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newbie- sleep onset apnea

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p3000g +1 point · 3 months ago Original Poster

Hello all,

Here's my story so far. Recently I am having sleep transition issues where I would wake up gasping as I was about to fall asleep. This would happen several times at night , and would leave me awake for hours at a stretch. I had a sleep study done on recommendation from my doctor and results are still awaited. Searching through the net, I found something called sleep onset central apnea , which seems to fit my symptoms.

I also came across many articles , which seem to suggest that these are a part of normal sleep transition. My question is : How can they be normal when they start interfering with your normal sleep cycle? How do people cope with it? As expected, the following day, I am quite sleepy and tired and have to take repeated naps during the day. This is beginning to affect my work..

What are the best options for sleep onset apneas( not OSA or CSA which occurs once you are asleep)? Do sleeping pills help? Many questions.. Any suggestions/remedies welcome.. Please help me overcome this nightmare

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Spike +0 points · 3 months ago

I would just wait for your sleep test results, but it’s definitely good to research the issue. It is likely that you are having problems after you fall asleep as well. A CPAP machine would most likely prevent your falling asleep issues. Good luck!

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Sierra +0 points · 3 months ago Sleep Enthusiast

I have heard of this issue, and as you say it is considered more of a nuisance than a serious medical condition. I think it is a basically a change of shift problem. The day shift guy that is controlling your breathing goes home before the night shift guy takes over, to put it in analogy form.

My thoughts would be to wait until your sleep study results come in. For sure ask for a written copy of the study results as there is a lot more detail on the report than can be remembered with just a verbal discussion. If the conclusion of the study is that you have sleep apnea that needs to be treated with a CPAP, you might get some relief from the therapy. A CPAP addresses obstructive apnea by keeping the airway open with pressure. With a central apnea there is no obstruction, so pressure does not help. That said, if you have the right kind of machine, it can provide a split in the pressure supplied during inhale and exhale cycle while you are going to sleep. That MAY help prevent your issue of stopping breathing when you are going to sleep. I am a CPAP user not a medical professional, so that is just my opinion. And my opinion again about machines is that the ResMed AirSense 10 AutoSet does the best job of the getting to sleep phase. It lets you use this split pressure (Expiratory Pressure Relief - EPR) while you are awake, and then when the machine detects you are asleep it stops the EPR. Treatment during sleep can be more effective with EPR off.

You should also ask your sleep clinic that did the test what they think of your condition and might improve it.

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p3000g +0 points · 2 months ago Original Poster

Thanks .. Other than AirSense Resmed 10 are their any other CPAP/BiPap machines which help with sleep onset apneas? I have heard there are some machines which automatically detect absence of breathing for a set period of time and start it if absent. I also probably have mild OSA as per my sleep report( Though not official , i had a chance to peep into it as the tech was preparing it). The machine needs to be portable as well as O travel sometimes

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Sierra +0 points · 2 months ago Sleep Enthusiast

The AirSense EPR is probably not really intended to assist in breathing stoppage as its main purpose. It is unique in that it can use EPR during the going to sleep and then turn it off when you go to sleep.

The next step up from an APAP like the AirSense is a Bilevel like the AirCurve 10. There are various models but what it provides over the AirSense is the ability to provide more than 3 cm of EPR or Pressure Support as it is called on a Bilevel. With a higher differential between inhale and exhale it can assist breathing more when the person is not doing it themselves. Depending on the machine this pressure support can be variable in that it detects when you need more or less pressure support. In the AirCurve line there are some that have a S mode which provides a back up breathing assistance at I believe a fixed 25 bpm when it detects no breathing. These machines also have some settings that let you control how the switch from inhale to exhale pressure to fine tune the breathing assistance.

Then there is the AirCurve 10 ASV model which is an adaptive servo-ventilator machine. It monitors every single breath and assists on a breath by breath basis to maintain breathing. Here is a link where you can find more info on the various options. It is pretty high level however, and you have to get into the technical manuals to see what they really can do. Phillips Respironics probably have similar capability machines. Sometimes the bells and whistles differ a little.

