Still Over 3 AHI at 15 cm

[Rcol]

Here's last night.

Better than usual. As far as I know, I was flat on my back most of the night, with a pretty weak pillow.

I feel better than usual, and I dreamt - but still think my sleep was a little fragmented.

[WillSleep]

I suspect that my main source of obstruction is a small-ish jaw and a large tongue. Every dentist/ortho I've ever been to has commented on how "little room" I have, and I've had multiple extractions. I also had a lot of sinus problems growing up - largely resolved now (I've had tonsillectomy, adenoidectomy, and turbinate reduction). From what I 've read, this sounds like classic UARS to me. I saw an ENT and he basically just stuck a scope up my nose and told me my sinuses look fine, but did mention some narrowing at the tongue base. He said he was surprised I even have the level of obstruction reported on the home test.  

.. to see an orthodontist about some kind of expansion. I'm not sure what all is available in my area -- every ortho I can find that specializes in sleep just has a blurb about advancement devices on their website. I'm hoping my ENT can recommend someone who actually knows something about airway and can give me an honest assessment (and I'm totally open to the possibility that I'm completely wrong).

It would be significantly easier to just get an advancement device, but I'm skeptical that will actually help me.

As always all this is just opinion, not medical advice. 

Not often enough do I get to post simple summary statements.  If I am remembering correctly a MAD works best when you have a TMD today that the MAD will help fix.  And those without a TMD today often get a TMD from using a MAD (I cant post the links here but search for > tmj result caused mad apnea).    
    
TEMPOROMANDIBULAR DISORDER (TMD)  Definition  The temporomandibular joint (TMJ) is the joint that connects the jaw to the temporal bones of the skull. Temporomandibular joint disorder, known more commonly as TMD, occurs when there are problems with the muscles and jaws in the face.
Also If I recall correctly it seems like I saw posted a few self-assessments and cheap fast tests to see if a MAD device is more probable or less to help you or hurt you.  Some were simple and went along the lines of lines of:

• in a quiet place carefully stick your finger applying gentle pressure to the front side of the opening.  Slowly open and close your jaw doing one ear at a time.  The more abrupt movement you feel and the louder the spooky crunching noises the more compress your jaw is into your joint.  
  
• With friend standing behind you holding a yard stick against you from the top of your head down your back or standing six feet behind you watching to keep you honest (free from left-right tilt at the neck) use a level under chin to figure out if and which side of your jaw (left - right) is higher off the ground.   The jaw that is higher is more compressed.   
  
  A few other self assessments and clinical/CPT assessments exist and can be found on Google.
  

Now that you have crude idea of what is going on with your jaw google to find the gentle practices people do to relax the jaw and gently un-compress the joint to find relief from TMD pain.   If your jaw comes easily forward and when forward is better for your TMJ than worse and being forward also reduces airflow restriction then the MAD is more likely to work for you. If any of the work above showed no need to pull the jaw forward or identified pain through the assessment process it is less likely the MAD will work out for you.

WillSleep

[WillSleep]

.. to see an orthodontist about some kind of expansion. I'm not sure what all is available in my area -- every ortho I can find that specializes in sleep just has a blurb about advancement devices on their website. I'm hoping my ENT can recommend someone who actually knows something about airway and can give me an honest assessment (and I'm totally open to the possibility that I'm completely wrong).

Continuing the response above.  

From what I have seen palatal Expansion is really easy if you are 8 years old, ok if your 15, tougher at 19 and at 25 its really tough to do because things have really stiffened up and grown thicker in the roof of your mouth.  

Some 45 year old and 70 year old examples exist but are no more common than examples of painful failed attempts by 45 & 55 year olds.

It seems like the best approach to find a good Orthodontist for this work is to research to identify the best few for your medical procedure options and then identify good candidate orthodontists from the procedure champion's web site and those publishing in journals results of using the procedure on many patients over a number of years.  You may be flying to another city to get access to the best docs per option.

I have seen research papers published that used tests to identify the thickness of components of your skeletal structure above your mouth as a means to better determine if people over 25 are probable candidates for palatal expansion.

Also, there is a good bit of internet discussion on this topic found under the search terms Palatal Expansion, Myofunctional, Myofacial, and Myocranial


WillSleep

[WillSleep]

I own and used that machine at high pressures.  That machine running really in old school CPAP mode with no comfort setting enabled 15cm H2O.. I would not call that 'fine'.. I would say that looks painful to me.   

