+- Apnea Board Forum - CPAP | Sleep Apnea (https://www.apneaboard.com/forums)
+-- Forum: Public Area (https://www.apneaboard.com/forums/Forum-Public-Area)
+--- Forum: Main Apnea Board Forum (https://www.apneaboard.com/forums/Forum-Main-Apnea-Board-Forum)
+--- Thread: Long time CPAP user still fatigued (/Thread-Long-time-CPAP-user-still-fatigued)
RE: Long time CPAP user still fatigued - SarcasticDave94 - 09-22-2023
OK copy. For most the ramp tends to cause issues, like the transition from ramp onto therapy settings, it may cause less efficient therapy during ramp as well. If it's not a disturbance, then choose what is most comfortable.
Anyway good eve to you.
RE: Long time CPAP user still fatigued - THEVGE - 09-23-2023
I am currently also playing with my settings, as I am in a comparable boat as you are (great numbers, chronically tired). To me your therapy seems to have room for improvement before you dive in other things.
What I like about your graphs is leak control and flow limitations.
But I do see a lot of air gasping (and probably awakenings/arousals) in your flow rate. I have the same. But I have greatly reduced these by 1) going slowly (steps of less than 1 cm in my case) to a higher pressure and 2) staying away from EPR. At this moment I also disabled APAP as my Resmed basically misses most of my events anyway (as in your case!) .....
Most people swear by EPR and I understand why, but it does not work for me (or me with current settings) as I will get many CA's. So you could be one of "those people" like me ;-). Best is to make sure how you really respond to EPR and higher pressure, but give it some days to get used to a setting before you try another setting. And do not go to fast....I made both mistakes.
I am now on a pressure of 9 (coming from 7) and only have issues left during REM phase, I will continue experimenting to see if I can solve my issues. Strategy 1 is slowly increasing pressure and see what happens, I also ordered a BiPAP to see if this will help me (my flow limitations are not as great as yours).
Last tip, go into your OSCAR settings and set "Custom CPAP User Event Flagging" (under File --> Preferences --> CPAP). Here you can manually play with event flags and it will make visible for you how many events Resmed considers not relevant. It helped me improving my therapy because for me the AHI is useless. I suspect I might have UARS, hence I want to try BiPAP.
RE: Long time CPAP user still fatigued - enigmatic - 09-23-2023
Another night, another horrible morning. The good news is, the more I've been changing settings, the more horrible I feel. That tells me there is some correlation to the machine and my fatigue. Hopefully, I just need to find the optimal adjustment(s). I've given up so many times, but trying to get more scientific about it. I also read CBT books saying to sleep no more than 8 hours, and I start wondering if 9,10 is too much or too little causing the fatigue. Take calm and 1mg meletonin, to help fall asleep faster but maybe that's adding to the morning grogginess.
What I see is when I used EPR 2 and tightened the range, I get less OA (near zero typical) and more CA. I can look on the camera and see CAs are strongly correlated to turning, waking up and scratching, itching nose (in/out) etc.
I have scans for last night with the tighter range (reduced max press 17 to 15, only reasoniong is historical pressure pre EPS was like 17 and I rarely exceed 14).
The 2nd graph has apple watch sleep states and emay oximiter data. Have to substitute sleep state as Orientation, sPO2 as Inclination. Easy to visually see, I am limited to not having tools and knowledge to compile OSCAR label changes. Orientation 0,1,2,3 is deep,core,rem,awake Point being you can see in the third chart, there is strong correlation between sleep state transition and CA events. Further viewing those transitions typically happen with itching nose, or changing positions, telling me I'm awake. I created another time series showing those itchy nose, turning events and they seem to line up with both sleep state and CAs (couldn't fit third graph to OSCAR import). This tells me they are not true CAs, but I need to somehow control them.
@THEVGE thanks for the feedback. I set those flags you mentioned (20% 50% limit and 8 sec duration default). Not quite sure what that tells me that I can't see
in flow limits. Also have trouble getting the events to show consistently (they are there and many).
[attachment=54467]
[attachment=54468]
[attachment=54466]
RE: Long time CPAP user still fatigued - SarcasticDave94 - 09-23-2023
Overall this LOOKS really good. So you'll need to go by feel on this. And since you said edits exchanged obstructive for central, this is probably close to your balanced area.
Like you, I'd ignore the CA cluster as SWJ (sleep wake junk). Even if it's not, your AHI is 1.x for the 9 ish hours.
RE: Long time CPAP user still fatigued - enigmatic - 09-23-2023
@SarcasticDave94 Thanks and good to know, I only hope the quality of sleep will someday follow the numbers.
@THEVGE
Posting the graph with those UF flags shows strong correlation with sleep state transitions similar to the CA events (maybe even more).
Again, almost all my Apneas seems to be twisting, turning, itching face. Yet quality of feeling still terrible (esp first few hours).
