Straw Poll: CPAP or Positional?

Hi All,

I'm working through some lingering questions I have about why I can't seem to resolve daytime symptoms when using CPAP. I've worked hard to control leaks, get optimal comfort, and titrate to appropriate levels with Oscar, and all of that certainly made a notable difference, but not enough (you can check flow curve below for a typical sample). In my untreated study, my supine RDI is 36, and non-supine RDI was 11. Supine AHI was 19, and non supine AHI was 1, though only 25% of sleep time was non-supine....I'm 33yrs old and thin, male, 15in shirt collar size. I was lab-titrated to 8cm/8cm in/exhale, and as you can see have self-titrated to 9.6/6.6cm in/exhale minimum.

I've definitely tried using the Zzoma positional device. It pretty much keeps me on my side. Only problem is it gets a bit hot/uncomfortable, and also gets uncomfortable sleeping on your side(s) for the whole night! HOWEVER, the CPAP is no better, and probably worse tbh, though not sure why. I feel like I've gotten my mask config nice and optimized. Could be psychological? I can say that naps on my side always do the trick, reliably. I guess the only thing that is keeping me going with PAP is that it is the recommended and "best" therapy. And I just want it to be optimal...however, not sure pap is in fact optimal for me.

Anyways, the poll is, if you were in a similar situation, would you ditch the PAP, and go positional therapy? Or what would be your next steps? Is it conceivable that PAP causes problems at all with sleep that the positional therapy doesn't? thanks.

Other things I've tried:
I've tried bipap, and it's not better for me than the Apap. I used to do well with an Oral Appliance, but it started causing some bad jaw problems, so had to stop. Also tried treating PLMs, since I had them, though that didn't really do anything except the meds made me more tired!

Cpap.
It lets me sleep in whatever position the pain allows.

Should we just get this thread locked now, since we all know where it's going?

If you pile the Straw up correctly and use XPAP, your sleep will be better, That's why smart Dogs circle round and round to get the grass to lie down correctly before sleeping. Jim

Goofproof wrote: ↑

Sun Oct 04, 2020 6:01 pm

If you pile the Straw up correctly and use XPAP, your sleep will be better, That's why smart Dogs circle round and round to get the grass to lie down correctly before sleeping. Jim

Oops!
Ya made me pee.

Apneak wrote: ↑

Sun Oct 04, 2020 2:20 pm

go positional therapy?

Pick one.

JPB

Apneak wrote: ↑

Sun Oct 04, 2020 2:20 pm

Hi All,

.... I can't seem to resolve daytime symptoms when using CPAP...I can say that naps on my side always do the trick, reliably...I used to do well with an Oral Appliance....

What troubles you is common. Large numbers of PAPers, though a minority, report not being rested although AHI is low.

I'd like to see your all-night FR curve and its time matched 2-minute FR and FL views. I don't recognize your PLM if its in your OP graphs and I lack sufficient understanding to comment on those effects where applicable. I can't respond to PLM affected segments of your FR curve.

Thank you for these two hints which I hope to understand and expect to find valuable because of the similarity of your and my 2-minute FR curves--if for no other reason: 1. An oral appliance helped you; 2. Naps on your side always do the trick. Please indicate if that side napping state that reliably works is with CPAP.

I suggest you continue CPAP and your side sleeping, as much as you can tolerate the latter to control OSA. (I too must use a hard over-stuffed knapsack-vest to stop me, a side sleeper by necessity, from going supine and to higher AHI.) You may need to raise pressure as I think I must in what looks similar in my 2-minute FR views. Others can advise you about pressure better than I.

As in my own FR, your 2-minute FR clips show persistent inspiratory flow limits (IFL)--those raggedy FR peaks--that are below the flagging threshold of the Autoset and VAuto. Those deformed tips, except as you can see them, are "not there", not presently "visible" to those treatment devices, insurance, nor to many MDs' sleep care.

