ErElf (Therapy Thread)

[Sleeprider]

There are several different forms of flow limitation and these restrictions reduce flow enough to cause the hypopnea we see. No clear cause for the CA events, but strong recovery breathing on the other side leads into additional flow limited breathing. I talked about some measures that can be taken to mitigate chin-tucking. I think it would be worthwhile for you to implement some of that. http://www.apneaboard.com/wiki/index.php...cal_Collar

[ErElf]

Sleeprider - 

(A bit of rambling here. I have been thinking about this most the day. Need to move on, so rather than try to polish my posting, I'm just adding it. Feel free to respond or not.)

From my reading of many other posts on apneaboard, I actually came across the "Positional Apnea" and wondered if that might be part of my problem. From your response, I assume you are saying that from viewing my data, you think that positional apnea (as defined http://www.apneaboard.com/wiki/index.php...onal_Apnea) is at least part of my issue. 

Is that correct? How strongly do you see this represented in my traces?

I will absolutely follow up this idea and have ordered 2 collars to try. And from my prior investigation on positional apnea, I have created a camera mount to record myself while I sleep, but have not setup a camera yet, but have a car dash cam with IR. From reading the wiki and forum, I'm surprised that I have not come across any mention of someone doing this. And, it seems to me that this should also be a standard part of sleep studies. Seems that we should be able to get some pretty compelling evidence pretty easy. 

I went way down the UARS vs. OSA rabbit hole. My sleep study showed 0 Obstructive Apnea Events, but CAI=2.1; HI=12.3; RERAI=7.2. Reading http://www.apneaboard.com/wiki/index.php..._and_BiPAP, this sounds like a really close description of my problem. And the recommendation of treatment seems to be to use a BiPAP. (Which seems exactly contrary to next.)

You said, "No clear cause for the CA events, but strong recovery breathing on the other side leads into additional flow limited breathing." Which  I think is kinda what is said here: http://www.apneaboard.com/wiki/index.php...y_Clusters, but that page suggests the over-breathing (my words) results in the CA and that it is not from blockage. For me, the difference seems to be that in the end I wake. This leads me to think that the EPR=3 is NOT helping me. But I do not get an idea of what therapy would work.

He is another image of my pre-wake from a few days ago that really matches the /Optimizing_therapy#Clear_Airway_Clusters image:


I am impressed with the Wiki for the amount and consideration of the material I find there. I also assume much of the advice and help here is voluntary or with little or no compensation, so I hesitate to be critical. I am truly thankful that resources such as this exist. I will say though, that there are lots of improvements that would make the wiki data more accessible for newbies. For example:

• In reading: http://www.apneaboard.com/wiki/index.php...onal_Apnea, I do not see a good description of "Chin Tuck". After reading and re-reading, I pretty sure that this refers to bending at the neck to bring the chin down to the chest, as opposed to dropping the chin down to the chest by opening your mouth without moving the neck. Part of what confused me was the statement "...sit comfortably in a chair and relax. As you relax further let your chin drop towards your chest." This reads to me like "let your chin drop [leaving your head still]" as opposed to "drop your chin by keeping your mouth closed and tilt your head forward like a deep nod."
  
• In section: http://www.apneaboard.com/wiki/index.php...PS_and_ASV, the abbreviation ST is used a bunch. I could not figure it out. I finally guessed it must be a specific machine, but still have not found a definitive note on it
  
  

[Sleeprider]

To be clear, I think we need to eliminate chin-tucking as a root cause. The close-up views of the events shows hyperventilation leading to diminished volume then two very flow-limited breaths with possible snores and the apnea, followed again by hyperventilation. This is kind of a mixed bag of looking like apneic threshold periodic breathing with CA, and the possibility that you arouse, but don't awaken from the apnea and progressively settle into a chin-tuck and a new apnea. We know these events tend to be clustered and mixed with obstructive events, so I'm inclined to think the positional apnea is the more likely problem vs a true central event.

You are using 8-18 pressure and are generally seeing 9.0 to 9.5/6.0-6.5 pressure during sleep. An alternative to trying a collar is to simply titrate the minimum pressure a bit higher 1-cm at a time. Try a minimum pressure of 9.0 and see if this reduces arousals or events. As I've said earlier, avoid sleep positions that encourage a chin-tuck.

[fishfinderG]

Good idea on the dash cam! I’ve recorded my sleep many times with a cheap eufy webcam and learned a lot from comparing my position to OSCAR. I’ve advised people to get webcams before but I’ll add dashcam to my advice as some people might already have them but not realize they would work for looking at sleep if they have low light support.

