Sierra

If your ramp time is set to Auto, then I think you have not set your Ramp Start pressure high enough. I think you will gain some comfort by going to a Ramp Start pressure of 7 cm, EPR at 3, and set to Ramp only.

Your SleepyHead charts above indicate you have the EPR on full time. If you switch it to ramp only, your pressures should come down some, and/or AHI improve.

I see what you are doing with the test. Trying to sleep at only 4 cm might be pretty uncomfortable. EPR won't help for the test, as the machine will not go below 4 cm for pressure. However, short of going to a home sleep test, or lab sleep test, that is about the only way you can test the effectiveness of the MAD yourself.

Your second graph set shows that 10 for a max, especially with EPR on ramp only, may be enough. You just have to watch the graphs to see if it maxes out during the night.

I would be interested to see how it turns out for you.

I agree. The most common mistake made with pressure settings is having the minimum pressure too low, and just as important having the ramp start pressure too low. Out of the box these are both set at 4 cm, and some sleep techs do not bother to change them. A start ramp pressure of 7-8 cm and a minimum pressure in the range of 8 is much more comfortable.

What kind of machine do you have and what are the pressure settings on it? What mask works the best for you? That would help in trying to make some suggestions...

A quick check on line showed no interaction between pramipexole and melatonin. There is a moderate interaction between pramipexole and alcohol. See this link. I agree with BUG, in that the pharmacist is a good source of information in addition to the doctor.

If you post your questions here, I would be willing to try and answer them.

During the sleep test they monitor snoring either with a microphone, or by measuring the vibration in the air flow. Since they reported it in dB that is a sound level, so it must have been with a microphone. Stopping breathing is an apnea. It is measured in the number of events per hour, so you had 90 per hour of sleep. This is normally called the AHI score, or apnea hypopnea index. Oxygen goes down when breathing stops, and you had oxygen go down almost as many times as you had apnea events. Normally oxygen should not go down below about 90% and it looks like you hit 51%. That would indicate at least some of your apnea events are quite long. They have to be 10 seconds minimum to be counted, but could go on for minutes.

Those are all the standard numbers reported for a sleep test, so it look quite credible and it looks quite certain that you have sleep apnea. An AHI of 5 to 15 is considered mild apnea. From 15 to 30 is moderate apnea, and anything above 30 is severe apnea. Your apnea is at the high end of the severe range, so there is little doubt you have sleep apnea.

What is missing from your numbers is the type of apnea events. They are normally broken down into obstructive apnea, central apnea, and hypopnea. Obstructive apnea (airway getting blocked) as well as hypopnea and snoring are all obstructive issues. These can all be reduced with a CPAP machine. Central apnea is different. It is when the airway is not blocked, but your body simply decides to not breathe. This type of apnea is not corrected well with a CPAP machine, and it in fact may make it worse. So, before you go to the next step it would be important to clarify what type of apnea events you are having. Central apnea can be associated with heart issues, and certain medications, especially opioids.

If you have more questions just ask,

I am not a medical professional and the sum total of all the issues you are having is way beyond my understanding of heart and lung issues. That said, I think your APAP is set up as well as it can be set up, and most likely sleep issues and UARS are not likely the root of the problem. I think I have suggested it before, but my doctor believes bisoprolol is a better beta blocker than metaprolol. You may want to ask your doctor what they think and if you could benefit from a switch. Here is an article to read about beta blockers. I think one of the issues with beta blockers is that they should be introduced slowly and taken away slowly so they do not cause a rebound effect. The other difference between them is in how uniform they act during the 24 hour period. Bisoprolol tends to be more uniform than metaprolol. And that is about all I know about it!!

I wouldn't give up on your CPAP just yet. There are a few things that seem a bit abnormal. First your setup clip shows a full face mask. Is that correct? If you have a full face, it does not make a lot of sense that you would need a chin strap. Some wear them, but mainly to keep their mouth closed so air does not leak out when using a nasal or nasal pillow type mask. Your graphs do not show the leakage rates. It would be helpful to see if leaks are an issue. For the leakage graphs to be accurate the mask type has to match what you have for a mask.

