Lost & need help (APAP? BIPAP? ASV?) - 2 sleep studies

[jasondub]

Hi everyone,

I'm hoping I can get a little bit of input on my situation as I can't quite figure out what to do next.

BACKGROUND

I've been sleeping awful for years. Falling asleep is fine, even the first half of sleep isn't really an issue however, the 2nd half of sleep I can't stay asleep for the life of me. I'm easily aware of 10+ arousals every night where I have to actively try to fall back asleep.

November 2020 I did one of the Lofta sleep studies and got prescribed a Resmed Airsense 10. I tried to use this with settings of 4-20cm. I tried this for a week and after no luck began playing with the pressure settings but, no matter what I did, I still had the same issues during the 2nd half of the night.

I gave up for months and later stumbled upon UARS and the significance of tracking RERAs when it comes to sleep studies. I contacted AXG and got a much more thorough Diagnostic Polysomnogram that revealed that my issues seem to be happening during REM sleep.

According to the Lofta study, my AHI is 5.3. According to the AXG study, my AHI is 6.4 - BUT - REM AHI is 27.4.

DATA



Full AXG report (8 pages): https://imgur.com/a/GpvMo0Y



Full Lofta report (15 pages): https://imgur.com/a/BcS5bJI

ME

I'm 40 years old, 5'11", about 220, roughly 20% bodyfat.

I workout quite a bit so I'm a little broad in the shoulders, chest, and neck. I do feel like my fat is concentrated in the midsection area (mostly visceral) that feels like it creates some resistance when breathing. I'm guessing this creates challenges for me at night which is why I tend to sleep on my side.

WHAT CAN I DO?

I'm not sure what to do at this point. I haven't had any success with the Airsense 10 so far, but I don't know if that's because of my settings. One frustrating issue I had w/ the Airsense 10 was that it was difficult for me to exhale against the pressure so I'd constantly need to open my mouth and take a deep breath.

Anyone here have any suggestions on what options I should explore to get back in the game? I'm open to trying a BIPAP, ASV or anything else - even if it's pricey, I'll pay for it if it means I can get some sleep.

Any thoughts and suggestions would be greatly appreciated!!

[Pugsy]

So let's start with the data from the machine.
Read this
viewtopic/t158560/How-to-post-images-for-review.html
and go get OSCAR
OSCAR https://www.sleepfiles.com/OSCAR/
http://www.apneaboard.com/wiki/index.ph ... stallation
http://www.apneaboard.com/wiki/index.ph ... rpretation

Post a typical detailed report from OSCAR per the parameters I outlined in the first link I gave you above. We don't want all the graphs the machine will give you.

If you don't have a SD card in the machine....get one...it must be in the machine during the night to get the detailed data.
Any generic SD card will work just fine...32 GB or less. While large will work it does involve more work and more money and it really isn't needed. 2 GB is actually plenty big in size but hard to find and when found a bit pricey. I use a 16 GB Sandisk I got at WalMart....way more than I need but it was cheapest I could find locally.

It is actually common for sleep apnea to worsen in REM stage sleep and the fact that you are having more problems the second half of the night is also common because that's when we tend to have more REM.
Google "sleep stages" and look at the normal progression of the sleep stages to get an idea what goes on.
Normally first REM sleep stage occurs about 90 minutes after sleep onset and it's rather brief but as the night progresses REM comes on more frequently and lasts longer. We end up with a lot more REM the second half of the night.

I am very familiar with REM worse OSA. I have it myself. A little worse than yours but not all that unusual.
In non REM sleep my AHI is mild but in REM my AHI is over 50 events per hour. This makes our overall AHI average on the low side due to averaging.

We don't know if you need a different machine at this time....let's work with what we have available right now and see what's going on and then decide if different options need to be looked at.

So we need to start with what the machine can show us now and go from there.

In the meantime I will go read your full sleep study from AXG to see if there is anything out of the ordinary in it.

[Pugsy]

I strongly disagree with the Lofta report pretty much pooh poohing off hyponeas as just "shallow breathing"...I feel this gives people the impression that they aren't an important part of the criteria for a diagnosis.
1...it is MUCH more than shallow breathing...
To me shallow breathing is when we just don't take a deep breath for whatever reason....there's a big difference between a small breath because we just don't make a big effort and not taking a full breath because we can't. With hyponeas...we can't move enough air because of airway tissues blocking the airway. Big difference between can't and just don't out of habit.
2...if it wasn't important it wouldn't be one of the things they test for, look for and document in the sleep studies used for diagnosing OSA

[jasondub]

So let's start with the data from the machine...

Thank you! I'll pick up an SD card and begin collecting data tonight.

