Sorry for the delay. I maxed out my posts per day due to all the newbie UI questions and saying thanks to each reply. My limit is 15 posts. I had to wait until the day switched.
I'm not sure what time zone the forum uses to define a new day. I stayed awake and tried at 2am my local time but it was still rejecting my post. I gave in and went to bed.
I DID try @bonjour suggestion to set EPR= 0 but I was so tired I forgot to take my SDcard up to bed.
----------------------------------
Here's my total sleep-related history. Sorry for the lengthy tome.
I have been feeling fatigued during the daytime for over a decade... maybe even two decades. I can't remember waking up feeling "bright eyed and bushy tailed" for at least 2 decades.
I have spent a lot of my adult life living alone and therefore do not usually have someone to observe my sleep and notice if I snore or stop breathing or twitch my legs or talk in my sleep etc.
In 2011, my partner at the time told me I stop breathing in the night and was scared by it. This gave me the evidence and the prompt I needed to find out what that might mean.
My general doctor at the time was not very attentive to details. His standard protocol seemed to be to offer sleeping pills or anti-depressants or pain-killers or antibiotics for any and all ailments and not much else.
After I said I had heard about this "Apnea thing" he referred me for a sleep study.
When I went for the sleep study in 2011 I had poor sleep efficiency (60%) and we never got a chance to attempt titration because I did not get enough sleep to allow apneas to manifest until it was too late to do anything else that night. For example, I did not reach Stage-3 or Stage-4 sleep in that first study.
Nevertheless, we DID detect a rate of AHI=12 with a lowest O2 saturation of 87%. This was primarily Hypopneas with a few OAs and CAs sprinkled in. Anything over 5 (or 10) qualifies as a diagnosis in the States.
The recommendation was to try a second sleep study using a sleeping pill with the hope that titration may be possible on the second study.
Question: doesn't a sleeping pill alter your sleep patterns and therefore risk biasing the sleep test? Has anyone seen any research on this?
My sleep efficiency was better but only "fair" in the second study (76%). The lowest O2 saturation was 81% which was worse than the first study. I can't tell easily from the reports if the apnea counts were pre-titration or during titration. I suspect they may have been during titration because the OAs were zero in some of those tables but the CAs and Mixed and Hypopneas were non-zero.
The worst aspect of the titration attempt is that they only tried me with a nasal mask. I did not know anything about apnea at the time and never knew to question that decision.
It turns out that I am a mouth-breather and that I was suffering from undiagnosed deviated septum and enlarged turbinates at the time of these studies. I should have been using a full face mask but the Lab people never even mentioned that they exist.
Needless to say, the titration attempt was shockingly bad. The air was being forced up my nose and coming straight out of my mouth as I gasped for air trying to breathe.
We did manage to do some initial titration tests but I abandoned the study at 4am because I simply could not breathe and certainly couldn't sleep properly. I felt like someone was trying to water-board me.
Once again, I did not reach Stage-3 or Stage-4 sleep according to the second report.
That was in 2011 and that marked the end of my passing superficial interest in the world of apnea!
In the intervening years, I have been getting various conditions (finally) diagnosed and (finally) treated and they are now under control via drugs &/or surgery.
The deviated septum has been "fixed" and the turbinates have been reduced slightly. Nevertheless I still have "narrow nasal passages" even after the surgery and they tend to close up partially (and sometimes almost completely) when I lie down. This explains why I continue to be a mouth-breather. I wondered about having a more aggressive turbinate reduction performed but I don't want to risk going anywhere near "empty nose syndrome".
So now fast forward to 2019
I am in the American medical insurance game and it just so happens that I have maxed-out my out-of-pocket payments for the year.
For the benefit of people unfamiliar with the US medical system, this basically means that any medical procedures I have before year end are effectively "free" for me. If I let them slip into January 2020 I will need to pay for them in full. It's an unusual system for anyone coming from a State-funded system.
Once I transitioned into the "everything is free" stage I decided to revisit some of my neglected health issues to try to get them sorted out in the final few months of 2019.
This led me to revisit the apnea situation.
