[Treatment] Still fatigued, history, are these CAs real?

[GuyScharf]

I started APAP therapy about two years ago.  My problems at the time were falling asleep whenever I sat down to watch TV, read a book, and a risk (didn't happen) of falling asleep when driving.  Plus, I slept a lot.  APAP therapy immediately resolved those issues so I consider the therapy very successful from that viewpoint.  Plus I am able to sleep through the night without having to go to the bathroom every three or four hours as before.

I was pretty sure the problem was sleep apnea so I just asked my PCP to prescribe the necessary tests and later write an Rx for the AutoSet for Her.  That all worked well.  But I have not seen a "sleep doctor" as such.  The DME, of course, is of no assistance except for being a source of supplies (all covered by Medicare).

But I (still) have problems of fatigue during the day.  I don't feel energized when I wake up and drag through the day.  My goal is to get about 9 hours of sleep each night; that seems to work better than smaller amounts.  I usually take one or two 1 hr+ naps during the day.

I'd really like to increase my energy level during the day.  I don't know whether sleep apnea is a cause or not -- it could be lack of exercise, mild depression, cardiac, or diabetes.  The latter two seem under control and I see doctors regularly for them.  Depression, if it exists and I'm not sure it does, is mild.  The gyms are closed at it is 110 F in the shade.

So I'd like to take a look at whether there is anything about my sleep apnea treatment that might be relevant.  Attached are two screenshots: an overview of a recent, typical night and a zoomed-in look at all the CAs.

The four Hypopneas during the night were all during periods of waxing and waning of breath.  It looks like sometimes time was just long enough for the machine to flag it as a hypopnea.  There were no OAs -- I may see an average of one a night.

I have been using a pressure range of 10-15 recently.  Over the past year, I have also tried minimum pressures of 9.8 and 10.4, with only a minor shift in the balance between CAs and Hs.  I did try changing EPR to 2, but that increased aerophagia and I was uncomfortable, so I returned to EPR=3.

I do regularly have lots of flow limits.  The flow limit graph is typical, perhaps just a slight bit less than average.

I've included a zoomed-in view of all the CAs and would appreciate your thought about whether they are "real" or just an artifact from repositioning.  The first one looks to me like it might be real, preceded by flat-topped inhalations caused by flow limits.  The others I don't know about.

In the overview screenshot, I have replaced the snore graph with Fitbit Charge 4 sleep data for the night.  Snoring is rare, and on this night there were only a few instances around the first pressure peak.  Also included SpO2 and pulse data from a CMS50F.

Thanks for any advice!


          

[Gideon]

As you said, a lot of flow limits, I'd like to see you try a VAuto with PS=4.

The only CA I can't say definitively is a central apnea is the first one, but I have absolutely nothing indicating that it is not obstructive.  Tie goes to the system, I'm calling it a Central Apnea.

Note the waxing and waning in the flow rate (blue ovals), and no, this is not a Ford commercial, That indicates CO2 induced artifacts CO2 induced hypopneas and CO2 induced flow limits.  Some of it is very subtle, others are pretty obvious.

There is enough here that you should consider an EERS trial to slightly increase your CO2.  This, as well as the flow limits could be causing your issues.

edit
Also consider a max pressure of 11.4, possibly going lower, to minimize the pressure excursion which is being driven by flow limits may be contributing to your discomfort.

   

[Sleeprider]

If you want a second opinion, I think a Vauto would make a world of difference. With a 95% flow limit of 0.11, that is still moderately high and is what drives your pressure, and results in any respiratory effort related arousals and hypopnea. You are already using the maximum pressure support/EPR available from the Airsense 10 Autoset. Pressure is relatively low and it might be interesting to see what happens with a minimum pressure of 11.0 and EPR 3 which is 11/8 pressure...not very high at all by Fred and my standards. This would stabilize pressure, perhaps reduce flow limitations, and should minimize arousals related to pressure changes.

In this case, Fred and I are taking different approaches. I am suggesting increasing minimum pressure to 11.0, while Fred suggests limiting maximum pressure near that level. Both recommendations accomplish a more stable pressure, but I think the increase in minimum pressure has a better track record in cases like this to minimize disruption. In support of this, I suspect neither Fred's nor my pressure normally fluctuates more than 2-cm, without high-side pressure limts.

[Gideon]

Not as different as you suspect, I was considering an increase in min to help with the Flow Limits such as we do with PR machines, I wanted to knock off a bunch of the IMHO unneeded pressure increase first.

My pressure runs in a 0.5 band 11.0-11.5 mostly. Since I can easily handle whatever the machine throws at me, my max is set very high, I forget if it is 20 or 25, Vauto's max. It never goes near there because I have my what were very wild flow limits well tamed.

[GuyScharf]

As you said, a lot of flow limits, I'd like to see you try a VAuto with PS=4.

The only CA I can't say definitively is a central apnea is the first one, but I have absolutely nothing indicating that it is not obstructive.  Tie goes to the system, I'm calling it a Central Apnea.

Note the waxing and waning in the flow rate (blue ovals), and no, this is not a Ford commercial, That indicates CO2 induced artifacts CO2 induced hypopneas and CO2 induced flow limits.  Some of it is very subtle, others are pretty obvious.

There is enough here that you should consider an EERS trial to slightly increase your CO2.  This, as well as the flow limits could be causing your issues.

edit
Also consider a max pressure of 11.4, possibly going lower, to minimize the pressure excursion which is being driven by flow limits may be contributing to your discomfort.

Thank you so much!  I have been wondering about both EERS and VAuto.  I should be able to cobble together an EERS adaptation pretty easily; it looks relatively straightforward.  A little harder to find a VAuto to "try" short of buying one.  (I'm doubtful about getting Medicare to approve one given my AHI numbers.  Might need another sleep study too.)

I'll try dropping the max pressure tonight and see what happens.

I'll post a question about EERS in a bit.

Thanks also about the reading on the CAs.  That's why I don't give therapy advice -- I know just enough to know I don't understand enough.

[GuyScharf]

I am using an F30 mask.  Presumably it has some dead space in it.  How long a tubing should I add for EERS?  If I understand EERS correctly, I just need to add some volume between the mask and the vents.

[Gideon]

the coraflex tubing cuts in 6-inch segments, each end compatible with our tubes., that is the first try, then you try a 12-inch segment, and finally an 18-inch segment. I don't recommend going over the 18 inch length as that was the longest recommended length. The normal vent is blocked and the new one is added between the coraflex and your existing CPAP tubing. for an FFM you want an anti-affixation valve to be functioning. The different lengths is how you titrate and we do so against results. EERS also allows you to use more PS/EPR.

[GuyScharf]

Thanks. I've ordered the parts for EERS. With luck, I'll be able to try it next weekend.

[GuyScharf]

I used a range of 10 - 11.2 last night.  AHI was 0.57, which is at the low end of the range of values I typically see.  Not sure if I feel much different; it will take a few days to know if there is a difference.  I am sure that I don't feel worse. Fitbit says I got a bit more deep sleep than usual.

As I skim through the flow graph, I see a lot of waxing and waning.  Attached is one example that includes both a CA and an H.

I wonder if I should try a fixed pressure?

           

[Crimson Nape]

I've found that I'm extremely sensitive to pressure changes and perform better on a static pressure setting.