[Equipment] CSA #'s that require BPAP or BPAP-SV?

[robysue]

It's either a transitional thing (only 2 mo. of CPAP) or the "Complex" part of CSA (CSA during CPAP). [No significant CSA was detected during the sleep study; only with CPAP.]

I'm just curious how much time to give it before being convinced it's CSA. Perhaps somewhere in a 6-12 month window I suppose. I really seem to be stuck on that 5 CA events/hour number. I don't know if that's the cause of the ongoing crummy sleepless nights on CPAP. (It's not a tolerating thing.) The OSA is down to a low 2, but sleeplessness continues (awake every 1.5 hours last night).

Just how restless are you during the night? Seriously, how much WAKE time while masked up are you talking about? And are the CAs being scored during times that you know or suspect you're not fully asleep?

Wake breathing is much less regular than sleep breathing. We breath deeply for several breaths, and then take longer before the next inhalation. We momentarily hold our breath while concentrating---even on something as simple as turning over in bed. And in some people, machines will sometimes mis-score normal, but ragged wake breathing as CAs. So if many or most of the CAs are scored during times you're likely awake or drifting in and out of a very light sleep, some or all of the CAs may not be real central apneas---if you were in a lab, they would not be scored as an apnea because the EEG says you were awake when they happened.

The transition to sleep also is rougher in some individuals than others. As the CO2 sensitivity trigger for breathing is reset when responsibility for managing the breathing is handed over from the voluntary nervous system to the autonomous nervous system, it's pretty common for a "central" apnea or two to occur. On an in-lab sleep test, these sleep transition apneas are NOT scored as "real CAs" (unless they're so numerous that it's clear they're the cause of the patient not being able to get into real sleep.) So if the centrals are clustering at the points where you are dozing---going in and out of sleep, then another possibility is that they're just normal sleep transition events.

So the answer to "How long should I keep PAPing before I should be convinced that what I'm seeing really is Complex Sleep Apnea (CompSA)?" is "A few weeks after you are sleeping well with the device, where well means you're not reporting that the nights are restless and sleepless" As long as your sleep is badly fragmented and you're spending a lot of WAKE time breathing with the mask waiting (or fighting) to get back to sleep, the CAs are likely to be considered part of WAKE breathing or sleep transition breathing by the doc who's treating you.

For now, I'd suggest letting the sleep doc know what you are seeing, but follow his lead about prudent watching of the CAs. And focus on trying to sleep more soundly with the PAP machine. If the CAs don't once you're sleeping more soundly, then you know that there is a real possibility that the CAs are a symptom of CompSA

The machine's set at a constant 12 at the moment rather than variable, which seems to be the number that almost ends the OSA. The pressure doesn't really bother me, but my stomach each morning is sure ballooned/bloated/cramped.

The stomach would probably profit from a reduction in pressure, but then the question is how high will the obstructive events go? In the long run, you may be better off with a slightly higher AHI and a lower pressure so the stomach is happier and the sleep is more continuous.

Have you reported the aerophagia (the bloating and cramping) to your sleep doc? If not, you need to start there. If you've been dealing with serious aerophagia for two months, it's time to get the sleep doc's attention about this. Until the aerophagia is dealt with, you're not likely to sleep well with the PAP. Until you're sleeping better with the PAP, there's no way to tell if the CAs are a real problem or not.

So focus on doing what you can to minimize the aerophagia.

Standard advice for aerophagia includes:

• Do all the GERD self-help stuff---in particular, try sleeping with the head of the bed raised and don't eat too late.
  
• If you have Flex turned OFF, turn it on and see if that helps.
  
• If you have Flex turned ON, play with the settings---don't automatically assume that "more" exhalation relief equals "more" comfort. Some people find a Flex setting of 1 or 2 to be more comfortable and more natural feeling than a setting of 3.
  
• If you have Flex turned ON, experiment with turning Flex OFF.
  
• Consider prudent use of the Ramp. On the PR machines, if events start happening during the ramp up period, the machine will raise the pressure by about 1 cm and then continue ramping up to full pressure from there. By prudent use of the ramp, I mean two things:
  • Set the starting ramp pressure not too far below your prescribed pressure, and set the ramp time to be reasonable---long enough for you to get to sleep, but not several times longer than it will take you to get to sleep. With a prescribed pressure of 12, I'd suggest a starting ramp pressure of around 8cm if you can tolerate it.
    
