Bipap Titration advice needed.

[Sleeprider]

Regarding your question on CA events with ASV mode, the ASV algorithm does not use FOT (forced oscillation technique) to determine apnea type, but instead responds with pressure support on any apnea. in ASV the events are recorded as UA (unknown). Typically, only UA are present and OA and CA are not differentiated. We don't know how your machine is working, but even with severe positional apnea, which would presumably have a lot of OA events, the chart looks like this (from soft cervical collar thread): http://www.apneaboard.com/wiki/images/th...llar_1.png

With ASV, we are biased to interpret UA as obstructive, because any apnea with an open airway should allow for an airway response with adaptive pressure support.

[amafra]

Regarding your question on CA events with ASV mode, the ASV algorithm does not use FOT (forced oscillation technique) to determine apnea type, but instead responds with pressure support on any apnea. in ASV the events are recorded as UA (unknown).  Typically, only UA are present and OA and CA are not differentiated.  We don't know how your machine is working, but even with severe positional apnea, which would presumably have a lot of OA events, the chart looks like this (from soft cervical collar thread): http://www.apneaboard.com/wiki/images/th...llar_1.png  

With ASV, we are biased to interpret UA as obstructive, because any apnea with an open airway should allow for an airway response with adaptive pressure support.

That graph looks very similar to some of my on ASVauto, pressure goes up, leak goes up, pressure goes up again to compensate.
Airbroke, lol. I think that asv is working, at least on the latest firmware I patched. I will test some days and return to stock firmware and see if there is any change.
Here is last night's SD card. There are so many events. I usually fall back to asv because the graph looks better with no CA. Two polysomnography that I did, none reported CA and basically all modes I tried on resmed did, except for ASV that I now know why.

Here is my SD card from last night, I will keep it without formatting it since I will keep Vauto for more than 2,3 nights.

[amafra]

OK.  I shall try to encourage him to take a more logical approach.



amafra
I will be on Vauto, AVSauto and Autoset for 3 days each.


STOP THAT!!  FIXED PRESSURE 11/8!!! NO AUTO ANYTHING!!!  STOP ****ING AROUND!!!

Buddy, I can't stop laughing with this message. STOP F AROUND. lol. Thanks for funny direct suggestion.

Ok , I will put it on fix mode. Vauto was recommended by Crimson Nape as sudo-S because it will record flow limitations that S does't.
Going to used fixed sudo-S fixing Min + PS to be equal to Max IPAP.
Tks

[amafra]

Just sayin, 11/8 pressure sounds familiar.  I got a couple hours out of him before the dial winged back to ASV.

Thank you again. 
I'm going to use 11/8, 12/8. I usually move back to ASVauto because I fear CA's would mess up my brain and higher AHI on other modes. I know you are going to say it is messed up already. 
I will use the above settings for more nights and see what happens.  Thanks for keeping up the good faith.

[amafra]

Quick note, I do have TI max 4, TI min 0.3. On modes that does not have easy-breathe I feel I like to inhale more air, but machine stops pushing air at 2 seconds mark if TI max is default to 2, so I moved it to 4.
I think feel I need it when I put the mask and do long breathing before sleep.
Not sure of impact of it after sleep. 
On S, that option easy-breathe appears, if set to on, it does not matter, it does not stop flow after 2 or whatever TI max is set.

[Rubicon]

At the end of the night, some spectacular and significant obstructive hypopneas are revealed:



As noted, they could be REM-related.

I know we said let's let things soak for a few days, but IMO we should add a cm or 2 to attack that area at up to 15/11.

Centrals don't look like they're a big problem, and I don't think that should change since the only time the machine maxed out was at the end of the night.

The thing about pressure-induced centrals is that if left alone they will usually resolve on their own.  Wingin' the dials and modes all over the place will not allow that to happen.  So IMO if we sneak up on these guys we can fix them w/o creating new issues.

Overall, there is some good sustained sleep.

[amafra]

I really had better sleep. I could not fall asleep so around 2AM I took an Ambien. I had a power outage so I could not start the cpap, at 5 I woke up to the light was back, I took another 10m zolpidem and turned on the cpap and slept.
I tried not to move too much to not wake her up. She said I snored a bit with a mask, first time and she listened to me having chokes, apneas not much before I woke up. At that time she was not in the bed so I had more room to move. I think positional things have a good change. How could we explain these clusters of apnea?
I was set to use 12/8 on Vauto as 8, ps 4 Max IPAP 12.  What about Min Epap 8, PS 4, Max 15?

TKS

[Rubicon]

Sorry I didn't get back to you.  I am a notorious advanced sleep phase short sleeper.  I am a "lark" whereas you appear to be an "owl".  Look that up.  It's interesting.

Also research "sleep hygiene".  Any reputable sleep organization will do.  IMO that will also get you a lot of bang for your real.

What you claim to be good sleep was seen in the download.  There were a couple of good blocks.

Based on your "hipnograma" your apnea is much worse in REM.  It takes about 90 minutes to get into REM (and perhaps more with certain medications (like Ambien).  So with those short blocks of sleep you usually have:



and if you weren't supine, perhaps no REM or supine REM, existed in the data you presented thus far. I shall go back and try to find a similar response in some of the >2-3 hour blocks. If I can find any.

The bad news is perhaps REM, and related bad apnea, happened (is happening?) when you were (are?) without therapy.  If anything, this should convince you to use therapy continuously.

But in answer to your question, inching up a couple cmH2O is a great idea.  IMO huge swings in therapy can create pressure-induced crap, so sneaking up on stuff is an overall wise strategy rather than just wingin' the dials around.
y

[amafra]

Hi buddies,
You must be short of sleep, I always see you online, mostly. Last night I used maxIPAP 15 (min TI 0.3, max TI 2) on pressure. At some point I backed down max IPAP to14. I  have recollection of taking the mask off, once because discomfort of a tight mask to fix a leak and the second time when I woke up belly hard with a lot of air, like aerophagia. 
The AIH seems pretty good.

Hospital just called me, someone will not attend polysomnography and I can go tonight for Bipap titration that was scheduled for end of may. 
Any recommendations?

(updated SD card) https://drive.google.com/file/d/11hWeEtK...sp=sharing

[Rubicon]

At least 3 of the events should be ignored because they're junk, so your AHI here is <1.0, which is fabulous.

However, which such a short sample, there can be nothing conclusive.

IMO the success of your titration will boil down to 2 things:

1. Insuring your supine REM is effectively treated. This will probably be a very aggressive pressure.

2. Using Auto settings that when supine REM is over, baseline is allowed to return to a lower pressure that effective treats true obstructive but prevents therapy-induced centrals.

BTW this last download demonstrates some hysteresis, so IMO having settings that float a little are very helpful.