Would like some advice (OSCAR data)

[dandmt]

Hello everyone,

I was put on CPAP treatment by my pneumologist earlier this year after a sleep study.
He adjusted my settings multiple times at the beginning of the year but since then nothing, I am supposed to have an appointement every year and the next one is scheduled in march of next year but I cannot continue like this.

I am extremely sleepy and cannot function normally during the day

Recently decided to look at my own data using OSCAR and even though I know little about it I know something is wrong just looking at the graph.

I saw that most days the event graph is completely filled with events with an AHI >40 sometimes even higher (reached 120 one night)
And sometimes (very rarely) I get to have a "normal" night of sleep with an AHI of 6 or less.

I really know little about the subject so I would really appreciate if you could give me some advice about what you think my condition may be and settings you would adjust ?

Here are screenshots:
   
   
   

[staceyburke]

I'm not a expert on your machine but from what I see you have Positional Apnea.  You can see positional apnea where either H or Oa or U events are clustered together.  Getting rid of as many as you can will lower your AHI.  Positional apnea can NOT be controlled by pressure changes.  You have to find out what position you are getting into and cutting off your own airway.  Have you changed your sleep position?  Sleeping on your back?  Using more (or new) pillows?  These things can cause positional apnea by chin dropping to your sternum and cutting your airway.  Think of it of a kinked hose – nothing can get through – you have to unkink the hose…

IF you can’t make a simple change like changing to a flatter pillow helps then you will need a collar.  I have a link to collars in my signature at the bottom of the page.  It shows people who are not wearing a collar and the SAME person wearing a collar.  There is a huge difference between the two.

Positional Apnea would be a reason that some nights are low AHI while other nights they are out of site.

[dandmt]

Thank you for your reply

Indeed, I tried changing my position many times, tried sleeping on both sides, on my back with no pillow, 1 pillow, 2 pillows, even tried semi-reclined.

From what me and my wife has seen, position does not seem to affect my sleep apnea that much.

The nights where I have few events are VERY rare, like 5 nights a month.


I will try getting an appointements earlier but I'm afraid it will still take ages like always 

[staceyburke]

Again, I would try a collar. The height you need for the measurement is the distance to your sternum. A collar is not very expensive and help a lot instead of just waiting until you talk to a DR. And most Drs. not know about passional apnea.

[coutherino]

Hello, welcome to the forum. I'm sorry to hear you're having a difficult time with CPAP, I hope the people here can be of help. I am... not surprised that you're exhausted throughout the day. Those are some pretty extreme numbers. Before I go into more detail, I must admit to some inexperience with BiLevel ST in particular. Is there any specific reason you were prescribed that machine? I assume it must be because of a lung condition, as you also mentioned your pneumologist. Correct me if I'm wrong though.

It'd help to see more data, but those are almost certainly central apneas, which seem to be occurring back to back throughout the entire night. As opposed to obstructive apneas where your airway is being physically restricted by collapsing tissue, central apneas occur when your body is literally not trying to breathe at all (or barely trying to breathe). Typically obstructive apneas are characterized by a slow decrease in airflow as your airway collapses, until the waveform flat lines and you eventually gasp awake. Cheyne-Stokes respiration (a form of central apnea) is typically like what you can see in the 1st image you sent. Big deep breaths before an immediate flat line, followed by more big deep breaths and another flat line. Your machine doesn't seem to tag centrals, so it just marks them all as unclassified apneas.

Did you happen to do an in lab sleep study, and if so, were you diagnosed with obstructive sleep apnea or central sleep apnea? Those very well could be treatment induced, but if not, you may be on the wrong mode of therapy entirely. Like I said, lack of experience, but from what I know ST does not treat Cheyne-Stokes respiration.

The main thing I'm curious about is what causes nights like the 2nd image. You're clearly not having Cheyne-Stokes during nights like those. You said they're rare. Do you happen to take any medications or substances that you occasionally skip? I just don't think there's any way something like position changes could explain the difference between central apneas literally the entire night and seemingly none another night.

I'll make some recommendations, but first let me explain my reasoning behind them. Normal CPAP (a fixed pressure, which you are not on) has a natural ventilatory effect, meaning it causes your body to expel more CO2 in any given moment than it would without CPAP. When you add something like BiLevel (a higher inspiratory pressure, which you are on) it increases this ventilatory effect, as it becomes even easier for you to expel CO2. It is the buildup of CO2 within our bodies that triggers the drive to breathe, and if you expel enough at any given moment it can erase the drive entirely. Like how if you hyperventilated right now, you wouldn't feel the need to breathe for at least a little while. The same concept applies here, and it's why PAP therapy can induce central apnea in some people. Especially people on BiLevel, and ESPECIALLY if they have a big gap between their inspiratory and expiratory pressure, which you do. It may seem counterintuitive, but I recommended bringing your IPAP (inspiratory pressure) down a bit. You likely need to be on a higher overall pressure just from what I can see from your breathing on the night where you weren't having Cheyne-Stokes, but more than anything I want to see if that would get rid of that issue.  

