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Brain Fog - seeking guidance in optimizing my therapy
#1
Brain Fog - seeking guidance in optimizing my therapy
Hello,  I'm looking for some help in understanding my data.  I've been experiencing brain fog and fatigue for years. I recently visited an allergist who has extensive experience in sleep medicine.  She thinks I'm not getting proper sleep.  After inspecting my mouth and nasal passages she thought my machine settings may not be correct.  Without seeing my data, she felt my pressures should be between 10-15 with an epr set to 3.  I made those changes and don't feel any more rested than before. My previous settings had the pressure set between 6-10 with epr off.  

I'm attaching my original sleep study results from 2015.  Also attached are my Oscar screenshots from before the setting changes and another from last night.  I have tried to go through the pages about understanding the data but I'm having a very hard time focusing on the information and with cognition in general.  

Hoping for some insight based on this info.
   
   
   
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#2
RE: Brain Fog - seeking guidance in optimizing my therapy
Please repeat the two OSCAR image postings, but this time include the top two charts with the 'events' showing the vertical lines in colour where the events appear in the timeline.  Also, where there are any events longer than about 10-12 seconds (place your cursor over those coloured vertical lines and you'll see the duration displayed in a pop-up), you can click repeatedly there on the flow chart and the timeline will expand to become more discrete.  We would appreciate seeing images showing about a minute on either side of any of the more notable events to see what the flow looks like.  We'd look for 'flow limitation's, and we'd look for clustering where events are repeated in close succession.
Serial Tapist
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#3
RE: Brain Fog - seeking guidance in optimizing my therapy
Adding additional charts as requested.  I'm shocked at how difficult it is for me to interpret what's being asked, @mesenteria.  I'm usually very sharp and quick with these things but this is taking some serious effort.  It's very frustrating to feel like I'm losing my cognitive abilities.  

Hopefully, I've interpreted the request properly.  

The only numbers I see when hovering an event are in parentheses for Obstructive events so I have only zoomed in on those with values greater than 12.

This set is from right before the latest machine changes
   
   
   

These are from last night, about 2 weeks following the change in pressure and erp.
   
   
   
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#4
RE: Brain Fog - seeking guidance in optimizing my therapy
Does the plateau of the flow limit indicate a mouth leak?
   
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#5
RE: Brain Fog - seeking guidance in optimizing my therapy
Had a visit with my allergist again who is adamant that I need a bipap based on my narrow nasal structure. She sent my 2015 sleep report to the DME so I’m waiting to see if that’s enough to get approved for a new machine through my insurance. In the meantime she had me adjust the setting for pressure from min 10 max 15 to min 11 and max 16.
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#6
RE: Brain Fog - seeking guidance in optimizing my therapy
First, if your allergist is willing to prescribe a Resmed Aircurve 10 Vauto, take it. It is the best machine on the market for your suite of symptoms. That said, we can get you some immediate relief by changing some settings. You have already done the most important thing by adding EPR at 3. You also need to turn off ramp, or at least change to a higher start pressure and Ayto ramp. The Vauto will finish the job by adding more pressure support and finer control of advanced settings. I am in complete agreement to get a Vauto, just don’t get stuck with a Dreamstation BiPAP. .
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#7
RE: Brain Fog - seeking guidance in optimizing my therapy
Thank you for the feedback, Sleeprider.  I've turned off the ramp as suggested and have attached the charts

I've been trying to quickly learn as much as I can about the BiPap machines so I can make an informed decision on the machine choice.  Specifically why the Dreamstation should be avoided.  My allergist felt that due to my narrow and small nose structure that the Resmed would be too much force for me (something about Respironics being more of a sine wave versus Resmed's more of a sawtooth).  She also felt that the humidity provided by the Resmed machine was not adequate for the mostly dry climate we are in.  Also mentioned is that Resmed purposely programmed their AHI lower so it appears that the patient is treated whereas Respironics programs it higher.  So while she feels strongly that I need bi-level therapy, she has recommended using Rispirtronics.  She never used Dreamstation by name though.

I just want to make sure I have the latest correct info so I make the best informed decision. 

       
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#8
RE: Brain Fog - seeking guidance in optimizing my therapy
Deocoder, the Resmed Aircurve 10 Vauto produces an identical mask pressure curve to what you have on the Airsense 10 with EPR. Look at closeups of the mask pressure, and it looks like cresting ocean waves, and corresponds perfectly with your respiratory flow. Ask your allergist to show you what the mask pressure flow looks like on the Philips...don't bother, he can't and his comment is completely based on what Philips reps have told him. The reality is, the Philips produces a more square-wave pressure change that can be adjusted by changing the rise time setting or BiFlex. Respironics has not changed its pressure delivery in 20 years. The Easybreathe by Resmed is far more sophisticated and comfortable. I have used both the Philips Respironics and Resmed VPAP and that information is B.S. I could post an image of the mask pressure and respiratory flow wave from my machine, but I'd rather you look at your own.

You are probably familiar with how the Respironics machines are slow to change pressure and maintain an effective therapy pressure through the night, and how the auto-algorithm of those machines produce a "sawtooth" pattern of pressure increases through the night to test a higher pressure. It is a ridiculously crude approach to pressure compared to Resmed and allows a lot more events, especially hypopnea. When you look at the whole night on your machine you will see some relatively abrupt pressure changes, at least compared to Philips; however if you zoom into those pressure changes, as you did in the closeup above, the pressure change is not abrupt at all, but occurs over a time period of 10 to 90 seconds. Since you use an optimized pressure range, it is not disruptive. In your current chart the difference between the minimum pressure setting and the 95% pressure is about 2-cm. I would challenge you to try a Philips which will raise and lower the pressure over a 90 second period every 20 minutes for no reason at all.

I'm not quite done yet. Only the Resmed lets you adjust the sensitivity of trigger (IPAP) and cycle (EPAP) and adjust the minimum and maximum times of inspiration. These are both comfort and therapeutic settings, and if you mention them to your allergist, you will get a blank stare.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
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How To Deal With Equipment Supplier


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#9
RE: Brain Fog - seeking guidance in optimizing my therapy
My BiPap titration was on a PR. They switched over and I immediately woke up as the device produced a solid square wave of pressure. They said I did poorly on my BiPap titration, I said what did you expect with that square wave and that I could adapt to it. I could handle the pressure being on fixed dumb CPAP at 18 since it couldn't reach my prescribed pressure and an APAP that was also maxed out. I requested a ResMed VAuto and got it. Real easy with the VAuto.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#10
RE: Brain Fog - seeking guidance in optimizing my therapy
Thank you for the feedback, Sleeprider and bonjour

I spoke to the DME yesterday and they say my allergist has not provided enough documentation to make a case to the insurance company.
I have an appointment on Tuesday with the sleep specialist I have seen in the past.  I want to go in with enough knowledge of my charts to state my case for Bi-level therapy and make sure they provide enough documentation to the DME as I push for the Aircurve VAuto.

Here are my charts from last night.  For some reason, it looks like recording stopped at 7 am when in fact I didn't stop a fair amount after 8 am so not sure what happened there.  I've zoomed in on a couple of areas. I'm trying to understand what indicates the need for EPAP based on the charts.  

           
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