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Brain fog, lack of energy -- why did dropping my EPR make such a difference?
#41
RE: Brain fog, lack of energy -- why did dropping my EPR make such a difference?
OK copy, go with best comfort first then low events second is my suggestion. And I feel you're pretty close to a decent dialed in state, so unless it's uncomfortable, try it 2 nights and see if we can see hints of a trend, good or bad.

PS as for replied, it's OK if they appear disjointed some.

Do be mindful of the sight impaired members and use quote minimally, thanks.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#42
RE: Brain fog, lack of energy -- why did dropping my EPR make such a difference?
From the 2 examples you posted it is pretty clear to see that

a) Flow limitations were improved.
b) Obstructive apnea was worse.
c) Central apnea wasn't an issue.

This makes me think the EPR of 3 was good but your EPAP was too low. When you compare the two nights sure enough your average EPAP on the 15th was 8.9 compared to only 7 last night.

Furthermore in your data last night you can see how the pressure graph would spike due to OA, decline back to around the same point, spike due to OA, decline back to same point and keep doing so over and over. That point where EPAP keeps bouncing off of appears to be around 7 cm indicating that min EPAP of 7 may be what you end up needing. The new setting you are trying of min pressure of 9 and 3 EPR gets you up to 6 EPAP and that along with APAP might be good enough, if you still have OAs then I would try a min pressure of 10. 

What may seem odd to you is why on the 15th your mine EPAP was 4.6 and average EPAP was 8.9 but on the 21st you had a higher min EPAP of 5 but average EPAP ended up only being 7. This is because flow limitations affect your machines operation. Resmed APAP is programmed to increases pressure to treat flow limitations, and when your EPR was only 1 you had lots of flow limitations and they kept your EPAP high enough that you didn't have OA. Increasing EPR did a double whammy on your EPAP by lowering EPAP directly (since EPAP = pressure - EPR) and because your machine was no longer trying as hard to treat flow limitations. 

The next question is will centrals come back? CAs are notoriously inconsistent and it is possible that this was just a good night. It is also worth noting that OAs can trigger CAs by causing high amplitude recovery breaths that lower CO2 levels triggering a CA, hopefully getting OAs under control will keep CAs at bay.
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#43
RE: Brain fog, lack of energy -- why did dropping my EPR make such a difference?
Hi. Here is the OSCAR data from last night, EPR 3/Min Pr 9/Max 12.   I have inched Min Pr up from 7, keeping EPR at 3, to see if I get better sleep than my prior settings of  EPR 1/Min Pr 5.5/Max 12. 
  
What matters most is how I feel, so here’s a report on that.   I woke up frequently last night.   I also got too few hours of sleep.  After about six and half hours (interrupted by waking up a few times), I had a run of “CA” events.   I wanted to go back to sleep but those CA events made that impossible.   So, I feel groggy and foggy and kind of miserable, but the latter might be because I’m frustrated over titration challenges

I got a slightly higher median EPAP score with Min Pr 9 than with Min Pr8.   [Comparisons:  EPR 3/Min Pr 7-9 showed lower EPAP scores than (my best sleep ever) EPR 1/Min 5.5.]

I got a lower 95% FL score than with other settings, finally bringing it below .10.  

WEIRD OUTCOME:  I have a headache that is getting worse as the day goes on.  I had the same pattern yesterday:  mild headache upon awakening, worsening as the day goes on.    I wonder if it’s connected to these new settings of 3 EPR with Min Pr at 8 (yesterday) and 9 (today).   Any input?    It is very unusual for me to have a headache, so I do think there must be a connection.


“CLEAR AIRWAY EVENTS”  (i.e., treatment-induced central apneas):  I got a flurry of CA’s near the end of my time in bed.  The CA’s came after an OA woke me up.   I am drifting between awake and asleep.  I shift positions, eventually moving to my side – that seems to be a sign that I’m having trouble breathing, as that’s what I’ve always done when I had a string of episodes.  I don’t get back to sleep for more than a few minutes.   Eventually, I give up and get out of bed.