If you want more specific recommendations I will give them, but I want to hear your response first. Obviously if you were indeed diagnosed with central sleep apnea none of that applies, and lowering your IPAP is unlikely to do anything.

[dandmt]

Hi
Thanks so much for the detailed reply and explanations!

Last year after a visit to the neurologist for my pain problems he recommended me to do a sleep study.
Where I live the pneumologist is the only specialist that can provide that.

I haven’t been diagnosed with any lung condition, and I don’t smoke or drink either; I do sometimes use light opioid medication for managing my pain, but this extreme apnea occurs on nights where I don't take any as well.

To be quite honest with you I don't have the full details of my diagnosis, I will try asking for more details about it next time.

And if central apneas are the main issue, would adjusting the settings on my current machine possibly make things more manageable in the meantime?

I’d appreciate any advice on adjusting the pressure settings or anything else that might help until my next appointment.

[coutherino]

I see. Opioids are known to cause central apnea. It's possible that CPAP is exacerbating the issue, but there's no way to tell until I can see what your breathing looks like on different pressures. It's also possible the nights where you aren't having Cheyne-Stokes are a result of the medication completely clearing out of your system, maybe those were nights where you had skipped taking them for multiple days. I'd imagine they could stay in your system for more than one day. I'm just theorizing though, I don't know for sure. But I'm willing to bet that's part of it.

Changing your pressure might help, but like I said I won't know until I can see a few more nights. When you get a chance can you send two more images like the first two zoomed in ones you sent in your original post? One from nights where you're having Cheyne-Stokes the entire time, and one where your breathing is (relatively) normal. Preferably from periods where a lot of events are being tagged. I want to see how much lowering your pressure would affect the obstructive side of things. It's definitely secondary to eliminating the centrals (at least at the moment) but still. Just out of curiosity, how long have you been on CPAP, and how long have you been using opioids for pain management, and were you using them around the time of your sleep study? How often do you use them? Do you think CPAP has made your sleep worse, and do you recall what your sleep was like before you starting using the opioids? Apologies for all the questions, I'm just trying to get to the core of all this.

It would definitely be helpful if you could get a detailed report of your sleep study, but I assume it'll be awhile before you can. In the meantime, I'd try lowering your IPAP to 11 just to see if that gets rid of the centrals. It's very possible you might have to cut out the medication entirely... Like I said, CPAP could be making it worse, but I'm quite confident the medication is what's truly causing it. I could definitely be wrong though. In the meantime, just consider making the changes I suggested, and if you do, let me know how it goes. Hope this helps.

[dandmt]

I'm on CPAP since january of this year and I've been on opioids for way longer (2+ years), I do take them every day (during the day, when the pain spikes) and it doesn't seem to be linked to me having apneas or not.

Here are some more screenshots, first is a "good" night second is a bad night and the last screenshots is one that seemed weird to me, I suddenly stop having apneas for whatever reason.

   
   
   

[coutherino]

Thanks for the screenshots. Not that I had any doubt before, but yea, those are definitely centrals. Apart from that, though, you do have breathing showing pretty big signs of obstruction in the first image. Those hypopneas are being tagged correctly.

I'm on CPAP since january of this year and I've been on opioids for way longer (2+ years), I do take them every day (during the day, when the pain spikes) and it doesn't seem to be linked to me having apneas or not.

Look, it might not seem like they're linked, and maybe they aren't, but it's a big possibility. I asked about medications and substances for a reason, and as soon as you said opioids I was not surprised at all. I've seen it before, and it's a well documented side effect. I'm not suggesting to completely stop taking them now, just to prepare that this might not be fixable without doing that. And this is definitely something you're going to want to fix. It would be an understatement to say it is destructive to your sleep.

Short of that, all you can do right now is keep decreasing your pressure and see if they go away. But eventually you'll get to a point where it might not even be controlling your obstructive apneas at all (which it honestly isn't even right now, but it could get worse). My theory now is that you were diagnosed with some form of central apnea, and that's why you were put on BiLevel ST. Which from my understanding is usually used in unique circumstances like treating people with COPD. It can technically be used to treat people with central sleep apnea too but ASV is vastly more suited for that, which makes me curious why you weren't put on that instead if all that is true.

Anyways, I just wanted to give some more insight about what could potentially be going on. Hopefully the decrease in inspiratory pressure makes it go away, that would definitely make everything much simpler.