Getting the pillow right is important. That is kind of personal and I suggest you try different types. The main purpose is to keep your head reasonably aligned so you are not kinking your neck, and also so there is room for the mask. I use a down alternative pillow and that works for me. Some people find they get a lot of help from a drug store cervical collar to keep their head neck aligned. Your rapid sequence of obstructive events one night that are not there another night kind of suggests this may be an issue. They are $20 or so at Walmart or other drug stores. I see no harm in using the MAD, but it really should not be necessary.

I would suggest your machine is not really set up for comfort the best. The minimum pressure of 4 cm is very low, and most people feel they are suffocating when using 4 cm as a start pressure. You also do not seem to be using the A10's AutoRamp feature, which I think is the best feature this machine has. I would also discourage the use of EPR when you are sleeping. The machine can be set so that it uses EPR while you are awake and then switched to no EPR when you go to sleep. EPR can reduce the effectiveness of the machine.

Here is how I would suggest setting up the machine for more comfort. To make some of these changes you have to go into the Clinical menu. That is quite simple. Just press and hold the rectangular Home key and the round Set key at the same time for 5 seconds. When you are in there you navigate the same as in the user menu. With what you have I would suggest the following settings:

• Minimum Pressure: 8 cm, you are currently at 4 cm which is too low for any comfort or effectiveness
• Mask: Confirm or set it to match what you are using for a mask
• Ramp Time: set it to Auto
• Start Pressure: 7 cm, you are currently at 4 which is too low
• EPR: On, you currently have it on which is ok
• EPR Type: Ramp Only, this will shut EPR off after you go to sleep
• EPR Level: 3, you currently have it at 2. Setting it at 3 is more comfortable, and it will go off after you go to sleep

When set this way, your machine will give you 7 cm on inhale, and 4 cm on exhale, which most find very comfortable. It will hold at this setting until you go to sleep. When you go to sleep the reduction in exhale (EPR) will stop, and you will go to 8 cm for inhale and exhale. You should not notice this, as you will be asleep by then.

That is about it, but when you are in there it would be good to go a bit further down in the menu to Options and make this change:

• Essentials: Plus, This will give you a more detailed sleep report right on your machine.

Hope that helps some. Here is a link to a technical manual that has all the details. If you do not feel comfortable making these changes yourself then ask your sleep tech to make them for you.

Once you get a handle on how the machine is reacting with the revised settings, and possibly using a cervical collar to help with what might be a positional issue while sleeping, you may want to revisit the minimum pressure setting. One can normally gain some reduction in AHI by trying higher minimum pressures. This will help to prevent unnecessary OA events, that trigger the machine to increase pressure.

Hope that helps. Any questions just ask.

I presume you in the US? In the UK their National Health Service will not treat sleep apnea unless it is over an AHI of 15. In Canada and the US the recommended treatment level starts at >5 for AHI. In your case oxygen seems fairly low, and I think snoring alone can disturb sleep especially if you have a sleep partner.

Dental MAD devices tend to be quite expensive compared to CPAP, but they certainly should be effective in the mild apnea (5-15) range you are in. An on line CPAP setup is in the $800-900 range. Losing weight of course would help and with an AHI of 7 you would likely get down into the normal <5 range.

It is kind of your call which way you go. At home sleep studies typically divide the number of apnea incidents by the time in bed. A lab sleep test will divide the number of apnea events by the time actually sleeping. For that reason at home studies can underestimate the actual AHI as we don't have apnea events when we are awake. So, it is possible your apnea is actually a bit higher than 7. Something to consider.

I think many suffer from that to some degree, and about all you can do is make the going to sleep part as comfortable as possible. I would suggest going to the Clinical Menu (hold home key and round set key at same time for about 5 seconds), and set you machine as follows:

Go to the Comfort section of the Clinical Menu and make these settings:

• Ramp Time - Auto
• Start Pressure - 7 cm (although if that does not feel like enough air, you can go higher. I use 9 cm)
• EPR - On
• EPR Type - Ramp Only
• EPR Level - 3 cm

This will make breathing easier until the machine decides you are asleep. When you are then it will ramp up to your normal 10.8 cm fixed pressure.