Seeing more UA and CA - due to being sick or AFIB med?

[Walla Walla]

I think I'd be looking somewhere else for a second opinion and maybe a new Doctor.

[Sleeprider]

The BiPAP is working better for you in several respects as compared to CPAP. Most of the time, your respiration looks much better now, and you have fewer events. You have a physical or positional obstructive issue, and have decided to use an ergonomic pillow to address it rather than a soft cervical collar. That is a choice that I think will be less consistent in effectiveness, but it's your choice to make. There are very inexpensive non-dental devices that you could try to see if restraining your tongue at night makes a difference. Your O2 desaturation last night got your attention, but it was very brief, and you should not over-react to it. Your event rate is within reason considering the last two nights, and one higher night does not mean failure.

If we look back at your results from February 12 or 15 in this thread as compared to this, you're doing much better now. Therapy appears to be working better with the increased pressure support. Your 95% EPAP pressures have not changed very much but the median is much lower on BiPAP and you seem to have less flow limited breathing. Just a couple observations; your events are always associated with leaks, probably from a change in position, and the events do not respond to increases in pressure. You have taken your dentist's assessment of your tongue size and drawn what I think is an incorrect conclusion. You may want to reconsider a soft, properly sized C-collar. BTW, it will work best with a thinner, non-ergonomic pillow if you want to try again, and if you really think your tongue is falling back into your throat, try a cheap tongue restrainer, and see what happens.

[MyronH]

Thanks for all the help. I appreciate it. I can try the collar I have again tonight. But last time I tried it, it didn't seem to make a difference.

Not sure if a tongue retaining device would fit inside my full mask but I can look into it and try one.

My dentist did clearly show me images that showed I have a small mouth with large tongue and small throat opening. Which is why he mentioned an appliance. Plus he wants to make money to I assume.

I just want a doctor to be honest. Telling me I had zero events when I showed them sleepy head made me upset.

So should I continue to try the BiPAP?

[Sleeprider]

BiPAP is significantly reducing your event rate. I can't imagine why you would not use it. I forgot you are using a FFM, so I don't know if any of the oral appliances will work with that. Did you ever try a nasal therapy like nasal pillows, or are you an incorrigible mouth-breather?

[MyronH]

BiPAP is significantly reducing your event rate. I can't imagine why you would not use it.  I forgot you are using a FFM, so I don't know if any of the oral appliances will work with that.  Did you ever try a nasal therapy like nasal pillows, or are you an incorrigible mouth-breather?

I am a mouth breather yes, but use a chin strap to try and stop that. I had picked a FFM from the start since I'm a mouth breather. Never tried nasal pillows, but may need to try them. Although if this is positional and my head dipping forward into my neck, those wont help either.

You did say "the events do not respond to increases in pressure", which is true. More pressure doesn't seem to help clear my airway. So what exactly is blocking my airway then?

I went to the dentist, stayed most of the day there as they had to do a cleaning and then take impressions for the dental appliance. I AM DESPERATE to get this resolved quickly, as it is affecting me mentally and physically. Even though my AHI <5, the events I have are long, up to 46 second so far.

The only reason my O2 only dropped for short time, is that my SPO2 monitor alerm went off waking me up. No telling if the events would have been longer, if I wasn't woken up.

Tonight, I'm sleeping on my recliner, reclined back 45 degrees, and going to use cervical neck collar.

[MyronH]

Okay this is interesting. I had (2) sleep studies with this same doctor. I'm losing faith in this sleep doctor.

The sleep study I had back in Nov 2017 says the following:
"A BIPAP titration was performed due to difficulty due to difficulty tolerating CPAP at any pressure utilizing multiple masks."

I never told them I couldn't tolerate CPAP/APAP, so not sure why they would think that. 

"CPAP compliance data over the last 30 nights , indicates the percent of nights use greater then 4 hours was 97%, there were NO OBSTRUCTIVE respiratory events with some leaks"

No Obstructive at all? If I go back into sleepyHead to Nov 2017, and Oct 2017, it definitely does show OA events during most nights. My AHI was always <5, but definitely there were OA/UA/CA events of some kind every night.

Now to my 2018 Sleep Study:
"EEG confirmed total sleep time 399min with poor sleep effciency of 73.2%. Sleep onset:25min, REM latency: 0min, Arousal Index: 19.5 arousals/hour."

So wait...I still had 19.5 arousals/hour during the study on CPAP/APAP? So if that is true, why doesn't he believe me I have events at home, when I gave him the sleepyHead charts?

"CPAP titration was initated per protocol at starting pressure of 6cm and titrated to 12cm. CPAP failed to eliminate respiratory events".
"BIPAP was initated at 14/10 and titrated to final pressure of 16/12. The most approriate setting is 14/10cm. At this pressure AHI was 0. RDI was 0. Arousal Index was 0. Sleep effciency 98.3%, SpO2 93%."

If the most appropriate setting is 14/10, then why did he recommend and set my machine to IPAP 16, EPAP 4, PS 4?

[Sleeprider]

That is a bunch of good questions. What's wild is you seemed to do pretty good at the low pressures. Want to try Vauto mode with EPAP min 9, PS 4 and IPAP max 16?

Your doctor is taking a sleep study performed by a technician to protocol methods, and repeating the results, the prescribing something wildly different. That's pretty much what you have. We don't know why he departs from the titration recommendation, and he doesn't discuss it.

[MyronH]

Tonight, I slept on my recliner, reclined back all the way. Wore a cervical collar loosely to prevent chin dropping. This prevented leaks, and I had less OA, but a lot more CA. Laying in recliner also seemed to resolve my O2 dropping issues. But....

Another new issue happened last night.....
My heart rate kept jumping up to 120+bpm. I would wake up with a weird warm feeling throughout my arms and legs. My HR already was starting to climb, but when I moved my legs or arms to stretch or just reposition a bit, my HR shot up 120+bpm. Then once I was awake for 5-10min, it went back down to normal. And when awake, everything was okay again. HR went back to normal and stayed there, even when i moved around in my recliner. This happened multiple times last night, waking me up.

I'm not sure what to make of this but I see my Electrophysiologist today. In the past, before I started CPAP therapy, I had some issues like this when sleeping in bed. I'd move from my side to back, and all of a sudden my HR shot up to 120+bpm.

I had no events during the times my HR shot up.
Thoughts?

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[Sleeprider]

Your respiratory rate follows your pulse rate and the CA events were created by hyper-ventilation. This looks like a panic attack or similar anxiety. I would encourage you to investigate this with your medical team, but I don't think the CPAP is a root-cause. Suffice to say, your results look excellent with the positional therapy, but a closer look at your respiratory rate at 23:45 might be interesting. That is a very sudden increase in respiratory rate for no apparent reason, and as you see, the heart rate effectively doubles.

Finding an explanation for this would be a a relief for you, but a heart rate of 120 is not particularly bad by itself. Unexplained heart rate increases over 100 bpm without physical exertion meets the definition of tachycardia.

[MyronH]

Here are a couple close-ups during that time. Looks like i did have increased respiratory, but I didn't feel like I was hyper-ventilating. At least not, when i was awake. 

I just came back from an appt. with my electrophysicologist. He wants to implant an ICD in me to monitor me for awhile. He says the ICD would show him the very start of the events, and should give more data on what is triggering them. They will call me to schedule the implant.

In the past, my doctors thought this was "anxiety/panic disorder", and in the past I was on medicine they tried. Also tried Melatonin and other sleep aids, but they didn't seem to work. 

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