[Symptoms] Sudden onset of symptoms?

[onsonby]

I'm wondering if the following is describing apnea.

About four weeks ago -- I can pinpoint the precise day it all started -- with no other obvious changes in my circumstances, I suddenly developed the following daytime symptoms, similar to what I've experienced occasionally if I fly a red-eye internationally and don't get any sleep for 36+ hours:

1. Intense (I mean *intense*) fatigue
   
2. Presyncope (dizziness or lightheadedness)
   
3. Constant yawning (dyspnea?) every coupe of minutes
   
4. Bradycardia (low heart rate)
   
5. General feeling of weakness
   
6. Little bit of occasional nausea
   

It has all lasted now for about four weeks. The intensity varies. Best times all I have is the lightheadedness, and it's mild. Worst times I feel like death warmed up.

Other information that may be material:

• I'm male
  
• Age late 40's
  
• Obese: BMI>40
  
• I have recently been cleared of any problems with diabetes, kidney failure, blood clots, low testosterone
  

However, here's perhaps the most important information. I already know I have sleep apnea. I was diagnosed a couple of years ago: severe OSA with untreated AHI of 94. And I had that confirmed (but slightly improved down to 80 probably because I lost a chunk of weight) earlier this year. I have a CPAP. I admit my compliance isn't great -- my mask(s) and I wage a nightly war of attrition on each other -- but I'm working on it. But crucially, there has been no change in my CPAP use at or around my sudden symptoms. I didn't begin to use it more; I didn't begin to use it less. They didn't change the pressure; I'm on the same mask. I haven't changed *anything* in any aspect of my lifestyle -- CPAP, diet, exercise, meds, *nothing*.

Last point: apnea aside, the most immediate suspect of my concurrent symptoms, is something cardiac-ish. And my GP and I are on that. But, via a cardiologist, we're almost completely through a set of tests and they're all coming up clear. I've had two good EKGs, and a good nuclear stress test. Next is an echocardio, but it's looking unlikely.

So, is it simply my apnea?
If so, any ideas what could have made the symptoms appear so suddenly, when other than these four weeks I've felt pretty normal?

[jgjones1972]

Hi onsonby and



First, and it goes without saying, you should definitely keep working with your doc to make sure something else isn't causing these symptoms. That being said, I do think it could just be the Apnea (I'm not a doctor). I'm just using my personal experience as a guide because my worst symptoms seemed to hit me all of a sudden also and some of those symptoms are the ones you listed. According to your profile you are on a set, constant pressure and I'm thinking the pressure needed to overcome obstructions may have increased - this has a tendency to happen as we get older or for several other reasons. Pressure needs may also increase due to other obstructive issues so a visit with a good ENT might be in order as well. Under other circumstances I would probably recommend talking to your doc about getting an Auto CPAP to find the right pressure, but since your current pressure is already toward the top end of what a standard Auto CPAP can provide it looks like a lab titration is probably necessary and you might have to move on to a Bi-PAP (they can deliver higher pressure).

[onsonby]

Thanks jg. You're right that in general the pressure is an issue. My original sleep study involved two titrations because although the first attempt, with CPAP, cured my obstructives, it introduced some centrals. So the doc eventually set me up on a BIPAP (not sure if it was Bi-Level or Auto-Bi-Level, my machine does both), and that seemed to fix the whole thing. Settings then were: E=10, I=20. However, despite trying a few masks, the thing was blowing my head off, so she pulled it down to E=8, I=15, to help with compliance.

However, for various reasons, I moved to a new sleep doctor, near my home. My aim was simply to get some help with my ongoing mask issues, but he insisted on also doing a new polysom. As a result, he said I didn't need BIPAP and he changed me to CPAP at 19. That meant I was back up almost at my original BIPAP I pressure, and without even the benefit of the lower E side pressure to ease things. Further experience with him has shown he is scatter-brained, doesn't pay attention to details, and disorganized to the point of making errors, and I no longer trust him. So I'm considering moving to another doc. But in the meantime, I'm going to ask my machine provider if they can simply revert me back to the original docs 8:15 settings which, although not perfect were *way* better than the current setting. The CPAP of 19 is very strong. Last night I was trying out a gel nose bridge, and it ended up flapping up and down across my eyeballs like a humming bird was sitting there!

Of course, all that said, I doubt any of it is specifically a component in my current woes. The change in machine settings happened almost six months ago. My sudden fatigue began only four Wednesdays ago.

One question on getting my machine settings changed though. I notice that as well as CPAP, my machine can also do Bi-Level and Auto-Bi-Level. My understanding is that while Bi-Level is two fixed pressures (one in, one out), Auto-Bi-Level is two *maximum* pressures (again, one in, one out). If that's right, any idea why one would ever choose the first of those? If Auto-Bi-Level is available, can't it provide everything the simpler Bi-Level can and more?

[trish6hundred]

Hi onsonby,
WELCOME! to the forum.!
Hopefully you can find a good sleep Dr.
Hang in there for more responses to your questions and best of luck to you.

[onsonby]

Oops, should also have included:

• I have recently been cleared of any problems with diabetes, kidney failure, blood clots, low testosterone, and any thyroid problems
  

[jgjones1972]

Sounds like mask issues could be the root of all the problems. A leaky mask at high pressures is intolerable - if you can get the leaks under control the high pressures aren't that bad once you acclimate and Centrals usually subside. Setting to Bi-Level might help alleviate hyperventilation and the discomfort of exhaling against pressure (both usually go away on their own with time); however, having quite a bit of experience with the Quattro FX Full Face Mask, I can tell you that it will be extremely difficult (maybe impossible) to get the leaks under control with pressure changes of more than 5 or 6 CmH2O. I don't know of any FFM that can handle big pressure changes without leaking horribly (maybe someone else can give suggestions).

