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A Lost Cause?
#1
A Lost Cause?
I have been discussing some aspects of my current CPAP situation on the Software Forum thread "Having a problem with screenshots".  Since I think I have solved that problem (hopefully), it seems more appropriate to go ahead with my presentation here in the Main Forum.

In spite of the title chosen, I assure you I'm optimistic that there is a solution and that with your collective help I'll be able to progress much more rapidly than if I were left to the tender mercies of my sleep doctor and his eager staff.

Brief History: I'm 83 and from the way I've felt over time it's quite possible I've had treatable sleep apnea for about 40 years. (I definitely do not want to discuss this dismal fact.)  I started my CPAP Dec. 26, 2018.  I've not been diagnosed with any particular respiratory disorder but told (and tell myself) that I "have allergies."  Incident to starting with CPAP I have felt considerable relief from night time congestion.

Rather than going on, perhaps the following screenshots will elicit some discussion:

The Ugly (Jan. 29, 2019):
       

The Bad (Mar. 6, 2019):
     

Although this still looks bad I would note that this is the first night I've slept eight hours in a while, certainly since starting CPAP.  Note also that pressure setting are higher here 8/15 whereas the ugly was 5/15.  Things started to "feel" better with an increase of min pressure from 5 to 7 and I upped it to 8.  I'm receptive to increasing the min pressure but uncertain just how much.  No problems accepting pressure increases so far.  So far as I call recall the pressure has never maxed-out at 15.

The Good:
???

obob
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#2
RE: A Lost Cause?
Things certainly improved with the increase in minimum pressure to 8.0. There are a couple odd things going on in the inspiration/expiration time that are fairly typical with Philips machines. We will need to see a close-up of the flow rate graph to really see what is going on, but I suspect flow limitation. Let me know what Flex settings you are currently using. You look like a better candidate for a Resmed, but we will work with what you have.

Zoom into a 2-minute time period so the flow rate wave form is clearly visible. I suspect we will see some flat-topped waves.
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#3
RE: A Lost Cause?
Like these (at lower & higher pressure)?
       

I can look for possibly better examples.  Any suggestions where best to look?

Thanks very much for your reply.

obob
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#4
RE: A Lost Cause?
Well, that confirms the suspicion of inspiratory flow limitation. The fact you improved with higher pressure, makes me want to have you gradually increase pressure, while making notes of both the results and how you feel. Most of your events at this point are hypopnea, and they are being caused by whatever is restricting your inspiratory flow rate, so that is the root cause that we want to go after.

There are several ways that this kind of inspiratory flow restriction can occur, including nasal congestion, pressure in the upper airway where the soft palate is, and pulmonary restriction such as COPD, bronchitis and such. I don't really suspect a pulmonary issue with you because of how easily you exhale, so we're going to focus on upper airway restriction. The upper airway is stented open by CPAP pressure. The pressure actually expands the airway allowing you to breath easier. The pressure does not necessarily assist your breathing effort, that is the job of a bilevel machine which can produce higher inspiratory pressure and lower exhale pressure. The difference between inhale and exhale is called "pressure support". Your machine doesn't do that, but it is a great way to treat flow limitation and hypopnea. In your case, we are left with increasing minimum pressure to help make your airway larger.

I'd like to start stepping your pressure up to 10 cm, but in 0.5 cm increments. Start at 8.5 and progress to 9.0, 9.5 and finally 10.0. As you go, let's keep track of your AHI and especially how you feel. We should see the flow limitation and resulting hypopnea be reduced. We will also want to monitor the Flex setting you are using, so please let me know what that is currently at. I would not advise any flex setting of 3, and would stick to 1 or 2.
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#5
RE: A Lost Cause?
Thanks Sleeprider for your thoughtful appraisal. I'm entirely committed to following your suggestions. Would you suggest incrementing my pressure up by 0.5 cm each week, or two weeks? I should note that for the first several months (to the present) results have been erratic, varying between AHI in the 20s and below 5, but averages progressing lower.

My machine is set on Flex A and Flex 3. I don't know what these mean but gather they relate to the pressure support the PR machine provides.

obob
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#6
RE: A Lost Cause?
Sleeprider: OK. Looked at the Wiki and think I understand, so I've set the machine minimum pressure up 0.5 cm (to 8.5 cm) and reduced flex to 1 (Flex A). I'll try that for a while and then up the minimum again. Headed for 10 cm.

Again, many thanks!

obob
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#7
RE: A Lost Cause?
That should work fine. A Sleep lab titration evaluates a setting for 20 minutes to 2-hours, so I'm usually able to make conclusions based on a night of therapy, but longer intervals are fine and give more certainty. Your issues are not really very complicated, and I think you're going to see a nice improvement as we move a bit higher with the minimum pressure.
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#8
RE: A Lost Cause?
OK I'll increase min P to 9.0 cm tonight.

Last night, with min P set at 8.5 cm.  AHI=3.40 seems pretty good ("cured" so far as the system is concerned) and except for the two clusters of CAs while falling asleep the score would be much better. I'll return to the CAs below, but for now say that I feel pretty good (50%, say, on a meaningless scale.) The test of that will be forthcoming this afternoon when I usually slump badly.  

   

The two 3.3 hr segments are, first, sleep on L side then on my R. I'm more or less immobilized by tennis balls strapped to my back, which usually works to keep me in place.  

Flow looks limited both at the lowest (EP=7.00) and highest (EP=8.00)(both in the second segment.)

       

Found an EP=8.10 in the first segment:

   

Thank you for looking at this.

obob

PS:  Subsequent to trying to write this while someone was talking in background I would lower my "feel score" to 40%
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#9
RE: A Lost Cause?
A brief comment about CAs, I've seen these differences before, of concatenated CAs occurring when falling asleep and waking. It has been the norm since I got my machine to have these (usually brief) CA strings, and sometimes very long ones before waking. They can be torturous if I am too immobilized to fully wake. I doubt they are pressure induced central apneas. More likely a hysterical response to flow limitation causing hyperventilation, CA, et seq.

The other pattern I've noticed is the reduction of H events and increase of REs. I'm not surprised to see them now. But here today gone tomorrow, there has been no consistent trend from Hs to REs.

obob
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#10
RE: A Lost Cause?
The cluster of CA right during sleep transition as you start to sleep or wake is often referred to as sleep-wake-junk (SWJ). I think it is even mentioned in the wiki. SWJ is common and usually disappears. Don't count it against your results. To me, the flow limitation looks improved, the higher pressure segment looks better th an the lower pressure, so I think we're headed the right direction. . The I:E ratio is improved, but still not where a Resmed would put you.

You didn't mention how your therapy felt qualitatively, but this just looks better all around. Let's continue.
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