gator5000e]

Thanks. I watched 2 of the videos and if I am understanding this correctly, it appears I am having real OAs because of the flat lines before and after the machine records an OA. Same for the CAs and Hs in the chart. Lots of flat line before and after the event. Am I reading this correctly? I will turn off the Flex but is there anything else I should try?

I've attached three charts below of events spread out to see if they are real (as I understand from the video).

Very appreciative of your help and any additional suggestions.

[palerider]

You need more minimum pressure, 11, maybe 12.

[Gator5000e]

OK, Flex off and more pressure. I will try it. The reason I am confused is that the PA I am seeing thinks the minimum pressure of 10 is too high and that it is causing me to struggle with exhaling and thus causing all these issues.

[Gator5000e]

A quick follow up, if I may. Would my severely deviated septum be a reason for any of these findings? I had an ENT offer me surgery to correct it, but if it wouldn't make a difference I'm not sure I want to go through with the surgery.

Thanks again.

[Pugsy]

I don't see how the nose structure can be a cause for central apneas.

[Gator5000e]

Ok, thank you. I wasn't sure if it would mess with my ability to exhale or something like that. Thanks again.

[palerider]

OK, Flex off and more pressure. I will try it. The reason I am confused is that the PA I am seeing thinks the minimum pressure of 10 is too high and that it is causing me to struggle with exhaling and thus causing all these issues.

More pressure does make it more difficult to exhale, however, less pressure causes more events, more fractured sleep, less rest.

You can crank the pressure down for the exhaling... but then you're degrading the effectiveness of the treatment, or stick with it, let your body get used to breathing with that *gentle* pressure (far less than it takes to blow up a balloon) and get better sleep.

How much pressure is 10cm/h2o? stick a straw 4 inches into a glass... blow, if you can make bubbles, you've just exhaled against 10cm/h2o of pressure.

[Gator5000e]

Ok, so last night I changed my Dreamstation minimum pressure to 11 and turned off Flex. My minimal pressure was set to 10 previously and Flex was set to 3. Unfortunately, I don't recall if it was A-Flex or C-Flex. I should have noted which it was. I don't know the difference between the 2 settings but I suspect A-Flex is Auto adjusting and C-Flex is continuous. Maybe? Can someone enlighten me on what it likely would have been set to? Will SH tell me that?

Anyway, two things happened. First, it was very, very difficult to exhale with Flex off. So much so that I gave up and turned Flex back on but to the lowest setting (as mentioned above I couldn't remember if it was previously set to A or C Flex). I didn't see Pale's note last night about sucking it up and trying to get used to the greater resistance during the exhale.

Second, the pressure did go up to 13.3 at one point and it was blowing air out of my mask, making noise that woke me up. I will give turning the Flex off again tonight. I just didn't sleep very well even though most of that was caused by the air escaping from the mask (Dreamwear Full Face).

Is there a big difference between having Flex on at the lowest setting and off? ANd I guess you guys think I should try again with Flex off? (Sorry I didn't bring my SD card in so I cold post the SH data but my DreamMapper app should the following:

6/6 - Total Clear Airway Apneas - 32 Total Obstructive Apneas - 14 Total Hypopneas - 13 AHI - 9.6

Thanks for any thoughts on this limited update.

[Pugsy]

Doesn't really matter if C or A Flex as the difference between the 2 is minimal. Part of it is the auto adjusting vs continuous thing and another is a teeny tiny difference in timing. Not enough for you to really tell the difference so it really isn't important to know if you used C or A. I think in auto mode you can choose which but in cpap mode you only get a choice of C Flex.

At the most the amount of exhale reduction by using either Flex option at the setting of 3 is about 2 cm drop during exhale.
Respironics does a more flow based drop in pressure than a per cm drop like the ResMed does. So it's how forcefully you breathe that ultimately determines how much of a drop.

And yeah....once we are used to that drop and then turn Flex off it can get ugly because we are used to things one way and all of the sudden we change it.

Don't try to make 2 changes at one time. Remember Science 101...keep your variables to a minimum so you can best judge the results and know what change gave whatever results.

Since it is not comfortable to totally go without Flex...and you increased the minimum at the same time. No wonder you had difficulty....
I would pick one change and try it for a week and then pick the other change and try it for a week.

If you want to use 11 cm minimum.....don't change Flex right now.
If you want to change Flex now...keep the minimum at 10 but maybe try going down in the Flex stage is increments...like try 2 for a couple of nights...then try 1 for a couple of nights and then try it off.

When you increased the minimum and turned Flex off....rather abrupt increase in the pressure that your body simply wasn't used to.
I don't see any need to "suck it up" though because I have found that "sucking it up" usually means I sleep like crap and anything that makes me sleep like crap is something I don't see any sense in doing unless there is absolutely no other way.

[Gator5000e]

Man, you guys are so patient!! Thank you so much. I will make make the adjustments as you recommend. Thanks again.

Oh, do you have a list somewhere of sleep professionals in local areas who know this stuff as well as you guys here on this forum? It seems you can run circles around the PA I am seeing thru my local hospital sleep center.

Thanks again.

[Jas_williams]

Oh, do you have a list somewhere of sleep professionals in local areas who know this stuff as well as you guys here on this forum? It seems you can run circles around the PA I am seeing thru my local hospital sleep center.

Thanks again.

We've learnt this stuff the hard way as users of Cpap devices using our selves as the guinea pigs and helping others along the way. I doubt there are professionals who have the time or inclination to do the research and learning we have done over the years so we have formed these self help groups to help others.