Second, are you comfortable that you have titrated that machine to it's best possible settings?  If from owning that machine and seeing others use it .. sometimes it gets sillier rather than better at high pressure and lower pressures perform better.   So an immediate thought for me is if you have not exhausted a really good a titration round to find out all your options is to titrate from scratch using a APAP titration approach.   


WillSleep

I'm not sure.

My score seems to consistently improve as I bump up the pressure, until around 12cm. Between 12 and 15, it's less obvious. I seem to get more nights under 2 AHI on 15cm, but I've had a few fluke nights on lower pressures. 

It's clear to me that the PR APAP algorithm is pretty unsuited to whatever I have going on. When I've used APAP mode, regardless of where I set the minimum pressure, the machine reported 95% pressure is ALWAYS 0.5 cm above the minimum. No matter what. I could set it to 8cm, and I'd have an AHI of 5-7 with a 95% pressure of 8.5cm. Even if I set the minimum to 15.5, the 95% will be 16. I tried explaining this to my sleep tech, who suggested I lower it from 14 to like ~10, and she didn't seem to understand what I was asking. I don't know what to make of that.

The pressure really doesn't bother me at this point. I used to get horrible aerophagia above 12cm. Now I only get slight bloating - I think a combination of my body just getting used to it, and the cervical collar doing something good. I still have to use ramp to fall asleep, but when I wake up in the morning, the pressure feels "normal".

Is it possible that I would benefit more from BiPAP?

Yes

I think it is possible:

• Might find a lower pressure config on the current DreamStation
  
• "PR APAP algorithm is pretty unsuited to whatever I have going on."   Some of the same PR algorithims you are using now also exist in the PR BiPAP so I would recommend you try a ResMed next.  
  
• Likely find that a $350 ResMed Autoset off Craigslist to be a better fit at lower pressures and may be all you need.  If you get a chance buy the Autoset for Her (sometimes at the same price) because it is a superset of the Autoset. The for Her model has an additional option to try a softer version of the algorithm.  
  
• A VAuto is largely a superset of the Autoset  
  

WillSleep

[Rcol]

Thanks for all of your responses man.

Here's last night, for the hell of it.


Honestly, I probably just need to shut up and bear it until my in-lab study next month. I'm fairly convinced that it's going to show that I basically don't get ANY stage 3 / 4 sleep. Until/unless I have that evidence, I'm not going to get anywhere with more serious treatments. 

I see two possibilities:

1) I just need SIGNIFICANTLY higher pressure - in which case I'll need a bi-level machine (I'm a little concerned that bi-level might induce centrals, since I got a lot of them when I used "flex" in the early days).           

2) The obstruction (likely base of tongue) just cannot be overcome, and I need surgical intervention (maybe tongue reduction, maybe MMA - though I know that's extreme)

[WillSleep]

Thanks for all of your responses man.

Here's last night, for the hell of it.


Honestly, I probably just need to shut up and bear it until my in-lab study next month. I'm fairly convinced that it's going to show that I basically don't get ANY stage 3 / 4 sleep. Until/unless I have that evidence, I'm not going to get anywhere with more serious treatments. 

I see two possibilities:

1) I just need SIGNIFICANTLY higher pressure - in which case I'll need a bi-level machine (I'm a little concerned that bi-level might induce centrals, since I got a lot of them when I used "flex" in the early days).            

2) The obstruction (likely base of tongue) just cannot be overcome, and I need surgical intervention (maybe tongue reduction, maybe MMA - though I know that's extreme)

 

Good news then.  Way, Way before those two possibilities you can go the less painful, faster and cheaper route of trying different machines that may just be a better fit for you.   

Given that the your love affair with your current Dreamstation APAP is not looking ... well for you, I am just not sure she is 'the One."  I am not feeling like that chart is messaging that this is the best long term relationship you are going to find.  

The therapy you are getting from the algorithms in that Philips Respironics are not knocking the ball out of the park for you night after night so you should try algorithms from other vendors.  Get out there a little bit.  Play the field for a while.   Don't settle.  Don't make a long term commitment until you find your true soul mate.

   
My recommendation:

• Consider trying alternative xPAP machines off Craigslist if the study does not take place soon. 
  
