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Seiko
Unread post  Post subject: Worsening CSA? Do I Even Have CSA?  |  Posted: Wed Oct 03, 2018 5:49 pm

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Hey everyone.

Really tough subject for me to talk about, because it's really been negatively impacting my life lately :( please be nice!

I've been struggling to sleep for a very, very long time. It started with jaw clenching and TMJ issues/headaches. A mouth guard helped with that. Then I began snoring a bit. Since sleep apnea runs in my family, I picked up an APAP. I had a few nights of really extended amounts of sleep (10ish hours). I didn't really feel all that tired, and I was happy that I was actually sleeping through the night and dreaming regularly, but I was still getting headaches and was just generally very foggy headed throughout the day even sleeping through the night on an APAP.


Then I had a very sudden onset of issues, primarily with falling asleep. I'm not sure if these issues are new, or if I'm simply more aware of them, but I'm not breathing as I fall asleep now. I get into that limbo/dreamy state where you're falling asleep, but not really aware it's happening. Suddenly I become alert, and I can recall that I was making absolutely zero respitory effort. I don't feel my airway open suddenly, and I don't snore myself awake. I simply feel like I need to conciously make an effort to breathe...and as I'm losing my grip on wakefulness, I'm no longer mindful of my breathing, and my body simply does not try. My chest, and abdomen are absolutely motionless.


I immediately stopped using my APAP, since I thought an overdose of air pressure may be the cause after watching Jason's video on CPAP induced CSA. However, it's been over a month now, and I'm still experiencing these issues. It's awful! It seems to affect me the most when I first get into bed, and early in the morning after about 6 hours of sleep...or at least that's how I seem to remember it. Perhaps it happens to me all night, and I'm just too exhausted to remember. But every night I deal with the same frustrating process of dozing off, catching my breath, dozing off, catching my breath...until I finally doze off for 5-6 hours for good, and fall back into the same cycle. It seems to be getting worse.


I like to think I'm in relatively good health at 26 (almost 27) years old and I go in for health evaluations once a year. I'm not on any medication. I can exercise fairly well, and although I could probably shed a few pounds, I'm still able to make my weekly 1.5 mile jog on Sunday mornings without collapsing or fainting. I do occasionally have shortness of breath while I'm awake, but it's short lived.

Happy to post Sleepyhead data if anyone can help me out. Does this sound like CSA? I'm thinking of trading my APAP for a BiPAP.


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Pugsy
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Wed Oct 03, 2018 6:46 pm
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Post a detailed report from a typical night.
Let's see what your machine thinks is going on.


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diamaunt
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Thu Oct 04, 2018 12:09 am
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Seiko wrote:
I immediately stopped using my APAP, since I thought an overdose of air pressure may be the cause after watching Jason's video on CPAP induced CSA..

Centrals are unfairly vilified.

Hold your breath for 10 seconds. that's a central. that's *all* it is.. no adverse affects.

The only time centrals become an issue is if you're having them one after another, and your oxygen levels start to drop... They're MUCH less harmful than obstructive apneas.

Pinch your nose shut, try as hard as you can to breathe for 10-20 seconds... fight it. *THAT'S* an obstructive.

Wear the cpap, don't be afraid.

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Seiko
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Fri Oct 05, 2018 1:25 pm

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Pugsy wrote:
Post a detailed report from a typical night.
Let's see what your machine thinks is going on.

Here is a link to last night for me. The mask is an AirFit F20 with the memory foam style cushion. Let me know if you'd like to zoom into any problematic areas. Apologies for the delay. I wanted to give myself a couple of "fair" nights to readjust, since I hadn't worn it in a while.


diamaunt wrote:
Seiko wrote:
I immediately stopped using my APAP, since I thought an overdose of air pressure may be the cause after watching Jason's video on CPAP induced CSA..

Wear the cpap, don't be afraid.


I certainly don't mean to sound afraid. I'm just ready, and willing to make an immediate change that'll improve my quality of life. If that means not wearing the mask to see how I sleep, that's what I'll do. :)


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diamaunt
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Fri Oct 05, 2018 9:22 pm
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I'd raise the min pressure to 8, and see how things go, probably need to go higher, but that's a starting point.

the 'factory default' setting of 4-20 is right for almost nobody.