I now have a very flexible and responsive sleep doctor who is willing to do anything and prescribe anything if I ask for it. They don't spontaneously volunteer much... but if I ask.. they tend to agree to it.
The two earlier sleep studies were poor quality due to sleep inefficiency but they were sufficient to diagnose (at least) Obstructive Sleep Apnea. I therefore was fast-tracked into a prescription for a Resmed Airsense 10 Autoset APAP without further testing. The machine was totally free for me (for the reasons explained earlier) and I now own it outright.
As I began to use it in October, I noticed that my OAs dropped to an insignificant level from whatever baseline those two prior studies think they measured.
As you can see in my earlier posts, the whole issue of CAs began to emerge. My questions became... are these treatment-induced? Will they spontaneously resolve themselves over time? Do settings need to be tweaked to make that happen or will it "just happen automatically" as I acclimatize to the PAP treatment over the first few months?
From a financial perspective, there is another question... can I get to the bottom of this before year-end while everything is free?
As I said, my sleep doctor is very helpful and lent me an ASV machine just to see if that could work for my CAs. The answer is.. YES it does work and it reduces my AHI to zero (actually 0.2) based on a one week trial. See my earlier summary graph showing the three time-zones APAP-ASV-APAP in post #17 for confirmation of that.
The doctor also sent me for an echo-cardiogram to give me a full heart analysis to make sure that I am not in the at-risk group where ASV treatment is contra-indicated. It turns out that I am not in the at-risk group and my heart appears generally normal. So that's nice to know. Left ventricle ejection fractions are fine. I can get the numbers if you care.
Now, if it were not for this artificial time constraint of trying to get answers by year end for financial reasons.... a more sensible approach would be to play with the APAP for a few months to see if we can resolve any treatment-induced CAs before rushing into ASV unnecessarily.
However, for a while, it looked like I might also be able to get a free ASV machine in addition to the free APAP machine because that would represent a new treatment modality and so BOTH prescriptions would be covered for free by my insurance.
So my doctor went ahead and prescribed an ASV for me even though the question of treatment-induced CAs is not fully answered.
However, it turns out that the insurance scheme will only allow me to RENT an ASV machine (not buy one) and the monthly rentals would be astronomical come January 2020 when I would be paying for them out of my own pocket.
I reently bought a used ASV machine on the internet instead for the same price as six weeks rental.
So that brings us right up to today.
I now own two machines but I only want to use the ASV if it becomes absolutely necessary because we cannot get the (treatment-induced?) CAs to zero using the APAP.
I mentioned to my sleep doctor that those earlier two sleep studies are not what I consider to be "reliable" baselines because of all the sleep efficiency issues. Once again the doctor was more than accommodating and has scheduled me for a NEW sleep study to try to get a more accurate baseline. This will happen in December and will therefore be free so I have nothing to lose by trying it.
I am not convinced that my sleep efficiency will be any better in this new sleep test.. but I may as well try it and hope for the best. The worst case scenario is that I will have yet another inconclusive study at no cost to me.
Hopefully this explains why I have two machines and why I am NOT using the ASV yet (except for that one week trial). I want to fully exhaust all avenues using the APAP and make sure that these CAs are not simply treatment-induced and might therefore be resolvable with minor adjustments and acclimatization to the APAP.
Hopefully that all makes sense.
When I get the results from the THIRD sleep test I hope to have a better idea about whether my baseline does or does not have significant chronic CAs and whether I am currently simply seeing a bunch of treatment-induced CAs.
In the meantime, all I can do is use the "best-guess analysis" using the data from the worst CA night todate and try to figure it out. Did anyone think my analysis was in the ballpark?
One final fly in the ointment... I live at 5000 feet altitude but I have lived here for 20 years.
If I had altitude-induced CAs 20 years ago, couldn't I have acclimatized by now? I'm not sure how that works. Some people tell me that altitude CAs can resolve after a few months at this kind of intermediate altitude. Other people say they don't resolve by acclimatization and you need to move to sea-level. Any peer-reviewed studies saying how long altitude-induced CAs last would be appreciated.