If your all night sleep is as similar to mine as your OP graphs show in 2-min. views, then, FWIW to you, after long, careful studies (of mostly my FR, FL, ragged peaks, coinciding motions and some published research on IFL) I am nearly convinced to reluctantly raise EPAP and, possibly, pressure support, just to further reduce the large number of my FR wave (recovery?) bursts that I think are arousals, though there is no FL flag, nor even, sometimes, any coinciding motion; raise pressure although my AHI has hovered at or near 0.0 for about 6 months. Raise pressure but not to the point of more Centrals or aerophagia. My sleep and AHI are vastly improved, but if my FR curve disturbances are arousals, reducing those would improve it much more.


Your (maybe the most egregious) two-eared or "M-tip" FR peaks, among your many other common peak deformations, are a focal point in both a 2018 ResMed patent application and other research on inspiratory flow limitation (IFL). (I hope that the recent patent application indicates ResMed will have improved FL detection and highlighting in next generation machines.)


I suspect you have a lot of FR spikes in your nightly overall FR curve--pin- or needle-like protrusions from the main FR curve. If you have those, some are likely to be sleep disrupting arousals that would help explain not being rested; other spikes, reportedly are innocuous, even beneficial. Those latter "sighs" reportedly come every 10-12 minutes with a peak FR 150+% of FR of their neighbors on both sides. (Instead of an M-tip, which is similar, the sigh's upper wave form is like the frontal view of a rabbit's head, the left ear folded down, the right ear erect.) Inspect each FL, spike and run of peak deformations in your whole nights' curves at the 1.5-2 minute view level. In my case, M tips are most often marked by a FL and sighs, only about half the time. I'm guessing that my "normal" sighs are bystanders that will just happen to clear a low level, near-emergent FL condition about half the time and make a FL pop out about half the time. I see FL at M's and sighs as last flagged signs of always continuing, hidden, sub-flaggable "FL" that IS continually visible in numerous peak deformations.

A trivial point regarding the indicated maximum FL in the OSCAR-sidebar summary table: The 0.08 FL maximum shown in your tabular summary, at least in my OSCAR spread, is often, if not most always, wrong (mouse-over the larger FLs and look at the FL scale number). The value of FL where the cursor is located is shown in the upper left corner of the overall FL graph frame. The discrepancy is a minor bug in (only my?) OSCAR? It's a reason I usually set the FL window range 0.0 to 0.1 to make small FL more visible and, if curious, I will mouse-over any large limit to see what is shown for the largest disruptions in FR.

Good luck. You've worked hard but keep on. Side sleep as you can. Don't give up CPAP yet. Meanwhile, I'll be factoring in your two hints, hoping to see you clarify whether those better sleep naps on your side are with CPAP. I have noticed that sleep on my right side causes more deformation of peaks than sleep on left side, and the endings of exhalations show much more pronounced cardiogenic waves. Also, I should mention that I had AHI down with my AutoSet like you, but FL was bad. Switching to the VAuto with PS 4 drastically reduced FL, even though EPAP was much the same as with my low side pressure and EPR setting on the AutoSet.

ASB

With CPAP you can get better feedback on a nightly basis about the effectiveness of the treatment - with side sleeping it's anyone's guess if and when you may need to do something better... (just saying I did the side sleeping 8 years and someone else insisted I be tested and I discovered I now had apnea on my side).

Apneak wrote: ↑

Sun Oct 04, 2020 2:20 pm

Other things I've tried:
I've tried bipap, and it's not better for me than the Apap...... .. based on what you said above, I would be very curious to take a look at your BPAP outcomes, I am afraid, rare complete failure (in particular should it be the Resmed Vauto and you had worked out positional, eventual chin tucking, and tongue collapse), see full night chart and 10-min duration windows, with FR, FL, MV, TV, pressures, and inspiration time. Such failures could turn out to be very educational for us all, I think

Many thanks, all the best

AmSleepnBetta wrote: ↑

Mon Oct 05, 2020 1:41 am

A trivial point regarding the indicated maximum FL in the OSCAR-sidebar summary table: The 0.08 FL maximum shown in your tabular summary, at least in my OSCAR spread, is often, if not most always, wrong (mouse-over the larger FLs and look at the FL scale number). The value of FL where the cursor is located is shown in the upper left corner of the overall FL graph frame. The discrepancy is a minor bug in (only my?) OSCAR? It's a reason I usually set the FL window range 0.0 to 0.1 to make small FL more visible and, if curious, I will mouse-over any large limit to see what is shown for the largest disruptions in FR.

fyi, what is happening here is that ResMed machines report a 99th percentile value rather than an actual max value. OSCAR carefully replicates what ResScan would report. The graph, of course, shows the true FL values, so there will be true maximum values that exceed the 99th percentile value. One of the projects on our list is to handle this discrepancy between the tabular summary and the graphs, whether by labelling or some other approach.