Btw, in that one, you had a totally insignificant number of centrals. :)

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Seiko
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Sat Oct 06, 2018 12:59 am

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diamaunt wrote:
I'd raise the min pressure to 8

Thanks! Do you think the pressure changes are disturbing my sleep? What do you think about using a soft response instead of standard? To me I see a direct correlation between pressure response and disturbed sleep. For example at 3:45 the pressure seems to ramp up without having an event, and immediately you see a disturbed flow/resp rate with CAs, then it calms as the pressure drops off.


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Pugsy
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Sat Oct 06, 2018 2:06 am
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The pressure increase at 3:45 "without having an event" only means that you don't see a flagged event at that time. Pressure increases are driven more by snores and flow limitations that aren't so easily seen.
Don't assume that because you see no flags that nothing happened.
To earn a flag the event has to last at least 10 seconds and have a certain amount of flow reduction. That's just part of the criteria needed to earn a flag of some sort and the whatever sort depends on the level of flow reduction.

So it's possible that whatever caused the pressure to go up could also have been a factor in the disturbed flow rate and maybe cause an arousal.

So maybe the OSA whatever caused the disturbed sleep...
or maybe the change in pressure caused the disturbed sleep.

Either way more minimum pressure may help either from reducing the whatever airway reduction that might be happening to cause the change in pressure or simply lessen pressure changes.


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Seiko
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Sat Oct 06, 2018 1:54 pm

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I sincerely appreciate the help from both of you SO much. One more question: I struggle with exhalation comfort at 8 while I’m awake. I’ve found that the auto ramp feature of my machine is a bit inaccurate. I’m awake and feel my cheeks bulge as the auto ramp ends. That’s part of the reason why I like the freedom to start out low at 4ish.

If I truly need more pressure, is there a major downside to EPR for comfort? Does it diminish PAP treatment enough to make it not worth it?

You can see from my chart that I lay in bed awake for a bit struggling to get back to sleep/overcome the pressure before giving up in the morning.

Alternatively, is it something I’ll likely overcome soon in your experience(s)?


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diamaunt
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Sat Oct 06, 2018 2:22 pm
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EPR *LOWERS* pressure, so if you want to try EPR, then *raise* your pressure by whatever you set EPR to.

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Seiko
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Sun Oct 07, 2018 10:49 pm

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I attempted an 8 - 20 last night, and unfortunately it didn't go too well. I woke up at about 3:45 AM, and was having a really hard time getting back to sleep for a half an hour. I ended up resetting my machine to 4 - 20 which I feel helped me stay asleep a little longer. Still not great.


HERE is the overall picture.

These seem to be my most common problems:



I'll give 8 another try. I really am wondering if BiPAP would be better for me. Those machines cost a fortune! :(


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diamaunt
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Sun Oct 07, 2018 11:27 pm
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Why would you think a bilevel machine would be better?

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Seiko
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Mon Oct 08, 2018 1:11 am

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diamaunt wrote:
Why would you think a bilevel machine would be better?

For the reason bilevel exists. Here's a few I can think of off the top of my head in a way they relate to me, though:

On average, I have over 150% more CAs flagged, than OAs.
I've mentioned feeling like I forget to breathe being a big reason why I find it difficult to fall asleep.
Intolerance to higher levels of therapy, and aerophagia that lasts throughout the remainder of the day.


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Pugsy
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Mon Oct 08, 2018 5:51 am
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Bilevel machines don't all treat centrals...so don't make that assumption.
For actual treating or dealing with centrals you need a machine that has a back up rate available and will breathe for you by push a big burst of air to jump start your own breathing.
You are NOT having enough centrals even if every single one of the centrals was the real deal to warrant a machine with a back up rate.

Now if you are having aerophagia issues with your needed pressure then one of the regular non back up rate bilevel machines might be of benefit.
Before spending that kind of money though...use EPR to see if bilevel helps because EPR is essentially a bilevel creating feature.


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diamaunt
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Mon Oct 08, 2018 9:11 pm
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Seiko wrote:
diamaunt wrote:
Why would you think a bilevel machine would be better?

For the reason bilevel exists.

Obesity HypoVentilation?
Chronic Obstructive Pulmonary Disease?
Restrictive lung diseases???

That's why basic bilevel machines exist... Yes, they're sometimes given to people for 'comfort' reasons.... I've got one just because I got a rippin good deal on it when I was looking for an autoset. But, like Pugsy says, basic bilevels don't do *anything at all* about centrals... though the extra ventilation will, for a small subset of people, make the centrals *worse*.