• For sure, choose/only accept a sleep center that will do your sleep study / titrate you with a machine other than Philips Respironics.  That way you are more likely to better clarify what part of the problem is you vs a specific set of algorithms.
  

WillSleep

[Rcol]

Good news then.  Way, Way before those two possibilities you can go the less painful, faster and cheaper route of trying different machines that may just be a better fit for you.   

Given that the your love affair with your current Dreamstation APAP is not looking ... well for you, I am just not sure she is 'the One."  I am not feeling like that chart is messaging that this is the best long term relationship you are going to find.  

The therapy you are getting from the algorithms in that Philips Respironics are not knocking the ball out of the park for you night after night so you should try algorithms from other vendors.  Get out there a little bit.  Play the field for a while.   Don't settle.  Don't make a long term commitment until you find your true soul mate.

   
My recommendation:

• Consider trying alternative xPAP machines off Craigslist if the study does not take place soon. 
  
• For sure, choose/only accept a sleep center that will do your sleep study / titrate you with a machine other than Philips Respironics.  That way you are more likely to better clarify what part of the problem is you vs a specific set of algorithms.
  

WillSleep

I think there's a possibility that a bilevel machine may help me - because having low expiratory pressure may help me tolerate higher inspiratory pressure / may in itself be helpful.

I'm not really hopeful about trying the resmed APAP - because like I've said, I'm not really relying on an algorithm as it is.

I have had better luck getting to sleep on my side lately. I spent most of last night on my side. I woke up at 5am feeling like I slept for the first time in months. Checked the machine --- 1.1 AHI.

It almost makes me angrier when I have a GOOD night. That I experience such a huge difference in perception between 3 AHI and 1 AHI -- and that my sleep tech has repeatedly assured my that I should basically just be happy with anything below 5...

[WillSleep]

Good news then.  Way, Way before those two possibilities you can go the less painful, faster and cheaper route of trying different machines that may just be a better fit for you.   

Given that the your love affair with your current Dreamstation APAP is not looking ... well for you, I am just not sure she is 'the One."  I am not feeling like that chart is messaging that this is the best long term relationship you are going to find.  

The therapy you are getting from the algorithms in that Philips Respironics are not knocking the ball out of the park for you night after night so you should try algorithms from other vendors.  Get out there a little bit.  Play the field for a while.   Don't settle.  Don't make a long term commitment until you find your true soul mate.

   
My recommendation:

• Consider trying alternative xPAP machines off Craigslist if the study does not take place soon. 
  
• For sure, choose/only accept a sleep center that will do your sleep study / titrate you with a machine other than Philips Respironics.  That way you are more likely to better clarify what part of the problem is you vs a specific set of algorithms.
  

WillSleep

I think there's a possibility that a bilevel machine may help me - because having low expiratory pressure may help me tolerate higher inspiratory pressure / may in itself be helpful.

I'm not really hopeful about trying the resmed APAP - because like I've said, I'm not really relying on an algorithm as it is.

I have had better luck getting to sleep on my side lately. I spent most of last night on my side. I woke up at 5am feeling like I slept for the first time in months. Checked the machine --- 1.1 AHI.

It almost makes me angrier when I have a GOOD night. That I experience such a huge difference in perception between 3 AHI and 1 AHI -- and that my sleep tech has repeatedly assured my that I should basically just be happy with anything below 5...

On your side and a better night.  Nice! 


"That I experience such a huge difference in perception between 3 AHI and 1 AHI"

I try to simplify it to better sleep is made of a number of key components.  The two we can see change in here across the three screenshots you posted are:

1. The most recent screenshot you posted had a lower AHI, less distruption and less battling restrictions all night long.   Better rest for your brain and your heart. 
   
2. The most recent screenshot you posted had more Oxygenation all night long.  Your Minute Vent. Median score was highest in this third, best screenshot.  That might be another lever to watch in addition to AHI. 
   

 
 
"I think there's a possibility that a bilevel machine may help me - because having low expiratory pressure ..."

You can try a little experiment to get somewhat of a flavor with your current machine.  Switch from APAP mode to CPAP at with pressure set to 15cmH20 or 16 cmH2O (1cmH2O higher than your running all night now) and enable "C-Flex+" at level 2.


WillSleep