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18 mths of apap: need help optimizing settings to feel better
RE: 18 mths of apap: need help optimizing settings to feel better
Hi, sheepless, Will

that's fine.... let us suppose your normal RR around 7.0....implies your RR would slow down by decreasing from 8.0....

I plan to go to more details later on.

for now, I suggest for next night:
EPAPmin: 7.6, PS: 4.4...we would need to quickly to adjust these parameters to tame remaining FL.....weird points, if they occur, are invaluabe to do this!
IPAPmax: EPAPmin+PS : 12.0

good luck
good luck
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RE: 18 mths of apap: need help optimizing settings to feel better
Hi, sheepless

Just to put some historic, and illustrate how hard is changing paradigms.
You started this thread on Sept 5th,2018; 425 days ago. On Aug, 30th, this year, I posted this here:

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
Flow limitation (compressed)
Flow Rate (-120 to 120)
Tidal Volume (max 1000, adding the median reference line)
Then plot some 10min-windows, please. Initial idea is to fly by your forest, before examining the trees.
Good luck

Your case called my attention because, hidden behind some arousal-associated fake CA’s, OA H, could be actually a typical case of unresolved UARS-PLMS. This diagnostic kept confirming day after day, since ASV times do most recent VAUTO times.
At one point in time, it became clear for me that ASV had become deleterious for you, basically because it was increasing-pressure responding to anomalous, false FL during PLMS-driven arousals.

Then, very fortunately, you decided to move to BPAP, which in my opinion would be the correct machine for you.

Now, I know it is hard to accept new paradigms in general. I think I know this very well, since my old days as a nature’s sciences’ researcher professional. I am resilient, though, at least up to the point I feel I am not bothering anybody.

Learning from 210-day therapy, and experiencing (registering everything) a great deal with BPAP, EPAPmin (4.0 to 7.8), PS (3.0 to 7.0), and so on, some 90 days ago, I realized I could manage this semi-quantitatively, empirically, and predictively. The median RR (includes drops associated with false CA’s themselves) would be the anchor, very sensitive to EPAPmin and PS.

CA’s increase with PS? Yes, they do, however only above the point tighten with your normal RR. And, also, is more difficult to surpass the CA’s triggering threshold while increasing EPAPmin at the same time.

Now, in practical terms, in what point you are in all of this, aiming at the best you could get with the BPAP and parameters ? Well, hoping you believe in me, you would be within maximum 30 days to get at that point, in part because you could count on my 210-days experiencing on that approach. And, also, of course, thanks to so many invaluable inputs from so many other experienced fellows here.

Concerning how you feel (HYF). Well, I wish we could go even faster than 1 month, overnight maybe, but I am afraid it would not be possible. That because, we have not yet given the very first step, that is, get your tailored EPAPmin and PS (I would predict this within maximum 15 days). After this, we will see how smooth is going to be your curves, concerning your tens of tens of micro arousals (1.5 to 3.0 secs), arousals (3.0 to 15 secs), and awakenings (>15.0 secs).

Then, you, your doctor, would see what be the best approach to tackle your PLMS, so that you could start experiencing going to some delta/REM sleeps, and, in consequence, experiencing better HYF.

Meanwhile, maybe it would be interesting bear in mind you have got significant achievements, in particular the diagnostic of what seems to be your main drawbacks, UARS-PLMS, and maybe the tailored machine to handle those, the BPAP, rather than the ASV.

Good luck
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RE: 18 mths of apap: need help optimizing settings to feel better
mper and anyone else that cares to comment:

for tonight I changed settings to your suggestions: dropped epap from 8 to 7.6, ps 4.4, ipap 12.0.  I changed trigger back to med from high (high substantially reduced ahi and cai, but now med as you suggest) and ti min from .03 to .08 as you suggest.  

screenshots from last night are attached.  these are intended to be a broad overview.  let me know if you want a different scale or different graphs. 

