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[CPAP] New and need some help lowering AHI
(12-13-2016, 07:02 AM)richb Wrote: Maybe, like SR says you should bring in your AHI 10 chart and play dumb. One way or another you are going to need an ASV machine because as you could see you aren't getting much quality sleep. Thanks for posting those snippets. Pretty much as I suspected.

Rich

Lol. I wish it was as easy as playing dumb. My machine came equipped with a cellular antenna and auto uploads every day to a portal my doctor has access to.
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So first night with EPR 1 in addition to 7.0CM pressure... I'm not sure what to think of it lol. My initial thought is that EPR is a problem for me. In fact I've thought it was a problem prior to this based on the problems I experience from pressure variation during APAP. Nonetheless I'm thinking of using it one more night just to gather data.

Something I noticed still and consistently is the last 1/3-1/2 of my night is always much worse. Additionally if you look at all the RERA events early on in the night I'm thinking that had a lot to do with EPR honestly. I have yet to figure out or understand why the last good portion of my night is so bad.

The large section of purple towards the end is immediately after 8:15am when I woke up just long enough to turn my alarm off, but went right back to sleep for about 30 minutes. It was 30 pretty rough minutes based on the chart and probably a good part of why I feel so terrible today haha.

Anyways charts are below. Thoughts welcome as always.

Whole Night: http://imgur.com/hGJyPTC
RERA: http://imgur.com/tikRv9G
RERA: http://imgur.com/OaqcquA
5 min: http://imgur.com/EY7bq1f

~Casey
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That kind of takes us back to where we started. You clearly are sensitive to the pressure support. Something to think about when considering ASV is that it is a bilevel machine with a variable pressure support. It may cause you to have many more hypopnea and central events, but will over-ride those with higher pressure support to keep you breathing. That's fine if you need it, but you do pretty good on CPAP without EPR. Richb had AHI in the 20 to 40 range using an Airsense 10 Autoset, and was never able to bring that down. He moved to a ST machine, and we worked with him for a while to build a case that ST was the wrong solution, and that ASV was required. http://www.apneaboard.com/forums/Thread-...d-SH-graph

I guess what I'm saying is, most of the time when someone with your problem gets on the forum and starts trying to resolve CA and H with CPAP, it doesn't work. They end up needing the ASV solution. It is probably to your advantage that you have found a CPAP solution for the time being. ASV does not stop the events from occurring, it mitigates them by causing a breath or larger volume of breath. With CPAP you are spontaneously controlling your own respiration, and you should not underestimate the value of that, in spite of a low frequency of events that get through.

Aside from the obvious increased CA that seems to result from EPR in this latest graph, note also the snores (obstruction) during ramp. You may want to increase your starting pressure by 1, and eventually eliminate ramp completely. I think you will eventually find that more comfortable anyway, especially since your therapy pressure is not very high. With regard to your misdiagnosis of OSA, this thread from Richb might help you to put that in perspective (Not picking on Rich, but his experience directly applies) http://www.apneaboard.com/forums/Thread-...be-a-charm
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(12-13-2016, 11:08 AM)Sleeprider Wrote: That kind of takes us back to where we started. You clearly are sensitive to the pressure support. Something to think about when considering ASV is that it is a bilevel machine with a variable pressure support. It may cause you to have many more hypopnea and central events, but will over-ride those with higher pressure support to keep you breathing. That's fine if you need it, but you do pretty good on CPAP without EPR. Richb had AHI in the 20 to 40 range using an Airsense 10 Autoset, and was never able to bring that down. He moved to a ST machine, and we worked with him for a while to build a case that ST was the wrong solution, and that ASV was required. http://www.apneaboard.com/forums/Thread-...d-SH-graph

I guess what I'm saying is, most of the time when someone with your problem gets on the forum and starts trying to resolve CA and H with CPAP, it doesn't work. They end up needing the ASV solution. It is probably to your advantage that you have found a CPAP solution for the time being. ASV does not stop the events from occurring, it mitigates them by causing a breath or larger volume of breath. With CPAP you are spontaneously controlling your own respiration, and you should not underestimate the value of that, in spite of a low frequency of events that get through.