ResMed Sleep Devices

When you get your sleep report you should discuss these options. However if your apnea is in the mild category, they are not likely going to want to consider anything more than an APAP. In that category I would recommend the ResMed AirSense 10 AutoSet for Her. The For Her version as an additional option mode which may be of use to a male or female, and the price is the same. You can select the For Her mode, or standard APAP mode.

On portability the standard AirSense model is quite portable, and what I would recommend using. They come with a nice carrying case that holds everything you need, and has a strap to attach it to the top of a rolling bag. We have a Z1 Travel Auto CPAP but don't use it, as it has too many compromises for my liking. In my view, a travel CPAP is a solution in search of a problem. A CPAP is considered a medical device and you can carry it on a plane in addition to your normal carry on limits. That is why it is handy to have one that attaches to your carry on rolling bag.

Hope that helps some,

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p3000g +0 points · 3 months ago Original Poster

Thanks for the responses. I called up the sleep medicine center and they said results would take upto four weeks! four freakin weeks! I spend upto 4 hours every night tossing and turning without sleep. I can't wait that long.. Do sleep meds help ? (I have already tried melatonin , no use). Should I ask my doc to prescribe some pills? Thanks.. and sorry for the rant..

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Sierra +0 points · 3 months ago Sleep Enthusiast

In general sedative type drugs have been blamed for causing or aggravating central apnea, with opiods probably being the worst. Sleep medications are more controversial as to their effect on CA. Something to discuss with your doctor for sure.

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p3000g +0 points · 2 months ago Original Poster

Got an appointment with the sleep doctor on 12th of November.. Hopefully can figure out something. Yesterday was another bad night (after a couple of good ones) with only about 4 hours of sleep and weird dreams

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S2S +0 points · 2 months ago

I would guess that it is OSA. Let me ask you this, Did you gasp for breath when you woke up, do you snore and did you feel your throat move when you woke up? Think about it. OSA does hit you when you are falling asleep, I used to notice it when falling asleep. Just starting to sleep, then the next you know is you waken up with a start and gasp for breath. There is also another thing that can happen, you slowly slow down with your breaths, then they get shallower until you stop breathing altogether, but it is not normal to wake up gasping, more you just get a start and start to breath again, this is more like CSA. I used to do this as well, but I didn't get a so big a gasp of air, but breathing did quicken until it caught up. OSA can leave you gasping, hart racing and a bit confused. I would wait until you get your results. If you do have OSA, ask for your report so you have a copy of your results. If you can get an APAP machine, these adjust to the pressure you need and are a lot better. You will have to work on thet one, ask your doctor to give you a prescription for an APAP.

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p3000g +0 points · about 2 months ago Original Poster

I would think so but I dont normally snore so it makes me think these are mostly sleep onset CSAs. During my sleep study the technician did tell me that I had mild OSA but I am not sure if these are playing up at sleep onset or are they Sleep onset CSAs.

I dont seem to have any 10 second breathing pauses normally associated with csa.

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Sierra +0 points · 2 months ago Sleep Enthusiast

This is what obstructive apnea looks like in a SleepyHead report when it occurs. Last night I had a series of 4 OA's in quick succession. After the first one in particular you can see the wild flow rate fluctuations and mask pressure fluctuations. Mask pressure is set at a fixed 12.2 cm, but it went as low as 8 cm and over 16 cm. I was probably gasping for air. Keep in mind that you can have an apnea just when you are going to sleep, not just when you are sleeping.

