18 mths of apap: need help optimizing settings to feel better [ASV]

[ajack]

The UA, H, FL are treated by min epap with an ASV. A normal bilevel is titrated differently. We don't know where the CA and other events like PB and such, that an ASV will treat, because they aren't flagged. You will need to zoom in and go along the chart. To see where maxps9 was used and if it was enough to clear the event. That's why it's easier to raise the maxps to at least the default setting of 15 and let the machine work it out.

[sheepless]

thanks. I'll take your word for it for this exercise but I still don't get it. if there are any 10 second pauses in the flow rate with the requisite definitional reduction in flow, they'll be flagged as ua. if that's true (and I believe it is), it'll be included in ahi. my current ahi is pretty hard to improve on.

it doesn't make sense to me that untreated ca would not be in ua and ahi because the machine doesn't differentiate oa and ca. how would it 'know' to include oa and exclude ca?

in addition, I've had open and higher max ps before and I have better results (ahi) with current settings, so I'm of a mind that even if I didn't know it I already let the machine work through it. have you had a glance at the 1.5 pages of settings I've tried, posted above?

again, not fighting you, just trying to understand. it'll be interesting to take a look.

I'll get back to you after I see what I can see.

[sheepless]

I started looking at ua. I don't know how to tell ca from oa. I need something to go on to differentiate.

large breath beforehand? no large breath beforehand? no bumps indicating respiratory effort? what?

replies and links to illustrations appreciated.

epap rose immediately after the 3 ua I had in last 2 nights. is that enough to rule out ca for those events?

edit: I've had 17 ua since 6.1.19. epap rises immediately after every one. only one is a bumpless smooth line and that was while holding my breath while rolling over during the first minute or so of a session. unfortunately, epap went up after that one too so IDK if epap is an indicator or not?

[sheepless]

going back 2 months, see attached shot of the 1st ua I've found that looks different than the others insofar as it is relatively smooth and without a biggish inhale just before it.  epap went up with this as it has with all others looked at so far.  is this the kind of thing I'm looking for (ca)?

[ajack]

That was a an obstructive UA the ps6 couldn't clear. You can see the mask pressure rise. to stop them you raise min epap. A H, FL is obstructive and you see them as you would on apap, it will ps rise to try and duplicate minute vent flow. a CSA will have a rise in mask pressure and a flow rate, it is whether this flow rate is enough.

A ca isn't flaged as a UA, for the same reason a H isn't, because there is enough flow with the PS6, to not register as a full obstruction. The ps6 is enough to vent the lung a bit and not flag as a restriction. No CA will be tagged, resmed say this themselves. It's whether they are effectively being treated is the issue.
I suggest you do some reading, I've shared all I know with you.

[sheepless]

okay, thanks for your attention this far. I guess we've both reached our limits; I don't know what else to do until/unless I understand how to recognize a ca in the flow rate.

always looking to do better but I really do think I'm doing ok as is. I'll play around with it for while based on what you've told me.

you are right, we're not communicating well.

almost afraid to ask: I'm not following your reference to ps6. did you mean ps9?

you said: "A ca isn't flaged as a UA because there is enough flow with the PS6, to not register as an obstruction." I don't think I understand that statement at all but I read it to imply all ua flagged at ps6 + are ca. somehow I doubt that's what you mean?

I need to clarify how asv deals with ca. not clear to me if ca are not flagged as ca or not flagged as ua.

guess I have some homework to do. meanwhile, if anyone can add to this discussion, and help me understand it, please do.

thanks again for trying ajack.

[ajack]

typo, I meant ps6. I just can't convey that AHI, that is displayed without counting CA, that you see in oscar. Is a minor part that cpap will treat. It is different to what ASV mainly treats.
I really wish you well, or I wouldn't have posted as much as I did. I think you are right and we should leave it here.

[sheepless]

ajack and others: I was going to wait a few more days but I'm impatient and things are a bit slow on the forum at the moment so...

you've piqued my curiosity.  I now have 4 nights after spinning the dial to get max ps 17.6 for max ipap 29.6; min epap 7.4 + max ps 17.6 = effective max 25 cmw.  I believe that's what you were encouraging me to do.

good ahi at 0.12.  no negative effects noticed (e.g., leaks, aerophagia -  I think it's high min pressures that worsen those problems).  

I still don't know exactly what you want me to look for.  I've attached 4 places in last night's flow that are relatively flat with ps rising to nearly 25 and epap stable.  are any of these what you want to see?  if so, I can reformat to increase the height of graphs by splitting them into 2 views.   edit: I see now that epap does rise slightly after the ua.

I think you are looking for ca that aren't resolved by max ps.  I assume most of these will be under 10 seconds and not flagged as ua.  I found 9 or 10 like that in nights before raising max ps from 9 cmw.  but I don't know how to tell ca from oa.  

my guess is that if any ca is left after ps goes close to 25, there's not much left to help with that anyway.  makes more sense you want to see the unresolved ca at a lower max ps like the 9 I had set before this.  but since I don't know what I'm looking for and these stood out to me your feedback might help me figure out what to show you next.  maybe the point is moot if I leave max ps at highest setting?  still, I'm curious.  and I'd love to learn how to identify ca.  

meanwhile, no apparent harm and maybe a slight improvement at this max ps setting.  after a few more days of this I plan to try to reduce flagged and unflagged flow limitations and try to reduce the magnitude of swings in ps.

[sheepless]

I'm so excited, I want to share:  despite one of the highest ahi in months, last night is the first night in decades that I can remember sleeping more than 8 uninterrupted hours!  8 hours 56 minutes.  I should frame the chart.  

session length has been creeping up for the last year with asv but this one is a huge moral victory.  they said it would take several days for rOPINIRole (no idea why it's spelled that way), brand name Requip, to work.  last night was my second dose and the pattern I associate with periodic limb movement is substantially reduced, almost but not quite invisible. it's early days but I'm hoping against hope this might finally be resolution to the horrible fragmentation I've experienced for so many years.

is this what normal sleep feels like?  today I feel almost euphoric, manic in comparison to my usual lethargy and complete lack of vitality.  a little like being high without the stupid that goes along with that; not really but you know what I mean.  I feel more alert and energetic than, well, maybe ever, certainly anytime in memory.  I want more of this please.  

[mper6794]

Hi Sheepless,
After going through this thread, trying to understand your case, I have these first impressions and questions:
(a)_What a quest and suffering from your part all these years; I empathize!
(b)_ Unfortunately, I don’t why, I could not get any picture from the time you used VAUTO rather than ASV, so I have not understood why you have been on ASV, exactly?
©_ It looks to me you have got lost into details of the waveforms;
(d)_It looks to me you have a very important and untreated UARS, as well as PLM’s. It was not possible yet to get the relationship between these two in your case;
So, I was wondering if I could help after so many more experienced people already have gone through your case. Anyway, I am curious. Could you please:
1_ replot your last full night picture, with wave forms and scales like this, from top downward
Don’t need event chart
Pressure
Flow limitation (compressed)
Flow Rate (-120 to 120)
Tidal Volume (max 1000, adding the median reference line)
Leak
Then plot some 10min-windows, please. Initial idea is to fly by your forest, before examining the trees.
Good luck