The flurry of CA’s (especially at the end of the night) was  a common pattern before I moved to EPR 1/Min 5.5./Max 12.    EPR 1/Min 5.5./Max 12 wiped out all or most of my CA’s.

Last night, I can see the CA’s coming after OA’s.  Geer1 writes, “It is also worth noting that OAs can trigger CAs by causing high amplitude recovery breaths that lower CO2 levels triggering a CA.”   

I append a detailed shot of what’s going on with breathing.  Do these look like “high amplitude recovery breaths that lower CO2 levels”?  

Is there no conscious breath control that we can do after being awakened by an OA?    For various other reasons, I’ve done a lot of work with breathing – controlling the length of in-breath and out-breath, controlling the length of a pause between them, etc.    Does the ABoard have any wisdom on breathing techniques that can keep CO2 levels where they should be?   Yes, I know this won’t do me any good if I’m asleep – but, if I’m awake for a few minutes after an OA, is there a type of breathing that might lessen the chance of sliding into a flurry of CA’s due to lowered CO2?

OBSTRUCTED AIRWAY EVENTS:   New information:  OA’s definitely wake me up.  Last night, I tried to disconnect my hose every time I woke.   I didn’t do it all of the time but I did it often enough to see that every wakening was preceded by an OA.   It does look like OA’s are a big deal for my sleep disruption.

Summary:   So far, the best sleep subjectively has been EPR1/Min PR 5.5/Max 12; it also produced extremely low AHI (averaging between 1 and 2), lower than my first two rounds of settings.   95% FL was a bit higher than any of the settings that I’ve recently tried (Min Pr 7-9).    [Reminder:  I started out on EPR 3/Min 5/Max 20:  miserable outcomes.   My MD changed it to EPR 3/Min 5/Max 16:  still miserable.   I changed it to EPR1/Min 5.5/Max 12 and got the best results since I started treatment.]

So, what next?

I don’t seem to have any improvement (yet) with the EPR at 3 and Min Pr set between 7 and 9.   Min Pr at 8 and 9 seem to have caused this weird headache that starts small in the a.m. and gets more serious over the next several hours.  Is it possible that I should stick with EPR 1/Min Pr 5.5?   It wasn’t perfect, but it was better than what I’ve had with EPR 3/Min Pr 6-9.    Or should I give EPR 3/Min Pr 6 or 7 or 8 a couple of days’ tryout?    Is it unreasonable to decide after a single day?

Is it possible that my body just doesn’t like whatever EPR does?   As strange as it sounds, maybe I am getting too little carbon dioxide with EPR 3?  Geer1 writes, “EPR can make central apnea worse because this extra flow reduces carbon dioxide levels in your lungs which reduces carbon dioxide levels in your blood. Carbon dioxide levels in your blood is what your brain uses to decide when it needs to breath so if carbon dioxide levels are low it may decide to take a break from breathing (central apnea) until carbon dioxide levels rise and kick start breathing effort again. Treatment emergent central apnea occurs in some patients because the CPAP machine lowers carbon dioxide levels below what their body was previously used to, sometimes they will go away after your body gets used to having lower carbon dioxide levels (but sometimes they do not).

Comments, advice, whatever is earnestly solicited!  Thanks.
 
     
   
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#44
RE: Brain fog, lack of energy -- why did dropping my EPR make such a difference?
Centrals could cause headaches but I would expect it would take more than what you had to be an issue, overall your results don't look bad.

The worst part of data appears to be leaks.

I would stick with current settings and continue to give body some time to adjust, if you feel you must change you could try EPR of 2.
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#45
RE: Brain fog, lack of energy -- why did dropping my EPR make such a difference?
It looks to me there's several sleep sessions, the last of which had the majority of the CA at 6 or so events. Given the short duration and that maybe you were between wake and sleep, maybe these CA were SWJ (sleep wake junk) which are caused by the awkward breath control handoff between waking and sleep.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#46
RE: Brain fog, lack of energy -- why did dropping my EPR make such a difference?
Thanks, Geer1 and SarcasticD.