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p3000g +0 points · about 1 month ago Original Poster

Ok learned folks.. Had an appointment with the sleep doctor about my sleep study. My AHI was 19.6 , which puts me in the moderate range, I guess. What surprised me was that out of a total of 104 events in 5 and a half hours of sleep , 103 were hypopneas! There were 0 OSAs, O CSASs and 1 mixed apnea event. The doctor advised me for a CPAP titration study. I do have the following questions for the learned members: 1) Is there any way to know if these hypopneas are central or obstructive, since the report does not tell about it? The doctor was fairly confident that these are obstructive in nature , since I don't have underlying conditions for a central. 2) What to expect during a CPAP titration test , since I am quite apprehensive about it? 3) What kind of CPAP device will be best suited for my condition ?

Thanks in advance for the wonderful website and support!

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Sierra +0 points · about 1 month ago Sleep Enthusiast

1) Is there any way to know if these hypopneas are central or obstructive, since the report does not tell about it? The doctor was fairly confident that these are obstructive in nature , since I don't have underlying conditions for a central.

One would have to look at the breath by breath flow charts to see what is happening. In my experience looking at results on SleepyHead a hypopnea can be either central or obstructive. If you are getting a waxing and waning of breathing depth in a smooth cycle that does end in a full apnea, then that would suggest a central event. And I would think during the sleep test they would monitor not only the flow but your effort to breathe. Central apnea is basically a reduction in effort to breathe. Perhaps the doctor has looked at that when making the opinion.

They should be able to tell during the titration test though. If increasing pressure does not resolve the hypopnea then that suggests they are central in nature.

2) What to expect during a CPAP titration test , since I am quite apprehensive about it?

If you had an in lab sleep test it should be very similar to that. They will just increase the pressure over the night and find out what is required to resolve your hypopnea. They will also be checking for any indication that increasing pressure causes central apnea events.

3) What kind of CPAP device will be best suited for my condition ?

If pressure resolves your hypopnea, then the two obvious choices would be a fixed pressure CPAP, or an APAP. I push as much as you can for an APAP that saves detailed data to the SD card. You don't want to get stuck with a fixed pressure "brick" that gives you no data to monitory your results. I would push for the ResMed AirSense 10 AutoSet.

Now if the pressure does not resolve your hypopnea because it is central in nature, then an APAP may not work that well. The other choices would be a BiLevel machine or ASV. Probably a bit premature to be considering them at this point though.

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p3000g +0 points · about 1 month ago Original Poster

Thanks agai My main apprehension is about wearing the CPAP mask and adjusting to it. Will it be too suffocating? What happens if the pressure is set too high?

During my first sleep test I had all the wires hooked up but no mask. I guess it is goi g to be a challenge sleeping with the mask on

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Sierra +0 points · about 1 month ago Sleep Enthusiast

Some things to consider. The sleep technician is going to spend some time with you to fit you with the best type of mask for you, and ensure it fits you well without leaks. The test is normally started with the lowest pressure, and then over the night it is increased to find out at what point your hypopnea is normalized. My expectation would be that you will not go to very high pressure as you are not experiencing full apnea, but there is nothing real predictable about CPAP so you never know for sure. And as far as the suffocating feeling, you are more likely to find it easier to breathe with the low to intermediate pressures. I consider the pressure my friend! They need you to be asleep to monitor apnea events, so the pressure is going to be increased when you are asleep and you are very unlikely to notice it, unless you wake up. I presume then, they will back pressure down and wait for you to go to sleep again.

I find the main issue with wearing a CPAP is the comfort factor of having to find a place on the pillow where the mask is not going to be dislodged, and a location for the hose that is not in your way, and you are not sleeping on top of it. You have to be able to change sleeping positions with some ease. And, of course they know all that, so they will help you get that sorted out.

I would focus on just relaxing and getting as good a sleep as possible under the circumstances.

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sleeptech +0 points · about 1 month ago Sleep Commentator

Simply put, there is no such thing as a central hypopnoea. Hypopnoeas are not actually classified as obstructive or central, they are just hypopnoeas, so I wouldn't worry about it. A better question is "does CPAP get rid of them?", which a titration study will tell you.