  • Hit the ramp button whenever you wake up with your stomach feeling bloated or ballooned. The lower pressure may ease the stomach problems.
• If there's evidence of mouth breathing, the consider using a FFM or a chinstrap or both.
  
• Experiment with sleeping positions. Sleeping on the right side may make the aerophagia worse than sleeping on the left side---it has to do with the internal arrangement of our organs. Sleeping on your back may make the aerophagia a bit easier. Also consider your head position relative to your chest. Some people find having their chin pointed away from the chest helps prevent the swallowing; others (including me) find that it's better to have the chin pointed down towards the chest.
  
• Experiment with the humidifier setting and the temp setting on the hose if you use a heated hose. Too much or too little humidity may cause congestion or nasal or mouth dryness that leads to swallowing. Too much or too little heat may also cause discomfort in the sinuses or the mouth, which can lead to swallowing.
  

If nothing seems to help OR if the aerophagia is really severe, the make sure you call the doctor. For some people the only real solution to aerophagia is to be switched from CPAP/APAP to a bi-level machine. The EPAP on a bi-level machine can sometimes be set lower than the CPAP setting without any statistically important increase in the number of obstructive events, and hence the mean pressure needed to control the OSA can be reduced, and this in turn can lead to real relief of the aerophagia problems.

[robysue]

Hi wakeuptime
i`am as just as you
i tried autoCpap for months and dident help at all

How long is "months"? 2 months? 6 months? or 12 months?

Did you ever try straight CPAP? Some people are physically bothered by the changing pressures in AutoCPAP, and they don't do very well on AutoCPAP, but do fine on plain old CPAP.

AHI was below 2 and CSA was about 5 and my sleepiness and HUGE MEMORY LOSS!! continued....
1month ago I bought RESMED ASV and my AHI is under 1 ,but that too, dosent work for me much

Was a doctor involved in this process? Did you have a proper ASV titration study? And what are your current settings?

I almost wake better than before but after some minutes!! sleepiness and HUGE loss of concentration!! comes back
I`m really frustrated,very very very depressed
what other things I supposed to do?
HELLP!!

Have you told the doctor what is happening? Yes, I know from hard experience that many docs just don't get it---I'm on sleep doctor number 4 because sleep docs #1-3 "just didn't get it." But some docs (or their PAs or nurses) do get it. And they're in a position to actually do some good.

And when I say "Have you told the doctor what is happening?" I don't mean you've just told the doc that you're dealing with a huge memory loss and sleepiness in the daytime. I mean---have you told the doc about what happens in your bed when you try to sleep with the mask on your nose? Are you waking up multiple times during the night? Are you finding that the machine wakes you up just as you're starting to fall asleep? When you wake up, do you think it's because of some kind of physical stimulus coming from the machine? Do leaks wake you up? If so, where are the leaks coming from? Do machine or mask noises wake you up?

Tweaking the pressure settings on an ASV really needs some input from a sleep doc in my opinion, because the large swings in pressure from IPAP to EPAP that are used to "trigger" inhalations and keep the target minute ventilation in line can also trigger a huge number of PAP adjustment problems. Leaks are usually far harder to control on an ASV machine, and the need to get the breathing into sync with the ASV machine is also a difficult skill for some people to master.

[Peter_C]

We need more history please, five surgeries? What types and when?

[nasnas]

Hi wakeuptime
i`am as just as you
i tried autoCpap for months and dident help at all

How long is "months"? 2 months? 6 months? or 12 months?

Did you ever try straight CPAP? Some people are physically bothered by the changing pressures in AutoCPAP, and they don't do very well on AutoCPAP, but do fine on plain old CPAP.

AHI was below 2 and CSA was about 5 and my sleepiness and HUGE MEMORY LOSS!! continued....
1month ago I bought RESMED ASV and my AHI is under 1 ,but that too, dosent work for me much

Was a doctor involved in this process? Did you have a proper ASV titration study? And what are your current settings?

I almost wake better than before but after some minutes!! sleepiness and HUGE loss of concentration!! comes back
I`m really frustrated,very very very depressed
what other things I supposed to do?
HELLP!!

