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[CPAP] New and need some help lowering AHI
#41
(12-03-2016, 02:33 PM)caseyfontneau Wrote:
(12-03-2016, 12:40 PM)robysue Wrote: caseyfontneau,

How sound asleep do you think you were between 6:00AM and 9:00AM? Remember any extended periods of "dozing" or "tossing and turning" during that three hour period?

Since the obstructive stuff is very well controlled at the pressure range of 6-10cm, you might want to see what happens if you lower the max pressure just a bit: Try using 6-9cm of pressure. Pick EPR to make yourself most comfortable.
robysue,

I'll look at possibly lowering to 9CM and EPR 1 seemed to be comfy enough, but was considering trying EPR 2. If richb is right about when the pressure goes down I have clusters I'm thinking that a more mild EPR of 1 might be better or even off. Also I kind of toss around all night to be honest. Flip or change sides or positions every couple of hours. As for 6am-9am I was a little warm so probably a little more restless than normal.
Flipping over in bed every couple of hours is pretty normal. It's interesting that some people have a very distinct breath pattern that corresponds to when they flip over and that for some people, PAP machines can (and do) score a CA (or occasionally and OA) in the middle of the "flip over in bed" breathing pattern.

Lots of restlessness can indicate trouble getting into a stable sleep stage. Stage 1 sleep is very light and is transitional. If you're doing a lot of bouncing back and forth between WAKE and Stage 1 SLEEP, then the probability of sleep onset CAs increases.

Part of why I keep coming back to your comfort when it comes to the EPR setting is that the more comfortable you are with the settings, the less likely you are to get stuck bouncing back and forth between Wake and Stage 1 sleep.
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#42
(12-03-2016, 10:55 AM)richb Wrote: Your chart is interesting. One thing that I notice is that you have clusters of CAs after you have had a pressure spike. The CAs seem to be occurring as the pressure returns to your minimum. It looks like the change (drop) in pressure is triggering CAs. I suggest that you try a range of single pressures starting at your current max and decreasing by 1 CM H20 over a few nights. You can try both EPR on and off. My original suggestion to you was to try a range of pressures to identify the point where Hypopneas begin to dominate. I also would like to see some blow ups of your wave forms. Highlight a 5 minute segment of your flow wave form and select it. This will give you a view of the individual breaths. We still don't have visual evidence as to the type of Hypopneas that you are experiencing.

Rich

Rich,

Here are the screen shots of zoomed in 5min segments. I included areas of CA clusters and areas w/out issue from past 2 nights for comparison.

Last night...
http://imgur.com/u1DGfuB
http://imgur.com/SNfgCSf
http://imgur.com/uOVYGve
http://imgur.com/lTGH174
=================
2 nights ago...
http://imgur.com/1rCTjNT
http://imgur.com/MUC4ami
http://imgur.com/0r8hFKx
http://imgur.com/5HUSYpN
http://imgur.com/vvB1euu

-----------------------------------------
RobySue,

I'm definitely more comfortable with EPR at 2 than I am at 1. I feel like it's easier to fall asleep as well. Thinking I'll give that a try tonight along with the 6-9cm settings. Additionally I'm going to put more water for the humidifier because running out sucks haha. I'm thinking to possibly go with 6-9 and turn EPR off for the next night if it continues to be high.
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#43
So last night I went with EPR 2 all time and a 6-9cm pressure range. When looking at the charts keep in mind I was awake for the first 3 hours or so trying to get my hours up. It looks like I had roughly the same amount of CAs with most of them being towards the last couple hours before I woke up again. I'm quite perplexed by this haha.

My mask seal was awesome last night so I know that's no the issue. I'm thinking of trying a 7-9 range, but what do y'all think? Charts below, zoomed in and full view. (see the other dialed in 5min view on my previous post)