With pressure set at constant 19, just how bad are your leaks? Bad leaks could be undermining therapy - could be the case that leaving the pressure where it is and getting leaks under control takes care of things. Mask should "seal" against face with silicone cushion inflated. The only air escaping should be the air blowing out of the ventilation ports on the front of the mask. If you are unable to accomplish this, then the therapy is compromised and extremely uncomfortable.

If you think the mask issues are the root of the problem, then I and several others can offer quite a bit of tips, tricks and advice on trying to get it under control.

[onsonby]

Sounds like mask issues could be the root of all the problems.

jg, I wish I could convince myself of that. Rather that than I find I've a brain tumor or something! But I'm finding it hard to believe that this is an apnea simply because of the sudden onset but without any change in mask/machine/anything to explain it. Until about four weeks ago, I had little or no subjective symptoms of apnea -- or at very least, I was so used to them I'd just accommodated. But then BANG!, four weeks ago *something changed*.

HOWEVER, no matter what this current thing ends up being, I think I do need to fix my general mask and compliance problem anyway. I don't want to derail this thread in case someone else can come up with some ideas on whether these recent acute symptoms could be OSA-related, so I'll go start another thread on that because I definitely would like your advice.

thanks!

[Shastzi]

I see that the Philips Respironics System One 750P is an Auto Bi-PAP.
Are you using it in the auto mode?
That way the machine will find and float you at the best pressure during the night and also
minimize the pressure effects.
Nailing the mask leaks down is vital.
I wipe the sealing surface off with Wet Ones and then do the same with my face just before putting the mask on.
I run an APAP set on low=14 high = 20.
The machine runs the pressure up and down as needed during the night so I dont end up with as many side effects.
Fewer CA events as well.
When I burp a lot in the morning I know I have visited a few high spots though. (SleepHead verifies all this)
Your machine has the capability to function as an APAP and I think it is worth a try if you aren't doing it already.
Hang in there & Best of Luck!

[vsheline]

About four weeks ago -- I can pinpoint the precise day it all started -- with no other obvious changes in my circumstances, I suddenly developed the following daytime symptoms, similar to what I've experienced occasionally if I fly a red-eye internationally and don't get any sleep for 36+ hours:

1. Intense (I mean *intense*) fatigue
   
2. Presyncope (dizziness or lightheadedness)
   
3. Constant yawning (dyspnea?) every coupe of minutes
   
4. Bradycardia (low heart rate)
   
5. General feeling of weakness
   
6. Little bit of occasional nausea
   

It has all lasted now for about four weeks. The intensity varies. Best times all I have is the lightheadedness, and it's mild. Worst times I feel like death warmed up.
... there has been no change in my CPAP use at or around my sudden symptoms. I didn't begin to use it more; I didn't begin to use it less. They didn't change the pressure; I'm on the same mask. I haven't changed *anything* in any aspect of my lifestyle -- CPAP, diet, exercise, meds, *nothing*.

Hi onsonby, welcome to the forum!

I wonder if you are suffering from exposure to mold spores. I suggest it is a good idea to buy a CPAP hose brush and clean/soak the hose at least monthly using Control III Disinfectant. It is important to keep the hose very clean/dry, and it is a good idea to replace the hose every 6 months or so, especially if this is covered by your insurance. (Also, non-heated hoses are very inexpensive on line.) If you do not dump the water every morning, I would suggest at least removing the water chamber each day from the machine, so the machine and hose will not stay damp during the day. Use only distilled water so there are no nutrients in the water to feed mold, or else clean water chamber more often. If there is any hint of rainout in the hose, disconnect it from the machine and hang it to dry completely.

I also use the hypoallergenic filters and change monthly, and keep my machine well off the floor so the air will have less dust in it to start with. Any dust which gets past the filter(s) can feed mold.

One question on getting my machine settings changed though. I notice that as well as CPAP, my machine can also do Bi-Level and Auto-Bi-Level. My understanding is that while Bi-Level is two fixed pressures (one in, one out), Auto-Bi-Level is two *maximum* pressures (again, one in, one out). If that's right, any idea why one would ever choose the first of those? If Auto-Bi-Level is available, can't it provide everything the simpler Bi-Level can and more?

Here is a link to the current PRS1 comparison guide:
http://www.healthcare.philips.com/asset....-guide.pdf

The straight BiPAP mode would allow compatibility with the more basic (non-Auto) BiPAP machine, which would be useful, for example, to allow a provider to revert to an older prescription (if needed) without needing to replace the machine.

On model DS760 (which I think would be like yours except compatible with the new heated hose option) in Auto BiPAP mode the EPAP can be set to a range and will self adjust to minimize Snore and Flow Limitation and obstructive apneas. The Pressure Support can also be set to a range and will self-adjust (very slowly, not breath-to-breath like in an ASV machine) to minimize obstructive hypopneas and perhaps RERAs (Respiratory Effort Related Arousals).

Below is a description of how Bi-Flex worked on the older "BiPAP Auto M Series with Bi-Flex" machine, which I think would still apply to your newer BiPAP Auto machine, but not to a non-Auto BiPAP machine which does not allow the PS to self-adjust.
http://bipapautomseries.respironics.com

Take care,
--- Vaughn