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Sierra +0 points · about 1 month ago Sleep Enthusiast

Sorry, but I can't agree with you on that one. I see hypopnea all the time in my SleepyHead that are clearly central apnea issues that do not go fully to an apnea or breathing stoppage. Here is an example. You can see a CA event, a second CA event in formation but not going to a full CA and is identified as a hypopnea, and then another CA event. They are all part of the same unstable breathing control system that causes my CA. These type of hypopnea are not resolved with more pressure.

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sleeptech +0 points · 27 days ago Sleep Commentator

I think you may be misunderstanding what I wrote. Whilst your hypothesis as to the cause of your hypopnoea is interesting it doesn't change the fact that, in medical terms, there is no such thing as a "central hypopnoea" because hypopnoeas are not classified as either central or obstructive. It's all down to the rules for scoring sleep. Apnoeas events are classified as either obstructive, central or mixed. Hypopnoeas are not. They are just hypopnoeas and don't come in different varieties. While we may make an informed guess as to the cause of a hypopnoea, it will always simply be classified as a hypopnoea because that is all the rules for scoring allow for. One day they may be modified to expand on this point, but until then we are stuck with only the one type of hypopnoea.

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S2S +0 points · 28 days ago

I can't agree either. When I was diagnosed in the UK, the Sleep Doctor (A Professor) sat down and explained OSA, CSA and Hypopnoeas. Yes CAs and Hypopnoea might be related, but they are not the same. He went through my data in detail and he pointed out the three types to look out for. His next words were "Do not play around with the settings!" "Yes Doctor" I said as I was already working out how to do it. He took the manual from me, but I sent away for another. He knew fine I was going to get the best out of the limited machine I had, I did as well. As machines got better so did the treatment. But he didn't keep the manuals from me after the second machine. There was little or no internet back then, or Sleepyhead. It took me a while to get an Internet connection worth using, it was very slow, but at least the modems had evolved by then. Dial up! Slow Dial up at that.

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sleeptech +0 points · 27 days ago Sleep Commentator

I think you may also have misunderstood what I wrote. I certainly didn't suggest that hypopnoeas and central apnoeas are the same thing. See my post above for an expanded explanation.

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Sierra +0 points · 27 days ago Sleep Enthusiast

There seems to be some recognition that both central and obsructive hypopnea events do occur although they may be difficult to classify. See this page from a sleep report posted by another contributor here. The columns for Central Hypopnea and Obstructive Hypopnea were not filled in, and they were all recorded under Unclassified Hypopnea.

Also see this article.

Scoring Obstructive Hypopnea vs. Central Hypopnea

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sleeptech +0 points · 20 days ago Sleep Commentator

The fact that there are columns just means that whoever was laying out the document was ill informed. The international standard rules for scoring sleep only allow for hypopnoeas, not obstructive hypopnoeas or central hypopnoeas. The columns doen't change that. Neither does that article. Whilst the theory is interesting enough, they will all get scored as hypopnoeas until the rules change.

It is also possible that some labs may decide to ignore the rules and do their own thing. That happens sometimes. Unfortunately it means the data they collect is no longer comparable to other data which does adhere to the standard rules.

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Sierra +0 points · 17 days ago Sleep Enthusiast

I think what is important is the cause of the hypopnea. Pressure will not correct a hypopnea that is caused by lack of breathing effort (central).

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p3000g +0 points · 23 days ago Original Poster

Ok folks.. An update on my situation. I finally had the first taste of an xpap machine at the sleep lab. It was not as bad as I thought it would be. I slept about 5 and a half hours during the test which is not bad as per my standards, though the mask kept slipping constantly and i had to adjust it through the night. A couple questions for the pundits:

1) the machine used in the sleep lab was a resmed vpap. Is vpap same as a bipap? Does it help with sleep onset apneas/ hypopneas?

2) people and experts say sleep onset centrals are normal. How come I wasn't experiencing them before and now suddenly its an issue?

