Lingering fatigue: NHS unable to help

[gouravverma]

Dear All, 

I have searched over and after that I discovered this thread. I am also sailing in a comparable situation (as "gcritchley") with day time tiredness even after great AHI numbers.

Prior I was on Bipap Auto - oversold to me as I might suspect CPAP could have done the trick to meet my necessities. After moving to UK I counseled NHS where I have been set up on (CPAP)Airsense 10 auto set. With the utilization of CPAP I feel there is sudden transformation during around  4:00 PM and I begin feeling tired. I attempted with all the blood tests and all the results are within range. I have attempted various solutions however no karma with my tiredness. I tried to disclose this to my NHS however every time I got an answer that all my numbers appears to be great. 

I am truly depressed and not certain how to discover the answer for my concern. It would be ideal if you help, I am available to any proposals

[Moderator Note: This thread was split from http://www.apneaboard.com/forums/Thread-...eep-report as it is a new therapy thread by a different member ]

[Sleeprider]

Gouravverma, I split your post into a new thread because it is confusing for us to try to replay to more than one individual in a therapy thread. Your problems and discomfort arise from a different set of issues than Gritchley, who is using an ASV machine. I think the solution to your fatigue is pretty simple, and it begins and ends with flow limitations that are prevalent in your charts, and confirmed by the close-ups of the flow rate chart.

We have several wikis that deal with flow limitation, and you might want to take a look at the Optimizing Therapy link in my signature. Pay particular attention to the section on Positional Apnea as there is some indication your events are clustered and might be the result of chin-tucking. At a pressure range of 4-20 with EPR at 2, your events are mainly obstructive, and distributed between hypopnea and OA. Your median pressure is 8.5 to 9.0, so we can quickly conclude your minimum pressure of 4.0 is far too low, and because you require much higher pressure, the pressure changes are more disruptive as they cover a large range. I try to keep pressure fluctuations to less than 4-cm and for myself, pressure fluctuation rarely exceeds 2-cm through the entire night. Auto CPAP is a wonderful thing, but it needs to be optimized for comfort, effectiveness and to avoid disruption.

I think you will notice a positive change if you change your settings to a minimum pressure of 8.0 and increase EPR to 3. This will do four things; it will optimize your minimum pressure, it may reduce your flow limitations and hypopnea with EPR, it will better prevent obstructive apnea by raising the minimum pressure, and it will allow the EPR to be effective throughout the pressure range. I think in addition, it will reduce the maximum pressure you experience, and will reduce the amount of pressure fluctuation through the night. If you try this and post back, we can reevaluate the possibility of positional apnea and see if you are benefiting from a comfort standpoint. I should add your respiratory statistics are very good with a strong tidal volume, normal respiration rates and everything else normal. I think if we can address the pressure and flow limitation issues, you will do quite well with the therapy.

[gouravverma]

Gouravverma, I split your post into a new thread because it is confusing for us to try to replay to more than one individual in a therapy thread.  Your problems and discomfort arise from a different set of issues than Gritchley, who is using an ASV machine.  I think the solution to your fatigue is pretty simple, and it begins and ends with flow limitations that are prevalent in your charts, and confirmed by the close-ups of the flow rate chart.  

We have several wikis that deal with flow limitation, and you might want to take a look at the Optimizing Therapy link in my signature. Pay particular attention to the section on Positional Apnea as there is some indication your events are clustered and might be the result of chin-tucking.  At a pressure range of 4-20 with EPR at 2, your events are mainly obstructive, and distributed between hypopnea and OA. Your median pressure is 8.5 to 9.0, so we can quickly conclude your minimum pressure of 4.0 is far too low, and because you require much higher pressure, the pressure changes are more disruptive as they cover a large range.  I try to keep pressure fluctuations to less than 4-cm and for myself, pressure fluctuation rarely exceeds 2-cm through the entire night.  Auto CPAP is a wonderful thing, but it needs to be optimized for comfort, effectiveness and to avoid disruption.  

I think you will notice a positive change if you change your settings to a minimum pressure of 8.0 and increase EPR to 3.  This will do four things; it will optimize your minimum pressure, it may reduce your flow limitations and hypopnea with EPR, it will better prevent obstructive apnea by raising the minimum pressure, and it will allow the EPR to be effective throughout the pressure range.  I think in addition, it will reduce the maximum pressure you experience, and will reduce the amount of pressure fluctuation through the night.  If you try this and post back, we can reevaluate the possibility of positional apnea and see if you are benefiting from a comfort standpoint.  I should add your respiratory statistics are very good with a strong tidal volume, normal respiration rates and everything else normal.  I think if we can address the pressure and flow limitation issues, you will do quite well with the therapy.

Thanks Sleeprider for you help and advice. 

I have made the changes as suggested. Please refer attached report with the new configurations for today. Even yesterday also I slept with the new changes but the time in sleep was pretty less (close to 4 hours) there was a transformation yesterday in the day around 2:00 PM where I felt a sudden transformation and i can feel my body is becoming more lethargic and my brain is getting faded due it instant fatigue, headache started all of which got relived after sleeping today.

In today's report i can see there is one unclassified apnea where there is a gap of 2 minutes. Not sure why it happened like that, even there are no values for pressure. 

Please advice the next step.

[Sleeprider]

The revised settings seems to have reduced both events and flow limitations. It looks considerably better, but I don't know what is going on in that data-gap, and the breathing in that close-up is flow limited. I think it is notable that your median, 95% and maximum pressure is lower with the increased pressure support and higher minimum pressure. There is a bit of improvement in tidal volume and other metrics as well. I think we can hold at these settings until we see how it averages out, then make any further changes. I am under the impression you would do well with bilevel, but your results are looking much better now.

[gouravverma]

Hi Sleeprider,

I have changed the settings as suggested by you. I have started using chin strap from last 5 days i.e. from 28th Aug even then I dont wake up fresh and there is a sudden transformation that happens during day time which makes me lethargic. I am young (39 years old) and not too obese still trying to figure our sweet spot on pap which will make me energetic like all my other mates. 

For your review, I have attached the day-wise sleep report from Oscar. Please help

Regards
Gourav `

[gouravverma]

Added more attachments. Please help.

[sheepless]

first things first. your leaks are too much for the machine at times. for example, you can see the machine flags ua when big leaks make it impossible to distinguish oa from ca. gotta those leaks under control. there's a mask wiki to read and it's one of the most discussed topics on the forum to search. you have minor clumping of events that a soft cervical collar or neck wedge might help.

[gouravverma]

Thanks Sheepless for your valuable feedback. I will try with a cervical collar and come back. In meanwhile just want to ask other GURUS what they suggest based on my sleep data.

[mper6794]

Hi, Gourverama
very far way from this intimidating thing guru, I could eventually add some contribution on your most recent charts, or alternatively, August 31th. You might know, I am particularly interested in learnings from threads with FL (and PLM's) issues, which have to do with my case.
I was wondering if could post full night chart and some 10mi-windows (running through contrasts, particularly including low to higher flow rates strectches, organizing chart and scales like this, top downward (Pressure, FR-120 to120, FL-compressed, Tidal Volume (max 1000, with median reference line; essential), and leak.
good luck

[Dormeo]

Always worth asking: what medications if any are you taking?