Aside from the obvious increased CA that seems to result from EPR in this latest graph, note also the snores (obstruction) during ramp. You may want to increase your starting pressure by 1, and eventually eliminate ramp completely. I think you will eventually find that more comfortable anyway, especially since your therapy pressure is not very high.

SR,

20-40?! ouch! I couldn't imagine how I'd feel with numbers that high Sad.

Honestly if I can get the CPAP 'good enough' for the time being I'd be okay to at least wait out a year until I can be on better insurance that might cover an ASV anyways, but anything above 3.0 RDI really has me feeling quite terrible. In fact if I'm judging the way I feel CA events are FAR FAR worse than RERA events imho.

As far as RAMP goes it makes very little difference to me, I don't think I'd have any issue at all simply turning it off.

Now I know that you're a big proponent of 2 days of data and given that I'm going to the doctor tomorrow, tonight will be my last night of data I'll be able to use tomorrow. Should I keep settings as is for one more night OR should I turn off EPR and RAMP and see how 7.0CM w/o RAMP/EPR help?

~Casey
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I think the correlation of EPR and your CA events is well established, regardless of pressure. I'd turn it back off.

I edited my previous post, and wanted you to see this for your appointment: With regard to your misdiagnosis of OSA, this thread from Richb might help you to put that in perspective (Not picking on Rich, but his experience directly applies) http://www.apneaboard.com/forums/Thread-...be-a-charm
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(12-13-2016, 11:53 AM)Sleeprider Wrote: I think the correlation of EPR and your CA events is well established, regardless of pressure. I'd turn it back off.

I edited my previous post, and wanted you to see this for your appointment: With regard to your misdiagnosis of OSA, this thread from Richb might help you to put that in perspective (Not picking on Rich, but his experience directly applies) http://www.apneaboard.com/forums/Thread-...be-a-charm

Yeah I hear ya. So I'll go with EPR and Ramp Off Pressure 7.0CM CPAP in hopes of feeling tip top tomorrow Big Grin

I'm sure Rich doesn't feel picked oh haha. He's a good sport. That link goes to 404 page not found :-/, what am I supposed to be looking at?

In regards to a potential ASV let me make sure I have the order of steps correct regardless of insurance or self financing...

If insurance ever covers it I would have to do the following...
Prove that APAP/CPAP isn't effective enough.
Have a BiLevel Titration Sleep Study to rule out a BiLevel machine.
Would I also need to be prescribed a BiLevel machine to rule it out?
Then...
I would have to prior to anything be tested for Congestive Heart Failure?
Then go on a ASV Titration Sleep Study to determine ASV benefits?
Then be prescribed and get the proper machine etc?

And to your point about the ASV being a BiLevel machine and potentially a problem for my complicated CA / H issue... wouldn't the ASV sleep titration be able to tell me if ASV would be the wrong choice?

~Casey
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Sorry about the dead end link. Try this: http://www.apneaboard.com/forums/Thread-...be-a-charm

Several people have self-financed ASV by purchasing used. For example there is an Aircurve 10 ASV for sale by someone on the forum where they talk cpap for $1000, and he says he will take offers. Pretty good deal, but the usual cautions apply. As you know, I can't link or it's infraction city.
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Casey. Regarding your procedural questions: You Doctor can order a sleep study and titration using a multifunctional diagnostic machine that can first try CPAP/APAP and then move on to ASV when there is difficulty getting good results with the CPAP and APAP. Bi-level is a kind of APAP. You need to confirm that your Doctor understands Central Apnea and will prescribe ASV if needed. My first Doctor did not and would not. In my opinion, your poor sleep quality and almost continuous periodic breathing indicate to me that your present machine is not treating your condition. An ASV machine would intervene in nearly all of those periodic breathing, Hypopnea and Central Apnea events.Your sleep quality will improve dramatically. I also have a thick skin and a good sense of humor. Keep up the good work.