BlueDragon,

Thank you for that clarification. Am pleased to stand corrected and that the individual values are accurate. If you have information on how that metric is calculated individually, please share it.

I assume it is the difference between areas of two offset sliding windows of areas under the FR inspiration curve over certain fixed time spans.

Guessing here: Someone, if bored, highly motivated or silly could probably solve the puzzle if they had the numerical integration skill or software to take some isolated FL cases where FR is regular, do integration under the curve and come up with an answer looking at areas of different successive matched time cuts from the accumulating totals. (Those two eared peaks, in my curves, usually are followed by a FL in next mid-breath, for example, and are most often loners amid fairly constant amplitude FR with no other local FL.) I've idly wondered how their value is determined and how the FL start time mark is determined.

ASB

Apneak wrote: ↑

Sun Oct 04, 2020 2:20 pm

Also tried treating PLMs, since I had them, though that didn't really do anything except the meds made me more tired!

Don't know the status of your limb movements, but if they are still problematic your sleep and daytime well being will still suffer regardless of how you address your sleep breathing. If I could be certain it was effective, I would choose positional "treatment". If there is not enough data to be sure of that, I'd choose CPAP.

mper!? wrote: ↑

Tue Oct 06, 2020 7:24 am

Apneak wrote: ↑

Sun Oct 04, 2020 2:20 pm

Other things I've tried:
I've tried bipap, and it's not better for me than the Apap...... .. based on what you said above, I would be very curious to take a look at your BPAP outcomes, I am afraid, rare complete failure (in particular should it be the Resmed Vauto and you had worked out positional, eventual chin tucking, and tongue collapse), see full night chart and 10-min duration windows, with FR, FL, MV, TV, pressures, and inspiration time. Such failures could turn out to be very educational for us all, I think

Many thanks, all the best

So my results with BiPap have been quite complicated. I started with a PS of 4. (6cm/10cm) but it induced a significant amount of Centrals, which really confused me, until I read one of Pugsy's posts here somewhere that said that the extra PS can cause that, which was news to me. So I dropped down to 3cm PS, equivilant to my APAP. But it still averaged more Centrals, even adjusting both for "movement" induced centrals. What got me to relatively similar stats as APAP was a PS of 2.8cm (6.8/9.6). Not sure about MV/TV, but The FL, FR honestly looked fantastic at this setting, even better than the APAP...which I attribute to the more sophisticated waveforming algorithm (EasyBreathe). Everything was tested for at least 5 days. But subjectively my sleep was not better, and I was just confused by the whole difference in stats between Apap/Bipap, so I switched back to APAP just to better control variables. I will try and go back to try Bipap again.

I then tried a bunch of medications for PLM, but as I said they made matters worse, even if they stopped the movements. What I have since learned on PLM, though is that it is a big question mark. Many doctors, even at Stanford, do not think that it is significant, unless it is specifically causing arousals on your psg. 1 of my PSG showed 4.5 arousals an hour from the PLM, and the other showed 0. But I was on SSRI at the time, which makes PLM worse. It is unclear whether PLM are a primary cause of sleep disruption, or whether they are an expression of a hyperaroused state (basically parasympathetic nervous system not functioning properly for whatever reason). I've started iron/magnesium supplementation, and ceased SSRI, so will hopefully retest in several weeks.

But that whole PLM saga kind of threw a wrench in things. I'm sticking with Apap for a couple more weeks, then trying Side Sleeping again,

images (more in next post)

You would probably sleep your best by sleeping on your side WHILE using your pap machine. That's my vote in your poll.