AXG Sleep Diagnostics?

[cmpman1974]

Post that data here and see what we can see.  The ResMed AirCurve 10 ST-A is one of the more advanced machines out there.  Do you know why it was chosen?  Other than Apnea, what other medical disorders do you have? COPD, asthma, neuromuscular issues, Brain Injury, Stroke, Meds especially painkillers. anything anti-anxiety wide. what else is going on?

I have posted last night's sleep data.  I was told it was chosen due to me having Obesity Hyperventilation Syndrome.  My Arterial Blood Gases were normal at rest, but PACO2 was high normal.  PAO2 was completely normal.  I do not have the other conditions mentioned, but I do have pulmonary hypertension, Hashimoto's, etc.  I take no pain meds, though my back and spine are extremely stiff due to bad degenerative / stenosis issues.  I do take Baclofen at night (muscle relaxer - small dose). 

This ST-A machine has been a trainwreck for me honestly.  Every morning I wake up, my abdominal muscles feel sore.  My abdomen feels more swollen/distended.  I'm getting REALLY frustrated.  I feel no more rested at all.  Tried adjusting my mask every which way and zero success minimizing leaks.  The DME promised me this Vitera mask was 'the one' that would help...yep sure.  Funny how I never hear from them now after I have it. 

Also my O2 data from Lookee's Wrist monitor showed this last night:  54 min under 90%; 15 drops over 4%; drops per hr: 2.0; avg O2: 93%; lowest O2: 83%. ; Avg pulse rate: 54 BPM

[cmpman1974]

Just crazy stuff....

[Jay51]

Cmpman,  I was first prescribed the the ST (A) after my polysomnography also.  OSA, CSA, and hypoventilation.  Struggled horribly with it like you are.  I tried about 75 times to fall asleep with it, and only fell asleep with it once.  I woke up almost immediately after falling asleep though.  Gave up when I finally saw I was not going to meet compliance.  

Pain in my lungs (felt like they were going to pop - from being hyperventilated).  Pain in my stomach from ST (A) pumping air into my stomach.  Massive leaks from huge swings in pressure.   Your respiratory rate may be set too high.  Your tidal volume may be set too high also (it has been awhile since I have used it but I think ST (A) has a tidal volume setting - I know IVAPS does. Dialing these  2 settings back some and controlling leaks better could make for more quality sleep.   

I had to find a way to keep the machine from reaching such high pressures so I could tolerate it.  Soft cervical collar helped with OSA a lot (not sure with your spinal condition you could tolerate it).  Your tidal volume is higher than normal using ST (A).  Respiratory rate is normal.  Minute vent gets high also.  Normal Vt is around 500 for an adult male.  You have EPAP listed at 10.  Does ST (A) have an EPAP min and max?  If so can set min. lower at least to try and can keep max at 10 or even possibly higher. .  PS of 5 min and 10 seems ok to me.  

I had to make the radical move of sleeping more upright (recliner or 45 degree wedge) to better open my airway, and help me breath better through my nose, etc.  You may not be able to with your spinal condition.  A soft cervical collar is essential for me.  

The last major move was to get a PulseOX (capnography/capnometry) overnight home evaluation.  It diagnoses hypoventilation and got me this ventilator.  The AVAPS is the only machine I know that has an "auto" rate - if your spontaneous breathing rate is fast enough during the night it should work.  It is otherwise similar to the IVAPS.  I have tried both and AVAPS is slower reacting, which for me meant falling asleep faster and staying asleep longer (and turned out to be just as good therapy by SPo2 testing).  

I just wanted to share my experience to see if anything here might help you.  You have a good plan (possibly seeing Jason) also if you need to.  I hope you figure things out.

[cmpman1974]

Cmpman,  I was first prescribed the the ST (A) after my polysomnography also.  OSA, CSA, and hypoventilation.  Struggled horribly with it like you are.  I tried about 75 times to fall asleep with it, and only fell asleep with it once.  I woke up almost immediately after falling asleep though.  Gave up when I finally saw I was not going to meet compliance.  

Pain in my lungs (felt like they were going to pop - from being hyperventilated).  Pain in my stomach from ST (A) pumping air into my stomach.  Massive leaks from huge swings in pressure.   Your respiratory rate may be set too high.  Your tidal volume may be set too high also (it has been awhile since I have used it but I think ST (A) has a tidal volume setting - I know IVAPS does. Dialing these  2 settings back some and controlling leaks better could make for more quality sleep.   