[Sleeprider]

Going back to a couple questions you ask about a better description of "chin-tuck". Under the soft cervical collar section we describe a way to simulate the effects:
[quote]Two ways to check for this Positional Apnea

Sit relaxed in a chair and as you fully relax let your chin drop to your chest and note the increased airway resistance that may range from an increased effort to a snore or full blockage.
Another test is to gently push upward on the soft part of your jaw or neck right in front of the throat.

If your airway easily closes from that pressure, positional therapy in the form of a soft cervical collar or wedge may significantly improve your results.]/quote]

ST refers to a Spontaneous/Timed bilevel. This machine has the ability to provide Bilevel therapy with fixed IPAP and EPAP pressure and to trigger IPAP spontaneously or on at timed basis to maintain a set number of breaths per minute. This is the most rudimentary respiratory assist device with a timed backup rate rather than the more intelligent and adaptive pressures of ASV or iVAPS. If you have an interest in how different machines work, and the titration process to resolve different respiratory issues read the Resmed Sleep Titration Guide https://document.resmed.com/en-us/docume...er_eng.pdf

[ErElf]

Sleeprider - Thanks for the continued feedback.

I'll try the collar when it arrives. The physical tests described on the wiki for Positional Apnea do NOT seem to indicate that this is the problem at all. But, still seems highly possible as sleep is different than awake.

I'll also try to rig up my dash cam. May need to buy a bigger memory card. Unsure how well this will work but seems like it might provide good data. (fishfinderG I hope to have something to report in the coming days.)

As I have mentioned, I'm still really struggling to comfortably use the PAP, but slowly I seem to be adjusting. My early wakening has been an issue for years. And now that I'm seeing these event clusters on many of days where the PAP was well tolerated, seems to be worth some focus.

I appreciate the suggestion on adjusting the PAP limits, but will not go down that road yet. I see my sleep dr on 9/26. I expect the conversion to go like this:

Dr: How is your sleep with PAP?
Me: Sleep patterns and quality very much the same. Some new issues caused by PAP (discomfort, congestion, dry mouth, etc).
Dr: Okay, let's try it for a couple more months and see how it goes.
Me: Would you like to review the OSCAR data and my findings?
Dr: ??? (My guess is he will be thinking NO, but say something else.)

I am also wondering if we might have this conversation:

Dr: Your PAP compliance is not very good. You will need to use it more or insurance will take it back.
Me: I have used it EVERY night since I got it including during travel and camping.
Me: Seems like we need to figure out how to have it contribute to me sleeping and then my usage hours will go up.

[clownbell]

@ErElf -

First of all, congratulations on your commitment. That is so so important. Some folks throw in the towel, but not you. Excellent!!

Regarding the "compliance" conversation in the post above, please remember that you must use the machine an average 4 hours per night. Using it every night is important, and kudos for doing so, but it's the 4-house requirement that would be problematic.

There is one other possibility. I understand that you have pre-existing centrals indicated in your sleep study. You have probably read about "treatment-emergent" central apneas. My point is that your centrals MAY decrease to a baseline level when the treatment-emergent centrals go away. No guarantee, just a maybe. This is something to be watched.

Final item. The amount of time required to acclimate to cpap is pretty variable. A few lucky folks adapt from the first night. The other 99% of us take a while, some 2-3 months , some 6 months. So don't lose hope.

[ErElf]

clownbell - Thanks for the input. Yes, I have read about treatment-emergent centrals. And when I first thought about that, it made me feel like the PAP was making my sleep worse. But after seeing my OSCAR pattern described here (event cluster prior to wakening), I'm thinking perhaps that is not what is happening. They are actually part of my base sleep issue. Who knows? Who will ever know...

Anyway, I am losing hope of the PAP helping with my sleep. I will have 3 more weeks of OSCAR data to review before seeing my sleep doctor. I will keep the faith until then. I also hope to get more feedback from this forum. After that next appointment, though, I expect to create a new action plan.

For all the effort so far, it does not seem like much has been learned about my sleep problem other than it is breathing-related. Dr. has said it is OSA. Use an APAP. My sense is that that is TOO general a description to provide effective therapy. And, I do not see a path forward yet.

[ErElf]

In terms of usage hours, unclear how that will work out. Last night, for example, seems pretty typical for me. Mask on for ~3.5hours from 10:30p to 2a.


This night it seems my body hung in with the sleep for a bit longer, but I woke with a super dry mouth and very irritated rear-throat (in addition to the standard headache and general feeling like poop). I assume I had started mouth breathing and was thrashing around a bit (leaking) before waking. Here is the last half hour.


It took me almost 2 hours to recover enough to even feel like trying to sleep. The irritated throat was pretty bad and still has not recovered this morning. I did manage almost 3 more hours of (poor) sleep.

Anyway, there was no way I was strapping back into the PAP!