New Member Intro plus, no doubt elementary, question

[34south]

Thanks for a great forum!

I was diagnosed with severe OSA (30.1 API/hr) in November and have been using an APAP since November 25. I have been a Type 1 diabetic for forty years (currently well controlled with CGM) but have experienced debilitating daytime fatigue for the past fourteen years. As a result, by default, I was diagnosed with ME/CFS as I also suffer from chronic myalgia (for as long) and post-extertional malaise but I am not totally sold on that diagnosis as I suspect either my long-term diabetes or the long-term apnoea is more likely the cause.

It has been suggested by my endocrinologist, albeit not confirmed, that I may have the beginnings of autonomic neuropathy. I mention this due to the presence of central apnoeas, but perhaps my incidence is normal. I do have peripheral neuropathy though as well as the beginnings of osteoarthritis. This presents some discomfort at night which may contribute to restless sleep.

Despite all of this, I am upbeat and not obese and enjoy outdoor activities like flyfishing, camping and routinely go for brisk hour long walks with my dog every evening. I have been accepting of my physical discomfort, but the debilitating daytime fatigue is very disruptive. My API rate has fallen to around 2 since commencing with the APAP and I had my best night two nights ago. I also use SleepWatch which correlates well with the data from the APAP and the duration of deep sleep episodes, not its total, is what appears to have changed. However, and perhaps it is very early days, but the daytime fatigue continues to plague me. I do not dream, period, suggesting a lack of REM sleep. I was placed on low dose Yelate which helped but I discontinued it due to difficulty in waking in the mornings.

I attach my sleep analysis from my APAP for the last two nights simply because I wanted to ask why the pressure demand seems to increase only hours after going to sleep? Is this hormonal? My blood glucose has been within normal range during these nights. Heart rate dip seems to be key in ensuring improved sleep. Additionally, there is a narrowing but short-lived change to the amplitude of respiration almost consistently after 2am which seems strange. The APAP range set (5-20) seems perfect for me though.

   

[34south]

Just had a visit from the tech. Has adjusted my pressures to PMax 14.5 and PMin 4.5 to avoid potential leaks, which typically occurred if I did not seat the mask perfectly to avoid prolapse of the silicone flange on the mask. He was not particularly concerned about the centrals as their frequency was low and very likely not true events but more related to postural changes. The narrowing flow amplitude coincided with minimal obstruction, again likely due to a postural change. Another point worth mentioning is that I often crash before going to bed, meaning that my commencement on the APAP is often already long into my sleep cycle, thereby affecting the timing of pressure increases as morning approaches.

[staceyburke]

I would suggest you download (totally free) the OSCAR software at the top of the site then post a full nights sleep from you SD card that is in your machine. That is if you have a card (some machines do not come with one) or your machine will not give data. That is really the only way people on this site can make a judgement on what might help you.

[Sleeprider]

Stacey, the OSCAR software does not currently support the Prisma.

34South, I think the detail on your Prisma charts is hard to interpret, but your minimum pressure is clearly insufficient to get ahead of many of your obstructive events and RERA. Just as a rule of thumb, your minimum pressure should be within 3 cm of your 90% pressure. In addition, we like bilevel for RERA, snoring and flow limitation. If you have any exhale pressure relief, use it, but in conjunction with an increase in minimum pressure. Resolving leaks by lowering pressure and accepting more events seems like an odd way to solve a problem. It may lower the leak rate, but also therapy efficacy.

[34south]

Thank you for your prompt response and advice.

To confirm, no, unfortunately OSCAR does not yet support the Lowenstein Prisma units. This would have been ideal if it had as I am a Mac user and the Lowenstein PrismaTS software which I used to produce those charts (and made available on this forum) is, of course, a PC application.

The tech did suggest the changes as a trial with feedback in two days, but I take your point. The attached chart (from Lowenstein's online Prisma Journal utility) shows my 90 percentile pressures (in hPa, which is practically the same as cmH2O). The second attachment certainly shows that the highest occurrence of RERA, although low, is at 7 cmH2O suggesting, if I read you correctly, that it would make sense to increase the PMin to at least that level, but perhaps to as high as 10 cmH2O (admittedly still some distance away from your stipulated 3cm of maximum), and I will certainly query this with the tech. The reduction to 14.5 for PMax should cover the leak concern, although that is hardly occurring anyway, but it may allow me to loosen the straps to a more comfortable level perhaps.

I do use exhale pressure relief (Lowenstein calls it SoftPAP) which is currently set at the maximum level (exhalation relief with inhalation assistance). I had previously tried it at lower settings but found it uncomfortable.

   
   

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[34south]

Thanks, this seems a stock response and I do appreciate that Lowenstein is not used by many on this forum but it is not yet supported by OSCAR, which hopefully will change.

[Sleeprider]

I think the objective needs to be to comfortably get closer to that 90% pressure, and it looks like 7-8 cm is the sweet spot I would target. By getting the minimum closer to the optimum therapy pressure, we see less variation in pressure and lower peak pressure. Your pressure varies quite a bit from night to night, and I think you will see less variation as you close in on that optimum pressure. Less pressure variation tends to be less disruptive to sleep, resulting in few arousals and events. Finally, I would argue that starting off at a higher pressure can assist in establishing a better mask fit and pressure retention while you are awake, and this carries over to sleep.

We did have a developer from Germany that worked on the Prisma loader and had a working beta in the former Sleepyhead. Unfortunately, he did not stay with the development team due to personal issues. We hope that someone with the requisite interest in Lowenstein Prisma, C++ and QT development environment will pick up the project and make it happen.

[34south]

I think the objective needs to be to comfortably get closer to that 90% pressure, and it looks like 7-8 cm is the sweet spot I would target.  By getting the minimum closer to the optimum therapy pressure, we see less variation in pressure and lower peak pressure. Your pressure varies quite a bit from night to night, and I think you will see less variation as you close in on that optimum pressure.  Less pressure variation tends to be less disruptive to sleep, resulting in few arousals and events.  Finally, I would argue that starting off at a higher pressure can assist in establishing a better mask fit and pressure retention while you are awake, and this carries over to sleep.  

We did have a developer from Germany that worked on the Prisma loader and had a working beta in the former Sleepyhead. Unfortunately, he did not stay with the development team due to personal issues.  We hope that someone with the requisite interest in Lowenstein Prisma, C++ and QT development environment will pick up the project and make it happen.

Many thanks, makes good sense. Holding thumbs, especially for a Mac version!