I had to find a way to keep the machine from reaching such high pressures so I could tolerate it.  Soft cervical collar helped with OSA a lot (not sure with your spinal condition you could tolerate it).  Your tidal volume is higher than normal using ST (A).  Respiratory rate is normal.  Minute vent gets high also.  Normal Vt is around 500 for an adult male.  You have EPAP listed at 10.  Does ST (A) have an EPAP min and max?  If so can set min. lower at least to try and can keep max at 10 or even possibly higher. .  PS of 5 min and 10 seems ok to me.  

I had to make the radical move of sleeping more upright (recliner or 45 degree wedge) to better open my airway, and help me breath better through my nose, etc.  You may not be able to with your spinal condition.  A soft cervical collar is essential for me.  

The last major move was to get a PulseOX (capnography/capnometry) overnight home evaluation.  It diagnoses hypoventilation and got me this ventilator.  The AVAPS is the only machine I know that has an "auto" rate - if your spontaneous breathing rate is fast enough during the night it should work.  It is otherwise similar to the IVAPS.  I have tried both and AVAPS is slower reacting, which for me meant falling asleep faster and staying asleep longer (and turned out to be just as good therapy by SPo2 testing).  

I just wanted to share my experience to see if anything here might help you.  You have a good plan (possibly seeing Jason) also if you need to.  I hope you figure things out.

I'm sorry to hear you went through so much as well.  I truly am regretting accepting this machine as life has been pretty miserable from a functioning standpoint.  The one difference is I have had no issues getting asleep and generally staying asleep with it from day one.  However, it has not resulted in any measurable positive change healthwise I can tell.  I feel like crap and the muscle issues worsened.  I just got off the phone with my pulmonary doctor (not sleep specialist).  He concurred these are some big tidal volumes for someone my height as you indicated too. 

The Air Curve 10 ST-A has no min/max EPAP settings.  Just one setting for EPAP (currently 10).  It has pressure support min and max to determine IPAP levels. 

My bed has the ability to incline the head and foot area and I have the head up a fair amount, albeit not 45 deg level.   So far, no help from what I can see.  I don't believe this machine has an auto rate, but I could be wrong.   It has multiple modes on the menu.  I used to have Easy Breathe on my AutoSV BPAP I had before.  I miss that option. 

I hate the idea of dropping $300 on a consult, but my case is complicated and I may truly need in-depth help to try to improve.  There are some real bright people here, but they don't have full access to every min of every night to review on OSCAR.   I need to truly understand just how bad and how often things are happening on the ST-A and why I'm getting these massive volumes for median levels. 

Like you, I got the 24 hr O2 meter to supplement my BPAP ST-A unit.  I can't attest to accuracy on the Lookee unit, but as people said here, it's a baseline.  if O2 dropped to 84% during the night last night, it seems safe to say my therapy is not fully effective.   I have no doubt the herniated discs in the back and having two real bad shoulders complicates stuff too.  My muscles are so tight that it makes breathing naturally and fully a chore.  All the added weight also makes it worse.  I'm battling so many things at once.

[Jay51]

I looked through your 3 threads.  Definitely get AXG the last one, or all of your sleep studies (copies) if you choose to go that route.  They might show an important piece of the puzzle.  

Sleeprider looked at mine here and opened my eyes to some things.  You have gotten great help from Gideon here also.  One thing I noticed was that they used cpap, bipap, and bipap with back up rate during my titration.  Of these 3, cpap was actually the best (AHI in the single digits at least).  CA's when crazy high with bipap.  Bipap with back up rate was horrible because we could not sync.).  I was never fully titrated from my sleep study.  One RT did my sleep study, and another RT from a different DME got me my 1st machine, the ST (A).  I am wondering if you had similar results on your sleep study?  I think you said they had some problems titrating you also.  

I am just trying to think of anything I can to get you the most prepared if you choose AXG.  You can always post your last sleep study here if you want to also.

[Gideon]

what are all your settings on the ST-A? I expect to see some volume targets, and possibly a backup rate.  Your OHS is significant in determining your therapy and settings.

On the oximeter can you also report your duration at or under 88%?  That is Medicares criteria for nighttime supplemental oxygen.

would you mind sending a full zip of your entire SD card in for the OSCAR team to use for development? if so my dropbox is
Gideon's DropBox for receiving SD Cards:
https://www.dropbox.com/request/6VeFzBXa4qZ37EgphL5b  Please include your forum name in the zip file name so we know who the file is from.

[cmpman1974]

what are all your settings on the ST-A? I expect to see some volume targets, and possibly a backup rate.  Your OHS is significant in determining your therapy and settings.

On the oximeter can you also report your duration at or under 88%?  That is Medicares criteria for nighttime supplemental oxygen.

would you mind sending a full zip of your entire SD card in for the OSCAR team to use for development? if so my dropbox is
Gideon's DropBox for receiving SD Cards:
https://www.dropbox.com/request/6VeFzBXa4qZ37EgphL5b  Please include your forum name in the zip file name so we know who the file is from.