As usual , thanks to this wonderful forum, in particular Sierra and sleeptech for their wonderful insight and knowledge. Without this forum, I would have felt alone in this battle.

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Sierra +0 points · 23 days ago Sleep Enthusiast
  1. I believe the VPAP Tx machine is a special machine that ResMed makes for titration testing. It is not one that would be prescribed to a user for ongoing use.
  2. Did you get any feedback on the results of the titration testing? On the initial in lab test was there any indication of RERA events, or a RDI index value? They are helpful in determining what type of apnea you have.

In the absence of any further detail, my suggestion would still be to push for a ResMed AirSense 10 AutoSet For Her version. It has an optional For Her mode in the machine that is better for treating hypopneas and RERA events. It also has the advanced features that can be set for getting to sleep.

Here is a link that provides a deep dive into how a titration test is done and the various options for treatment. But, at this point it would be really helpful to get more detail on what the outcome of the titration test was. At this point I don't see anything that would suggest you need a AirCurve BiLevel or ASV type of machine.

Sleep Lab Titration Guide

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Sierra +0 points · 23 days ago Sleep Enthusiast

Getting back to your issue of apnea right at sleep onset, that could be either central or obstructive. Your muscles relax when you go to sleep and it is quite possible that your upper airway constricts to reduce flow or even collapses stopping flow as you go to sleep. Since your sleep report had no central apneas reported, it seems more likely that it is obstructive. It would be helpful to know if any centrals were detected during the titration test, as the pressure from the test can produce central apneas.

But, assuming the more likely case of it being obstructive in nature, and that the hypopneas are a flow reduction due to upper airway restriction, a PAP device is likely to address the issue. If you get the pressure in the airway up BEFORE you go to sleep it is much less likely to have the airway collapse when you do fall asleep.

The next step should be to get a trial machine and see what the machine can do for you in actual use at home. It would be most efficient to get a flexible machine like the ResMed For Her AutoSet, as it can be set up to get you to sleep in a few different ways, which you could try to see which works the best. They would be:

  • Use it in CPAP fixed pressure mode and start at that fixed pressure with no ramp up or hold in pressure. The machine will be active right from the start in detecting any apnea events, so you will quickly see if you continue to have sleep onset apneas, and what pressure is required to stop them. That said they should know that from the titration test...
  • You could add in the ramp/hold and use EPR and not use EPR during the ramp or hold.
  • You could use the For Her AutoSet algorithm to see if that works best for hypopnea reduction while sleeping, or if the standard mode works best.

In other words lots of options to try. I suspect one of them will work for you.

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p3000g +1 point · 18 days ago Original Poster

But won't starting the CPAP without the ramp make it uncomfortable for a first time user? Also , how much ramp time do you set initially?

Also, sorry if this has been answered before, can you please explain why the autoset for her is helpful for hypopneas?

Greatly appreciated

Thanks

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Subrahmanya +0 points · 18 days ago

Any comments on my reports ? Just wanted to know which part I need to take care in my report

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Subrahmanya +0 points · 18 days ago

can anyone please help me to review my report and where I need to take care ?

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Sierra +0 points · 12 days ago Sleep Enthusiast

I would try turning off FLEX to see if that helps.

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Sierra +0 points · 17 days ago Sleep Enthusiast

I find with EPR at 3 on ramp only I find a ramp start pressure up to 8 or 9 quite comfortable.

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Sierra +0 points · 17 days ago Sleep Enthusiast

If you set the ramp type to auto it will stay at the ramp start pressure until you go to sleep, 30 min max. The for her mode is more responsive to hypopnea, and less to apnea. And if it does not work well in the for her mode, you can just switch it to standard mode.

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p3000g +0 points · 10 days ago Original Poster

Going through this, one question popped up in my head. How could a hypopnea possibly be central?With Central sleep apnea you are either breathing or not breahing at all.Is there something like partial breathing? Like a partial airway closing in case of obstructive hypopnea .

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