I saw one paper that also suggested that supplemental oxygen may be an option too for some people. However the cohort in that study was focusing on people with known heart problems so I'm not sure how that relates to the general population.
https://emedicine.medscape.com/article/3...eatment#d9
So here is my plan at present..
1) Stay with the APAP and see if I can tweak the CAs away (hoping that they are treatment-induced)
2) Get the THIRD sleep test to get a better handle on my true baseline and see if any CAs are detected or not without titration.
3) Use the ASV if I am forced to
4) Sell the ASV if I get success with the APAP tweaks.
So now you see why I was interested in your responses to my "cold call" data without explaining all this confusion related to quasi-reliable sleep tests and altitude.
Most of you suspected treatment-induced CAs.
That's what I was hoping you'd say but I didn't want to influence your responses.
I also know why you preferred to see the sleep studies, but I knew they would introduce a lot of uncertainty that (hopefully) will be better answered by the THIRD study which is coming up later in December.
Phew! Is anyone still awake?
Now to answer explicitly the questions you asked me earlier. Hopefully I won't miss any.
@joeywallaby
I think your questions are answered in the above tome.
Thanks for those reference links
@opalrose
I think your questions are answered in the above tome.
Thanks for the UI help for a newbie who is trying to get up three learning curves at the same time.
I never did find that Chenes-Stoke option.
@bonjour
That said, do you know why you have central apnea?
Any cardiac issues?
Breathing issues other than sleep apnea?
neuro-muscular disorders?
Strokes or Seizures?
Brain injuries?
Drugs, either prescription or recreational?
The goal here is to eliminate possible causes.
Answer: NO to all the above.
I do have some anomalies in my brain MRIs (I've had three MRIs in 6 years) but they seem to be either congenital or possibly mini strokes (minor ischemic events) They have not enlarged or progressed over the past 6 years as measured by repeat MRIs. None of the Docs are concerned by these anomalies so I'm not concerned either.
I do take many medications but none that are hypnotics or opiates or anti-depressants etc. so nothing to easily explain CAs. However most drugs on the market mention fatigue as a related side-effect in their studies. That just adds another another moving part into the system.
One comment on tweaking my settings..
I am trying to cooperate with my sleep doctor and the technician who is monitoring my data for me.
I don’t want to change any settings until I’ve brought them into the loop out of respect for their profession.
Having said that, they are currently monitoring my data using the Resmed software that relies on modem data trasfer. We do not pass SDcards back and forth. I believe that the modem data does NOT transfer the detailed breath-by-breath data that I can see in Oscar. Therefore their monitoring and analysis cannot possibly draw any conclusions that rely on seeing that detailed data.
It’s interesting that the technician said that the CAs may "spontaneously resolve after a couple of months" but he did not mention that tweaks may be necessary to achieve this.
In my next phone call with him I will subtly mention any suggestions you offer and try to get him to buy into the changes without me just "going it alone" and risking losing his support and cooperation.
To summarize… your suggestions and observations were..
@bonjour Set your EPR= 0
I should be fine to do that because it’s a user option to set “Pressure Relief” to “Off”. That should not offend the technician. However, it will be hard to see a clear before and after comparison because, if you look at the summary I posted in post #17, my CAs are already quite low on some nights without changing ANY settings. Indeed, the last 6 nights have been very low indeed. (By that I mean approx 2.0 as opposed to the 32.7 I used for the initial set of graphs). Predictably unpredictable?
@sarcasticdave94 APAP is set to wide open 4-20
That’s because that’s how the technician set it up (presumably using a set of titration defaults).
If you have some other suggestions please let me know what they are and why you believe they may work and I’ll suggest them to the technician. I prefer to make the suggestion to him and let him agree first. That will also prevent him (or his software system) resetting me back to his initial settings via modem once he/it sees that the patient is playing around with the settings.
At some point I may need to cut loose from the Sleep Technician umbilical but not yet. They have been incredibly helpful and supportive so far and have prescribed me anything I’ve asked for. I want to keep them on my side if I can.
Finally... the two redacted sleep reports will be in the next few posts. There are many pages. I think I can only upload three at a time. We'll see.
Thanks enormously for all your responses and helpful suggestions.