Seiko wrote:
Here's a few I can think of off the top of my head in a way they relate to me, though:

On average, I have over 150% more CAs flagged, than OAs.


That's a good example of where percentages are misleading. In your latest screenshot, you had *one* CA per hour. on average... that's completely and totally insignificant. Heck, even a cai of 5 is nothing to be concerned about.

Seiko wrote:
I've mentioned feeling like I forget to breathe being a big reason why I find it difficult to fall asleep.
Intolerance to higher levels of therapy, and aerophagia that lasts throughout the remainder of the day.


A standard bilevel won't make any difference, if you don't breathe, it won't do anything at all, it'll just sit there.

Your max pressure is 12, that's far from "higher levels", Doctors don't typically start even thinking about bilevel till you're well past 15 as a baseline.

I think you may see that bilevel won't do you any good at all.

Now, if you wanted to go spend a grand or two on a used ASV (specialized bilevel), and were ok with it whacking you with pressures up to 25 when you "forget to breathe", when falling asleep... it'd certainly eliminate that one central you're averaging an hour.

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Seiko
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Mon Oct 08, 2018 10:00 pm

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Oh...how embarrassing! Thanks for schooling me. I thought bilevel therapy existed to provide two levels of therapy, rather than being exclusively developed for the three conditions listed above.

Other personal medical history aside, though, why are more CAs less significant than fewer OAs?

If I have 11 CAs, and 4 OAs, why should I be focused on my obstructive apneas?

Also, do I need one of the medical conditions you listed in order to look into this?

diamaunt wrote:
It *may* provide a more comfortable experience, but they're usually used for people that have trouble with cpap


Also, I thought I wasn’t supposed to assume nothing is happening if there aren’t any event flags.

Also, is it possible an insignificant number of events to one person may still mean feeling like sh!t to another person? Or am I off track here?

This is all just so difficult to understand. :roll: Thanks for the help!


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diamaunt
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Mon Oct 08, 2018 11:24 pm
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Seiko wrote:
Oh...how embarrassing! Thanks for schooling me. I thought bilevel therapy existed to provide two levels of therapy, rather than being exclusively developed for the three conditions listed above.

Other personal medical history aside, though, why are more CAs less significant than fewer OAs?

If I have 11 CAs, and 4 OAs, why should I be focused on my obstructive apneas?

Well, first, if you're not having two or more obstructive events *per hour*, then I wouldn't worry about it, that's a quite acceptable amount.

As to why obstructives are worse... try this experiment:

Hold your breath for 10 seconds, heck, even 20. no big deal, right? your O2 saturation probably didnt even drop noticeably. That's a central apnea.

Now, pinch your nose, keep your mouth shut, and try your hardest to breathe... for 10-15 seconds. Way worse, eh? that's an obstructive.

A central is you *not trying to breathe*, an obstructive is you *fighting to breathe*.

Centrals are only really an issue if you start having so many of them that your O2 saturation levels drop... they don't really disrupt your sleep, nowhere near what obstructives do.

Seiko wrote:
Also, do I need one of the medical conditions you listed in order to look into this?

Look into what?
Seiko wrote:
diamaunt wrote:
It *may* provide a more comfortable experience, but they're usually used for people that have trouble with cpap

Trouble, as in "pressures up close to 20, still having obstuctives" or "just can't exhale against the (gentle) pressure."

Seiko wrote:
Also, I thought I wasn’t supposed to assume nothing is happening if there aren’t any event flags.

You also need to look at the pressure line, how active it is, because snoring and flow limitations will also raise pressure, ... and they disturb sleep. The answer to that is.... more minimum pressure, which is why it was suggested that you raise yours.
Seiko wrote:
Also, is it possible an insignificant number of events to one person may still mean feeling like sh!t to another person? Or am I off track here?

There's more to sleep disordered breathing than apneas and hypopneas... and there's more to bad sleep than sleep disordered breathing.

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Pugsy
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Tue Oct 09, 2018 3:56 am
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If you want to experiment with a regular bilevel machine you can make your current machine do what a regular plain bilevel machine can do....sort or anyway. Close enough to give you a small idea about how it feels.

Just turn EPR on and set it to 3...that's essentially plain bilevel with PS of 3.
If you do this and your pressure is maybe a bit too low already....then it very likely will need to be increased a bit to help compensate for what happens during exhale with EPR set to 3.