[Pugsy]

I don't know if you have the provider/clinical manual for your machine but if you don't...
https://www.respshop.com/manuals/ResMed ... %20her.pdf
page 14 explains how to get to the clinical menu setup area.

I want you to try these settings.
Mode....Auto
Minimum Pressure....7
Maximum Pressure....20
EPR...turn it on & to full time and set it to 3
Turn Ramp ...OFF for now...come back here if you can't handle the pressure with ramp off.
I have some thoughts about your complaints with not being able to exhale at the starting pressure which I assume is the factory defaults and doesn't surprise me. The settings above should help with that exhale issue but if it doesn't....let me know.

[tan]

...
Anyone here have any suggestions on what options I should explore to get back in the game? I'm open to trying a BIPAP, ASV or anything else - even if it's pricey, I'll pay for it if it means I can get some sleep...

That is how I did it in Jan 2015: after failing with CPAP (mild OSA, moderate UARS) and after reading up a lot on the significance of treating FLs, I got a VPAP on my own in a drug deal-like setup late night in a parking lot.

VPAP did make my life somewhat easier for I could adjust pressure difference to a higher value than 3 allowed by APAP and I could tweak trigger/cycle setting to very high. But that's for me because even with EPR==3 it was challenging to exhale. Other people on this board found it counter-productive. It's a matter of experimenting.

I would address AHI first. Sleep hygiene is also very important for UARS.

Have you had a chance to get an ENT evaluation?

[jasondub]

I don't know if you have the provider/clinical manual for your machine but if you don't...
https://www.respshop.com/manuals/ResMed ... %20her.pdf
page 14 explains how to get to the clinical menu setup area.

I want you to try these settings.
Mode....Auto
Minimum Pressure....7
Maximum Pressure....20
EPR...turn it on & to full time and set it to 3
Turn Ramp ...OFF for now...come back here if you can't handle the pressure with ramp off.
I have some thoughts about your complaints with not being able to exhale at the starting pressure which I assume is the factory defaults and doesn't surprise me. The settings above should help with that exhale issue but if it doesn't....let me know.

I tried a night with it but only managed to last about 3 hours until I ended up taking it off. Found out the next day that my SD card wasn't recognized or something because no data was recorded. Got a new card this morning and once inserted, a popup appeared on the device saying it was getting it ready or something and when checking it, I see a bunch of config files on the card. The first card didn't have anything on it or show any kind of popup.

Should be able to get some data tonight.

[jasondub]

...
Anyone here have any suggestions on what options I should explore to get back in the game? I'm open to trying a BIPAP, ASV or anything else - even if it's pricey, I'll pay for it if it means I can get some sleep...

That is how I did it in Jan 2015: after failing with CPAP (mild OSA, moderate UARS) and after reading up a lot on the significance of treating FLs, I got a VPAP on my own in a drug deal-like setup late night in a parking lot.

VPAP did make my life somewhat easier for I could adjust pressure difference to a higher value than 3 allowed by APAP and I could tweak trigger/cycle setting to very high. But that's for me because even with EPR==3 it was challenging to exhale. Other people on this board found it counter-productive. It's a matter of experimenting.

I would address AHI first. Sleep hygiene is also very important for UARS.

Have you had a chance to get an ENT evaluation?

I made an appointment with what I thought was an ENT last month but when I got there for my appointment, they explained they didn't do anything with the throat. Long story short, their whole operation felt like it revolved around selling turbinate reduction surgery as it was all they were pushing for. I never even saw the doctor, just the nurse. Very disappointing.

I'll get back on that though, thanks for the reminder!

[tan]

...
Anyone here have any suggestions on what options I should explore to get back in the game? I'm open to trying a BIPAP, ASV or anything else - even if it's pricey, I'll pay for it if it means I can get some sleep...

That is how I did it in Jan 2015: after failing with CPAP (mild OSA, moderate UARS) and after reading up a lot on the significance of treating FLs, I got a VPAP on my own in a drug deal-like setup late night in a parking lot.

VPAP did make my life somewhat easier for I could adjust pressure difference to a higher value than 3 allowed by APAP and I could tweak trigger/cycle setting to very high. But that's for me because even with EPR==3 it was challenging to exhale. Other people on this board found it counter-productive. It's a matter of experimenting.

I would address AHI first. Sleep hygiene is also very important for UARS.

Have you had a chance to get an ENT evaluation?

I made an appointment with what I thought was an ENT last month but when I got there for my appointment, they explained they didn't do anything with the throat. Long story short, their whole operation felt like it revolved around selling turbinate reduction surgery as it was all they were pushing for. I never even saw the doctor, just the nurse. Very disappointing.

I'll get back on that though, thanks for the reminder!

I know what you are talking about. Yes, you may benefit from a real ENT. My insurance required a course of antibiotics first before considering CT scan, even if there was no sign of infection