Have you told the doctor what is happening? Yes, I know from hard experience that many docs just don't get it---I'm on sleep doctor number 4 because sleep docs #1-3 "just didn't get it." But some docs (or their PAs or nurses) do get it. And they're in a position to actually do some good.

And when I say "Have you told the doctor what is happening?" I don't mean you've just told the doc that you're dealing with a huge memory loss and sleepiness in the daytime. I mean---have you told the doc about what happens in your bed when you try to sleep with the mask on your nose? Are you waking up multiple times during the night? Are you finding that the machine wakes you up just as you're starting to fall asleep? When you wake up, do you think it's because of some kind of physical stimulus coming from the machine? Do leaks wake you up? If so, where are the leaks coming from? Do machine or mask noises wake you up?

Tweaking the pressure settings on an ASV really needs some input from a sleep doc in my opinion, because the large swings in pressure from IPAP to EPAP that are used to "trigger" inhalations and keep the target minute ventilation in line can also trigger a huge number of PAP adjustment problems. Leaks are usually far harder to control on an ASV machine, and the need to get the breathing into sync with the ASV machine is also a difficult skill for some people to master.

I really thank you very much
I usually have not much of problems with mask or waking in sleep because of machine, leaks,or...
I used autoCPAP for about 3months
I have tried different pressures in ASV,like PS from 00to06 with EPAP from 04to08 but nothing improved
my so2 is in normal range with average 97 and no desaturation detected
but.......

[nasnas]

We need more history please, five surgeries? What types and when?

hi peter!
about 4 years ago, begining with nasal septoplasty and valvoplasty, then uppp and glossectomy,then mandibular advancement and genioplasty,then RF turbinate reduction and a prosthesis in my nose to keep valve open, and another wedge resection of base of tongue
among them, mandibular advancement and genioplasty were the best and make me sleep better and feel better,but unfortunately it has relapsed 100%
and worst of them was glossectomy that had pain and nothing improved ,even my speech deteriorated!
thank you alllllot

[nasnas]

does anyone know what is the normal ranges in sleep:
minute ventilation?
tidal volume?
respiratory rate?
pulse rate?
mine are:
minute ventilation about 5
tidal volume about 350
respiratory rate about 13
pulse rate about 50

i think that my tidal volume and pulse rate are low
can i adjust the pressure so that both of respiratory rate and tidal volume get higher?
dose anyone suggest CAPNOGRAPH for testing my co2 level? maybe co2 accumulation make my feel sleepy during day?
any answers appreciated
thanks alot

[nasnas]

dose anyone know the normal ranges in sleep?
tidal volume? mine=350
minute ventilation? mine=5
respiratory rate? mine=13
pulse rate? mine=50

[nasnas]

i have not much dreams in my sleep probably because my REM is tooooooooooo short and no stage3&4 was detected in PSG!!!
has anybody this problem like me?
my sleep is not refreshing with or without cpap or ASV
thank you for your answers and your kindness

[WakeUpTime]

i have not much dreams in my sleep probably because my REM is tooooooooooo short and no stage3&4 was detected in PSG!!!
has anybody this problem like me?
my sleep is not refreshing with or without cpap or ASV
thank you for your answers and your kindness

The best REM sleep (dreams) happened for me during the first 1-2 days after getting on CPAP therapy. Although I've had a few micro drips (like 5 second video clips instead of little movies) in the past 3 months, it might be still the 'adjustment period'. I bet the seasoned CPAP pros with great AHI numbers are getting some much better REM sleep. That's my hope and encouragement perhaps for the future.

[nasnas]

i have not much dreams in my sleep probably because my REM is tooooooooooo short and no stage3&4 was detected in PSG!!!
has anybody this problem like me?
my sleep is not refreshing with or without cpap or ASV
thank you for your answers and your kindness

The best REM sleep (dreams) happened for me during the first 1-2 days after getting on CPAP therapy. Although I've had a few micro drips (like 5 second video clips instead of little movies) in the past 3 months, it might be still the 'adjustment period'. I bet the seasoned CPAP pros with great AHI numbers are getting some much better REM sleep. That's my hope and encouragement perhaps for the future.

so you did experience REM REBOUND
keep going,it seems that it works for you
but not for me! ahhhhhhhhh
good for you
thx for reply