You might....please note that I said "might"...find that the bilevel breathing is good for you and you sleep better with it (I had that happen to me) but you might also find that it doesn't. This CPAP stuff all comes with a big YMMV sticker. Some people don't do well with bilevel settings either simply from a comfort thing (they simply don't like how it feels) and some because bilevel can actually cause some breathing instability issues. Very small number of people but it can happen.

If the bulk of your flagged centrals look more like post arousal centrals and not a real central where you were asleep...it's very possible that sub optimal OSA therapy is causing you to have an arousal that you may or may not remember.
The one central above in your example 2...looks like post arousal to me.
Not real. When people have a lot of post arousal flagged events it usually means lots of arousals happened and they need to concentrate more on reducing the arousals first. Not always so easy to figure out why the arousals though....and then sometimes even harder to fix them.

A little while back I had a night where my AHI was a little over 2...unusual for me to have it that high so I went and looked at each apnea flagged event (about half were central flags and the other half obstructive flags) so I zoomed in and every single flagged event was a post arousal flagged event. None of them were real and it pointed more to simply crappy sleep than anything else. In my case it didn't come as a complete surprise because I already knew that I had a lot of wake ups that night because I was having some rather significant pain issues causing the wake ups.

Finally...an occasional real central apnea flag isn't totally abnormal anyway. It's entirely normal to have what is called a sleep onset central where we transition to sleep. So a central here and there doesn't necessarily mean something bad is going on. Now if someone has a lot of them because they have crappy sleep...it's the crappy sleep that is the problem.
And it's also normal to wake after each REM cycle. Most of the time we don't remember it but we still do it...and with each awakening there's going to be a chance that another sleep onset central will happen when the person goes back to sleep. So a handful of "real" centrals isn't necessarily a cause for alarm. We can all have them.

Have you done your homework and learned how to try to distinguish real asleep flagged events and arousal/post arousal flagged events?
http://freecpapadvice.com/sleepyhead-free-software

If the bulk of your flagged centrals aren't real centrals....you need to look more at how to fix crappy sleep first.
It might simply be that the OSA therapy stuff isn't quite optimal and the arousals will reduce if the OSA therapy is better optimized.
It might also be that the crappy sleep isn't related to sleep apnea at all.....like my crappy sleep due to pain.

Now would bilevel maybe help with crappy sleep in general? It might and it might not. Before spending some big bucks though....make use of EPR at 3 which is essentially PS of 3 and a bilevel situation. See what happens and how you feel.


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Seiko
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Fri Oct 12, 2018 7:45 am

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Quote:
As to why obstructives are worse... try this experiment:

I saw this in your first reply. I’m not entirely convinced I need to do this experiment. Both occur during sleep. What matters to me is an event that makes me fall asleep at the wheel driving home from work, forget what it’s like to dream, makes my heart race, feel like I just sprinted, and wake me up enough to send me here in the middle of the night.

At what point are other causes of arousals considered? I’m sure your airway being blocked sucks. What if instead of your airway being blocked, you’re just slapped in the face? Would’t that lead to the same ill effects throughout the day regardless of O2 saturation levels?

My point is I was hoping I could find a way to get the machine I have to put an end to this, or at the very least find some answers. Unfortunately higher pressure settings is providing neither of those things. It only provides me with plenty of air when I’m cognitively able to request it.

I realize how this looks. I asked for help, and the only thing anyone can use is my Sleepyhead data, and there’s only so much that can be interpreted. I promise you both, though, that there’s something more going on, and bilevel therapy is worth a try to me given my stakes, and what alternatively seeking professional healthcare will mean for my career...which I’ve spent far more on.

Until I find one, I’ll try to keep using EPR, and shooting PMs to people selling them. Wish me luck!


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diamaunt
Unread post  Post subject: Re: Worsening CSA? Do I Even Have CSA?  |  Posted: Fri Oct 12, 2018 10:33 am
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Seiko wrote:
Quote:
I promise you both, though, that there’s something more going on, and bilevel therapy is worth a try to me given my stakes, and what alternatively seeking professional healthcare will mean for my career...which I’ve spent far more on.

I promise you that it's not.

Seiko wrote:
Until I find one, I’ll try to keep using EPR, and shooting PMs to people selling them. Wish me luck!

Whatever... you're clearly not interested in anything that contradicts your ideas... so I'll just quit wasting my time trying to get you to see facts.

Best of luck to you.

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