Geer1, I have always looked only at the "large leaks" section of the summary report and those are almost always  zero so I thought I was doing well.  I guess you are prodding me to look at the actual numbers in the list of data.  Darn, something else to keep an eye on!   Sigh.   Yes, I certainly will do that.    I am having some trouble figuring out when my nasal pillows need to be replaced.  I don't know what the physical signs are.  I'll start another thread and ask for some advice.  I think I'm holding on to them for too long, if you're saying that my leak rate is too high.  I had believed that, if you didn't have large leaks, you didn't have a problem.

What kind of problems can these small leaks cause?  If you have any insights, please share them.  I'll also do a search on the ABoard posts to see what's been said in the past.    Can they harm sleep quality for some people -- so, maybe they could be part of my issues?    Hmmm.    Need more information, obviously.  I'm glad I'm in the right place to collect it.   Smile

I will stick with this high Min Pr and EPR of 3 (or 2, if I feel crummy after a few more nights on 3) for a week or so to see what happens.   When I have more data, I will post again.   

SarcD:   yes, I guess it could be SWJ.   But I felt urgency about lying on my side, and that's generally been a "I can't breathe" signal.   So, I think that something was going on other than funny breathing as I thrashed around.   I am intrigued by the OA-can-trigger-CA possibility and will do some systematic review of my data to see if it has any possibility for explaining some of what goes on with me.  But let's see what happens over a week or so.

So, more data in a week or two.   Many thanks!   If you have any thoughts to share, please pass them on.   I am diving back into tracking with a lot more knowledge than I had when I first posed this puzzle to the ABoard, and I'm very grateful to everyone who has chimed in or will chime in.

I am always looking for advice, so do post if anything occurs to you.
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#47
RE: Brain fog, lack of energy -- why did dropping my EPR make such a difference?
Agree with both comments above, and can totally sympathise with your headaches!
It can take a while for your body to adapt.
You have been making some not inconsiderable changes to your pressure and EPR settings.

Also I notice your tidal volumes have increased lately, 95 Vt from 460 on the 18th Aug to 720 on 22 Sep.
This could be the result of a combination of increased Min Press and increased EPR.
Not sure if this is related to your headache, but something you could keep an eye on.

It may be that for you a too rapid reduction in FL is counter productive.

As I see it you have 3 options.
1. stick with the current settings for as long as you can cope: hopefully you will adapt quickly, if you can't...
2. go back to EPR =1 with settings of say Min 8, EPR = 1 to give you a target starting EPAP of 7, and tweak it from there.
3. As Geer1 suggested, perhaps EPR 2 will suit you better, more of a middle of the road thing. Min 9, EPR = 2 again targeting EPAP of 7 to start with, tweaking it from there.

EPR of 2 should help to control the CA if you think they are worrying you.

You could leave your Max Pressure at 12 for now, you can fine tune this later if you need to.

Either way it will take a few days or even weeks to find your sweet spot.

Only you will know where that is, keep us posted. We are watching with interest!
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#48
RE: Brain fog, lack of energy -- why did dropping my EPR make such a difference?
Yep, you can try EPR 2 if you'd like.

Moving about and getting CA is a breath hold movement thing. If you're certain that at x o'clock you moved about, maybe breath holding, and CA are there, then it's much like SWJ. They may appear on the chart, but they mean little to your therapy and will not be a reason to edit settings just for those.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#49
RE: Brain fog, lack of energy -- why did dropping my EPR make such a difference?
I hadn't noticed the increased TV, if it and MV have noticeably increased on average ( not just one night) that is a sign increased EPR is helping. It will take weeks to months to fully adapt to change on settings and if changing to EPR of 2 my recommendation would be temporary and then trying 3 again so if bearable worth sticking with for now as you plan on doing.