Gideon, I will start with the easiest question first.  Settings are:

Target RR: 15
Target Va - 4.5 L/min (is this the back-up rate you're referring to?)

These three settings are shaded in light gray to indicate norms, but not specific to a patient:
MV = 6.4 L/min (calced by taking 428 mL / 1000 = .428L x 15 RR = 6.4 L/min)
Vt:  428 mL
Vt/kG: 5.8 mL / kg Ideal Body Weight - has nothing to do with a patient's actual body weight I believe

Rest of settings:

EPAP: 10.0 - no min or max stated so this is just a constant
Min PS: 5.0
Max PS: 10.0
Ti Min: 0.3 sec
Ti Max: 2.0 sec
Rise time - minimum
Trigger - medium
Cycle - medium
Mask - full-face

Yesterday, the Lookee wrist O2 meter showed 53 m under 90%.   It doesn't seem to specify a cumulative time under 88 O2, but does have a CSV file.  Attached is some, but not all, of the data points under an 88 level last night.  Going 16+ sec at an 83% O2 rate doesn't seem encouraging on 'effective' therapy.

I see absolutely no settings pertaining to a volume target, just the 4.5L/min back-up rate.  Obviously, my actual Vt and MV is WAY higher than what the target is based on a week's worth of data.  My actual MV ranges from 9-10 and Tv from 660-740 for the last week.  90-96% of my breaths are spontaneous based on machine reports.   My median RR is around 13.

Lastly, I included a copy of a recent polysomnogram de-identified.  Ironically the report consistently mentions high leaks, machine data mentioned high leaks (44 L/Min) and no one ever said a word  about it impacting therapy all these years.   Who knows if I can ever bring that down to a manageable level, but why not make it a focal point to try to improve after 10 years of BPAP? The part I am not clear about is if minimizing leaks to a low level can result in an impactful improvement in sleep quality when one already has pretty low AHI numbers or a negligible amount. It would be nice to know how ineffective a 44L/min leak rate makes BPAP.

[Lucid]

Hi, cmpman

I think all DMEs and many suppliers have a 30-day exchange policy for masks.  If you're on Medicare with a DME, definitely; if you bought it or insurance paid for it from a supplier, there are varying policies.  It's something to take advantage of either with this mask or your next.

Also, here are links to information on masks:

http://www.apneaboard.com/wiki/index.php/Mask_Primer
 
How to achieve the perfect mask fit - GUARANTEED! | Apnea Board

Apologies if this is coals to Newcastle, as you mention having been on therapy for some, but maybe something will help.  Your intuition that you're not getting effective therapy with so much leaking is certainly correct, and you're wise to focus on finding the right mask now.  Faces are shaped so differently, there's no perfect mask for everyone -- don't let them deter you from trying different ones.

I tried a wedge recently and it didn't work for me at all because it pushes my head forward, and is a bit too steep.  I've started carving out the top edge so that I can get my head into the "rescue position" and keep my airway open, but I'm going to need a flat piece behind the wedge to fully support my head.  If I ever figure this out I'll post about it.  I sleep on my back, but the wedge wasn't comfortable on my side, either.  In the meantime, I'm just using a multiple pillows of different sizes and degrees of firmness to try approximate what makes sense anatomically.  I've tried an adjustable bed in a store and it had similar problems to the wedge.

BTW, I, too, did a consultation with AXG Sleep Diagnostics and found it really helpful.  Jason has a more professional persona in these consultations than in his entertaining videos.  He listened well, was easy to talk to, and put me at ease.  Also unlike the videos, where he has fun segueing into in the promos for AXG Sleep Diagnostics and his sponsor, he never suggested that I pay for additional time beyond what I had signed up for.  There are also some cheaper options now, too.  

The consultation was like a tutorial, and what I learned has helped me to get more out of the Forum, too.  You can  fantastic advice here, but sometimes some contradictory advice (as you can see from parts of this thread.)  Early on, that would have been too hard for me to sort out.  For me, it was also beneficial to go over the charts and ask questions in detail, one on one, in real time.

Whatever you decide, you'll move forward.

[Jay51]

A few things jump out at me in your settings and sleep study.  Your settings don't look too bad to me (too abnormal).  Your respiratory rate looks fine.  Good spontaneous rate.  Your tidal volume is set at 428.  Your median inspiration is around 1.3  seconds.  So in 1.3 seconds (a little faster than normal), you are getting to the 428 target, and then on your own way surpassing that up to around 660 to 740.  Lowering the tidal volume settings and calculations probably won't help because you will just overshoot them.  If you could slow down your rate some, that would decrease your minute vent., but I don't know how you could do that.   It you set the rate lower, you would probably overshoot it also.  Maybe not.  Your expiration time is a bit long at 3.3 seconds.  