I remain interested in / concerned by the fact that pressure hasn't wavered off settings for the last 2 nights.  IDK why epap doesn't rise against obstructives and it's apparent the machine wants to go higher than ipap max.    

meanwhile, I'm not clear whether (and why) we're using rr/2 or rr*0.89 and exactly how it's used.  I guess I can figure out how to do a scatterplot in a spreadsheet or on paper but I'm still not sure what it tells us. 

re paradigm shift: yes, that's what this feels like.  altering one's assumptions and approach make me want to understand how and why, which probably sounds skeptical, but I'm open to finding out where this leads.  goodness knows, I'm still dragging.

re 'undisciplined nice fellow': great term! very tactful. it made me laugh.  I think the only thing anyone can know about my sleep hygiene is that I continue to nap during the day, so I assume that's what you're referring to.  all I can say is that the day I don't need to nap is the day I will stop.  it's an indication of how inadequate my treatment continues to be.  I yearn for the day I'm rested enough to not feel the need.  I believe my naps do more to compensate for poor quality fragmented nighttime sleep than detract from what might be better sleep without the naps.  someday when nighttime sleep is good, naps might have a negative impact, but I'm not there yet.  I have no trouble falling quickly asleep almost anytime of the day or night.

Attached Files Thumbnail(s)
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RE: 18 mths of apap: need help optimizing settings to feel better
Hi, sheepless
_ that was a interesting night! However, your settings were: EPAPmin 8...PS: 5.0...IPAPmax: 13, which accidentally brought invaluable information toward your fine-tuned parameters. It looks, as expected due to your very low RR while awake, you are going to tolerate higher PS without detrimental CA's, at least > 5.0, we already can see.
_ it looks we are moving in right direction. I have the impression your waveforms are becoming more smooth, which mean less awakenings, maybe. You know, we UARS-PLMS, target lower arousal/awakenings, not AHI.
_from your sooooooo compressed charts, it looks your arousals/awakenings are becoming, luckily, more RERA's-driven, maybe diminishing PLMS-driven ones. This would very good news, if it confirms. That because, we have room to fine-tuning your parameters toward this goal.
_to go further and suggest changes; I would need better understanding your patterns, starting discriminate between your RERA's-driven and PLMS-driven awakenings, etc: For that, I would need you blow up your charts for me, and only these ones, please, if possible, top-downward:

: no need for event chart, as long events are superimposed on the others
:no need for pressure, as we already know they are flat all the way
: RR pinned right on top, scale 13---22
: FR..-120 to 120
:FL (can be very compressed)
: TV, scale 250 to 800
: leak

Full night and 10min-windows at same curves, same order, scales, please. Otherwise this piece by piece analysis could be misleading.

all the best.
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RE: 18 mths of apap: need help optimizing settings to feel better
...median reference line on both RR and TV, please.

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RE: 18 mths of apap: need help optimizing settings to feel better
...to better understanding your curves: on what medications you would be? If any....
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RE: 18 mths of apap: need help optimizing settings to feel better
1. do you want me to revise the charts in post #213 or new ones from last night at your suggested settings, or both?

2. meds: atenolol, atorvastatin & baby aspirin for blood pressure, losartan for cholesterol, ripinirol for periodic limb movement, testosterone. frequently I use a certain strain of cannabis concentrate before bed that helps me sleep through plm.

3. new charts to follow later today.
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RE: 18 mths of apap: need help optimizing settings to feel better
Just so anyone looking on, myself included, can get on the same page, you're no longer on an ASV stated on your left panel profile and on a VAuto, is that accurate? I'm sure you're not adjusting Ti Min, etc. on a ResMed 10s ASV.

I'm not a doctor in real or fictional life. My posts include opinions based upon user experience regarding CPAP therapy and should not be considered medically professional direction or advice.

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RE: 18 mths of apap: need help optimizing settings to feel better
yes. experimenting with vauto. changing settings frequently and noting so in posts. I was going to change the profile if I don't revert to asv soon but your question tells me I shouldn't wait. thanks.
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