[attachment=54471]
RE: Long time CPAP user still fatigued - dean406 - 09-23-2023
My experience is that the algorithms used within the machines to determine AHI are optimistic in an effort for the manufacturer to brag about how good your sleep is. People have looked deeper into the statistics within the machine and determined apnea or hyponea was occuring when the machine wasn't adding it to it's accumulated nightly score.
Most of us eventually decide to become familiar with & educated on reading the statistics within the machine and adjusting things to achieve an optimal setting. As an example, some folk do better on a single pressure even if their machine has the capability to auto-adjust. I can live off a straight 10 cmH2O with an AHI of less than 3 (unless sick w/cold). I have my machine currently set between 9 to 14 and just checked it 15 mins ago. The darn thing ramped-up to 13.4 last night which is usually too high for me. Over 12 and I start getting leaks and some mild central apnea caused by excessive pressure. I just got an AirSense 11 last week and am trying to tweak it. DME set it for 6-14 which is childish and medical malpractice IMO.
At the suggestion from videos on youtube explaining that lab tests show Resmed exhalation pressure relief (EPR) can require higher pressures - making it counter-intuitive; I disabled EPR and will see if the machine leaves me between 10-11 tonight instead of ramping-up to 13 or higher.
I'd take matters into your own hands and basically learn to become your own sleep doc. Unfortunately, the field appears over-saturated with "professionals" who hand-out APAPs configured w/wide ranges and then consider their job complete. Tweaking is typically necessary to achieve good results & the AHI reported by the machines often are completely wrong. You could be having 100 episodes a night with an AHI of 7.9 and the machine might report "0.9". Resmed's airsense [app] will then send you happy-face stickers like an elementary child and won't show any meaningful data. You'd need an SD card + OSCAR to get data that can justify changes.
RE: Long time CPAP user still fatigued - SarcasticDave94 - 09-23-2023
Dean406, to run EPR, you'd need higher pressures to have EPR work correctly only if you try these combination of settings:
Min 4 EPR 1, Min 5 cmH2O needed
Min 5 EPR 2, Min 6 cmH2O needed
Min 6 EPR 3, Min 7 cmH2O needed
Why? Because the CPAP cannot give a pressure relief below 4. Each of the above combos attempts to reduce to 3 and it can't physically do it.
You're not running that low according to what you're telling us, so EPR will work as designed. ResMed EPR drops according to the number settings 1, 2, or 3 in actual cmH2O. If it were Phillips Respironics and their flex, totally different story.
If your pressures go above 12 and cause leaks, something likely isn't adjusted or fit well on the mask. My last 2 machines I used were ASV for CA, and ST-A because of the addition of COPD. Mine would hit up to 25 with minimal leaks. I had to work at it, but it was doable.
Sorry OP enigmatic, not attempting to hijack.
BTW somehow collectively AB will help get this working well. Apnea is Latin for frustrating and fatigued. Bonus is Dr. Dolittle our sleep pulmonologist.
RE: Long time CPAP user still fatigued - Lucky7 - 09-23-2023
"My experience is that the algorithms used within the machines to determine AHI are optimistic in an effort for the manufacturer to brag about how good your sleep is"
While I have zero doubts that the machine flags false events as real, and missing flag real events, I'd be stunned if that was intentional because it's a FDA cleared medical device.
With THAT said, wouldn't hurt if people were to say.....let FDA know. Wink.
RE: Long time CPAP user still fatigued - Lucky7 - 09-23-2023
@verge
"Last tip, go into your OSCAR settings and set "Custom CPAP User Event Flagging" (under File --> Preferences --> CPAP). Here you can manually play with event flags and it will make visible for you how many events Resmed considers not relevant."
Thanks for the tip. To me, UF2 looks a lot like RERA pattern.
RE: Long time CPAP user still fatigued - enigmatic - 09-24-2023
[attachment=54477]
Still tired, but very small victory. Yesterday, my eyes were all swollen along with the normal morning tiredness/grogginess (that's unusual too), I used an eye mask and eye drops- no eye swelling this morning. Guess that was due to machine wind and camera IR lights. Still feeling tired but less groggy/headaches.
Raised max pressure by 1 to 16, CAs dropped and 1 OA surfaced now (although odd cause/effect since my pressure range never exceeded 12). I guess that is like a sweet spot outside of stopping myself from rolling around at night. Oxygen looks mostly good, noticed respiratory rate drops to 0 after some Apneas, makes sense as average of flatline is 0, but a bit disconcerting first time seeing. All the apneas are occurring during core sleep mode, not REM or DEEP, which although not fully awake, along with all the arousals I see preceding apnea signals indicate due to tossing and turning itching mask face etc (stopped using camera for now as it corroborated those arousals).
I bought a cervical collar, and it felt like a noose, so I had to take it off. I tend to sleep on my stomach and that makes the pressure from collar and pillow smash into neck, even with loose strap on collar, I also get this strangled neck feeling and have tried to make pillow smaller and smaller to minimize that feeling (it is also globus/anxiety symptom).
Anyone find a collar that circumvents this?