Regarding leaks the biggest issue is how they affect your sleep quality. If they are mask leaks then you have air blowing out on the side of your face making noise and physical disturbance that will affect sleep quality. If they are mouth leaks then you have air blowing out your mouth which dries mouth out and causes sleep disturbance as well. Determining what type of leaks you have will help try and improve it, an easy way to do this is try mouth taping and see if the leaks go away. Large leaks just mean that the machine isn't capable of providing adequate pressure to maintain treatment, having leaks lower than large leak doesn't mean they are fine to have. The goal should always be to minimize leaks.
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#50
RE: Brain fog, lack of energy -- why did dropping my EPR make such a difference?
Thanks for this, team AB.

Geer1 and SA:   Hmmm.  Tidal volume.    Sounds like it requires a tropical drink with an umbrella in it, but I will read about it and learn about it.  I'll also download the OSCAR data and do some charts and maybe run a few correlations.  (I finally found the "download data" option. Hurrah!)   

SA, I appreciate your suggestions about maybe pulling back for a bit while my body gets used to things.    The whole concept of "your body needs to get used to this" requires patience and a new point of view.    It's so easy to believe that the right settings (whatever they are) will produce the optimal outcome on the first try.   I bet that this belief leads lots of newbies to fiddle frantically with settings and never get their treatment optimized.

Geer1:  Thanks for the input on leaks.  In the past, I had noticeable "lip flutter" (chipmunk cheeks?  mouth farts?  the terms vary).   Air was forced into my mouth and accumulated there until it could force its way out.   The sensation and noise of the escaping air woke me up.

I tried taping but (a)  then the air built up in my mouth and rolled around in it (like an increasingly large ball of something squishy but insistent) trying to escape and that woke me up and (b) the tape pulled off too much skin when I removed it.    With those two problems to solve, I switched to another solution that I read about on the Board:  I wear a girl's stretchy cloth headband over my mouth.  That does not stop the mouth leaks but it does stop the noise.  I thought that the only problem that I needed to solve was the problem of being awakened.   So, the headband solved that problem:  it lets the air escape slowly and quietly, as needed.   BUT, according to what you've explained, I am still having potentially problematic leaks through this route.   

I don't think I can use tape as a longterm solution (because of the sensitive skin issue) but I will experiment with tape over the next few weeks and track leaks w/ tape and leaks w/out tape.    That should be useful information.

As I noted in an earlier post, I am considering a full face mask to solve this problem.  Now now, of course, as I'm in the middle of too many other changes -- but maybe a few months down the line.  I have some trepidation about the FFM, though, as I've read so many posts in which people describe their endless FFM struggles.   But I will track my leaks for a couple of weeks and compare leak rates with these new settings and the leak rates with my own settings -- that will let me know if the problem has changed at all over the months.

SD:  great point!   I know that I have treatment-related central apnea but it is important to distinguish between TECA and SWJ.  (Look!  I am using acronyms just like the Big Kids.)    Before I decided to see if ABoard could help me, I was thinking about getting some kind of tracking device (probably in watch form) to see if I could get any additional information about sleep patterns.    I might continue looking for that kind of device and prioritize getting something that tracks movement.   Lots of movement = Clear Airway events that are SWJ.    No/little movement = genuine TECA events, indicating the need for some adjustments.     Does that make sense?   I am a bit obsessed with the "clear airway" events, mostly because my well-being increased so much when I got them to drop waaaay down with my initial tweak (from EPR 3/Min Pr 5/Max Pr 12 to much more restful sleep and almost no CA's with EPR 1/Min Pr 5.5/Max Pr 12).    I'm now working with very different settings but I think that they are still keeping "clear airway" events low, meaning that TECA is controlled.   

I'll post more data in about two weeks.    I will see if there's a way that I can "tag" you to let you know that I have posted or if the software gods of ABoard tag you automatically.
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