Rich
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(12-13-2016, 03:14 PM)richb Wrote: Casey. Regarding your procedural questions: You Doctor can order a sleep study and titration using a multifunctional diagnostic machine that can first try CPAP/APAP and then move on to ASV when there is difficulty getting good results with the CPAP and APAP. Bi-level is a kind of APAP. You need to confirm that your Doctor understands Central Apnea and will prescribe ASV if needed. My first Doctor did not and would not. In my opinion, your poor sleep quality and almost continuous periodic breathing indicate to me that your present machine is not treating your condition. An ASV machine would intervene in nearly all of those periodic breathing, Hypopnea and Central Apnea events.Your sleep quality will improve dramatically. I also have a thick skin and a good sense of humor. Keep up the good work.

Rich

Rich,

Oh I didn't realize that's how the sleep study / titration worked. Multifunctional sounds like an efficient time saver lol.

And New Englanders are born thick skinned! I'm from NH myself Big Grin

~Casey
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Appointment Summary...

Let me start with the fact that I do think the appointment was a success, but a lot went on.

The physician's assistant came into the office after I'd waited an hour after my appointment time which had me a little irritable. I stated w/out any derogatory tone that they must be really busy today. The PA responded by explaining that he didn't expect to have to read a slew of emails from my machine monitoring company stating that I've been changing the settings on my machine. He advised that this is not recommended at all and insisted on knowing why I decided to do that. I got into explaining how terrible the machine made me feel and how I lived with it for nearly 2 weeks on default settings before first attempting to seek help from his office and the machine monitoring company to no avail at which point I took it upon myself to study up and self-titrate.

I provided him with a two page document full of notes regarding all of my findings and concerns from the past month and upon his completion of reading that he had a much better tone and complimented me on how organized and prepared I was for this appointment.

Now that I felt we were on the same page I requested to open my MacBook and cover all the data charts with him and explain exactly what my concerns are and why. I made a case for complex apnea of sorts and upon completion of reviewing the charts he agreed with me, but hesitates to change the diagnosis until I've had a proper sleep study & titration.

We got into talking about why that wasn't done to begin with and not to my surprise he explained that is what they ordered originally, but insurance denied it and insisted on a basic Home Sleep Study. He went on to explain that even though it's clear to us now that I need the clinic sleep study & titration that he will still need to build a business case for insurance to approve that. He also advised that there will in fact need to be two studies with titration if I end up on an ASV because insurance will only approve a CPAP and BiPAP titration for the first study and if that fails they'll need to make another case to insurance to get the Congestive Heart Failure test and then proceed with the ASV titration that would be required to prove the ASV necessary.

All in all my doctor took me very seriously once we got on the same page and after explaining my insurance situation to him he worked with the sleep lab to push me in front of everybody for the Sleep Study with CPAP/BiPAP titration and is scheduled for Friday 12/23.

The only issue now is that this is the only appointment available this year so if insurance doesn't approve that sleep study/titration prior to the 23rd I'll be stuck with the bill regardless. Sad

At the end of the day I do feel like it's a step forward and I plan on keeping my settings at 7.0CM w/o EPR as last night was a pretty solid night with an RDI of only 2.36 (charts below)

Whole Night: http://imgur.com/VX3tq86
5 min RERA - http://imgur.com/6myuzFc
5 min RERA - http://imgur.com/O46X96e
5 min n/a - http://imgur.com/WqdQvJl

Finally I want to thank EVERYBODY, but especially SleepRider and RichB for all of their prompt and continued assistance. This forum has been amazing and you'd better believe I'll be paying it forward. I hope to be around here for a long time to come.
CaseyF
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