Is the increased tidal volume and minute vent causing the low SPO2 or is it a compensatory action on your part to keep your SPO2 up?  Not sure.  A person usually hyperventilates to raise their oxygen levels briefly.  So my guess (and it is just a guess) is that you have started compensating with your large tidal volume (your SPO2 might be worse than this if you didn't slightly hyperventilate).  This is just a thought and would make a good question for your PCP or Pulmonologist.  Or is the problem in your lungs?  Your lungs are not transporting enough O2 to your cells, and they are demanding more o2?  PCP or Pulmonologist may know.  I recently spoke to my Pulmonologist about related topics as this.  Is some organ in your body consuming a much larger amount of o2 than is normal?  PCP or Dr. question.  Can hyperventilating cause an SPO2 drop?  

Maybe someone who sees something else may want to comment also.  1 AHI is good.  But is this sustainable every night (the chest soreness)?  What is causing the downward spikes in SPO2?  I had some similar downward spikes at time, but not as low as yours.  I concluded that the best I could do was treat them as if they were obstructive in nature.  If I opened my airway to the maximum, that is about the best I can do (without a back up rate).  My spontaneous rate is good like yours though.  Also, if it is central in nature, then if my airway is open to the max, at least when I would recovery breathe, it would be quicker and easier with an airway open to the max?

[cmpman1974]

A few things jump out at me in your settings and sleep study.  Your settings don't look too bad to me (too abnormal).  Your respiratory rate looks fine.  Good spontaneous rate.  Your tidal volume is set at 428.  Your median inspiration is around 1.3  seconds.  So in 1.3 seconds (a little faster than normal), you are getting to the 428 target, and then on your own way surpassing that up to around 660 to 740.  Lowering the tidal volume settings and calculations probably won't help because you will just overshoot them.  If you could slow down your rate some, that would decrease your minute vent., but I don't know how you could do that.   It you set the rate lower, you would probably overshoot it also.  Maybe not.  Your expiration time is a bit long at 3.3 seconds.  

Is the increased tidal volume and minute vent causing the low SPO2 or is it a compensatory action on your part to keep your SPO2 up?  Not sure.  A person usually hyperventilates to raise their oxygen levels briefly.  So my guess (and it is just a guess) is that you have started compensating with your large tidal volume (your SPO2 might be worse than this if you didn't slightly hyperventilate).  This is just a thought and would make a good question for your PCP or Pulmonologist.  Or is the problem in your lungs?  Your lungs are not transporting enough O2 to your cells, and they are demanding more o2?  PCP or Pulmonologist may know.  I recently spoke to my Pulmonologist about related topics as this.  Is some organ in your body consuming a much larger amount of o2 than is normal?  PCP or Dr. question.  Can hyperventilating cause an SPO2 drop?  

Maybe someone who sees something else may want to comment also.  1 AHI is good.  But is this sustainable every night (the chest soreness)?  What is causing the downward spikes in SPO2?  I had some similar downward spikes at time, but not as low as yours.  I concluded that the best I could do was treat them as if they were obstructive in nature.  If I opened my airway to the maximum, that is about the best I can do (without a back up rate).  My spontaneous rate is good like yours though.  Also, if it is central in nature, then if my airway is open to the max, at least when I would recovery breathe, it would be quicker and easier with an airway open to the max?

Thanks for the detailed feedback.  I will certainly bring up these questions to my pulmonologist / sleep medicine doctor.  I have to admit I'm at a complete loss with all this.  I was in the hospital for a night as I was getting abdomen pressure / pain and other stuff that may be related to my machine.  All checked out OK, except for some mild inflammation in the area around my organs they were not concerned with.  I am just a wreck.  Struggling with headaches, fatigue, eyes/nose draining, stiff neck, and more.  I'm so wiped out it's hard to concentrate, though my labs generally look good.  

My one night in the hospital I had the best leak rate I ever had:  5 L / min.  Slept 7 hrs, AHI 0.3 events per hr.  Woke up feeling horrendous.  Feel like I'm chasing ghosts honestly. 

I think there is something bigger probably that goes on causing stuff.  I have ruled out so much, but stuggle so much.

Question: How does a doc diagnose you with Obesity Hypoventilation Syndrome when your Tidal Volumes and Minute Ventilation are above normal? I thought Hypo meant shallow - below normal breaths often. Yes I have some, but just curious on the meaning.

This article had some good insight on different things:

https://link.springer.com/article/10.100...20-00955-x