Full View - http://imgur.com/Pq3uckY
5min good sleeping - http://imgur.com/eWZhdUT
5min CA clusters - http://imgur.com/4Pvg1se
5min CA clusters - http://imgur.com/as0KJup
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#44
Thanks for the screenshots. The CAs are Central Apneas. You also exhibit periods of Periodic Breathing which is not scored as an apnea. In addition you have several breathing pauses that are too short to score. Your screenshot http://imgur.com/vvB1euu shows the rising and falling pattern of periodic breathing between the cluster of 2 and the cluster of 3 CAs. Screenshot http://imgur.com/uOVYGve shows some pauses that are also too short to be scored as CAs. I don't see much in the way of Hypopneas at these pressures. You still have a pretty good spread between your EPAP and IPAP pressures. You can Leave your EPAP at 6 and continue to lower your IPAP looking for a point where the CAs disappear and possibly some OA events begin to show up. You had your EPR set at 1 previously and now changed it to 2. I would go back to EPR 1. As the pressures come down you should need less EPR anyway. Another point is that you are showing a few OA events at these lower pressures. Lower pressures could bring out more OA events. This is a kind of titration in reverse where we are trying to see if there is a point where you have a higher number of Hypopnea events as you did in your sleep study. I found that at straight 5 CM H2O i had predominantly Hypopneas. Right now you are seeing a few obstructive events at these lower pressures and so far quite a few CAs especially in the last 1/3 of your nights sleep. You still need to confirm that the Central events occur at low pressure with little or no pressure differential. With a little more information you will be able to discuss having Mixed Apnea and the need for an ASV machine.

Rich
Apnea Board Member RobySue has posted a Beginners Guide to Sleepyhead Software here:  http://www.apneaboard.com/wiki/index.php...SleepyHead

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#45
(12-04-2016, 07:34 PM)richb Wrote: Thanks for the screenshots. The CAs are Central Apneas. You also exhibit periods of Periodic Breathing which is not scored as an apnea. In addition you have several breathing pauses that are too short to score. Your screenshot http://imgur.com/vvB1euu shows the rising and falling pattern of periodic breathing between the cluster of 2 and the cluster of 3 CAs. Screenshot http://imgur.com/uOVYGve shows some pauses that are also too short to be scored as CAs. I don't see much in the way of Hypopneas at these pressures. You still have a pretty good spread between your EPAP and IPAP pressures. You can Leave your EPAP at 6 and continue to lower your IPAP looking for a point where the CAs disappear and possibly some OA events begin to show up. You had your EPR set at 1 previously and now changed it to 2. I would go back to EPR 1. As the pressures come down you should need less EPR anyway. Another point is that you are showing a few OA events at these lower pressures. Lower pressures could bring out more OA events. This is a kind of titration in reverse where we are trying to see if there is a point where you have a higher number of Hypopnea events as you did in your sleep study. I found that at straight 5 CM H2O i had predominantly Hypopneas. Right now you are seeing a few obstructive events at these lower pressures and so far quite a few CAs especially in the last 1/3 of your nights sleep. You still need to confirm that the Central events occur at low pressure with little or no pressure differential. With a little more information you will be able to discuss having Mixed Apnea and the need for an ASV machine.

Rich

Rich,

That sounds like a plan. I'll do 6-8 with EPR 1 tonight and report back tomorrow.
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#46
(12-04-2016, 07:34 PM)richb Wrote: Thanks for the screenshots. The CAs are Central Apneas. You also exhibit periods of Periodic Breathing which is not scored as an apnea. In addition you have several breathing pauses that are too short to score. Your screenshot http://imgur.com/vvB1euu shows the rising and falling pattern of periodic breathing between the cluster of 2 and the cluster of 3 CAs. Screenshot http://imgur.com/uOVYGve shows some pauses that are also too short to be scored as CAs. I don't see much in the way of Hypopneas at these pressures. You still have a pretty good spread between your EPAP and IPAP pressures. You can Leave your EPAP at 6 and continue to lower your IPAP looking for a point where the CAs disappear and possibly some OA events begin to show up. You had your EPR set at 1 previously and now changed it to 2. I would go back to EPR 1. As the pressures come down you should need less EPR anyway. Another point is that you are showing a few OA events at these lower pressures. Lower pressures could bring out more OA events. This is a kind of titration in reverse where we are trying to see if there is a point where you have a higher number of Hypopnea events as you did in your sleep study. I found that at straight 5 CM H2O i had predominantly Hypopneas. Right now you are seeing a few obstructive events at these lower pressures and so far quite a few CAs especially in the last 1/3 of your nights sleep. You still need to confirm that the Central events occur at low pressure with little or no pressure differential. With a little more information you will be able to discuss having Mixed Apnea and the need for an ASV machine.

Rich

Rich,

As you suspected as the pressure changes and the CA events drop off other events pick up. Last night I had quite a few RERA events, more obstructive and more hypopnea. Still very dominantly CAs however. Last night was EPR 1 and 6-8cm. Screen shots below.

Whole night - http://imgur.com/taJAuLS
5min - http://imgur.com/81jaXFq
5min - http://imgur.com/PGJIKzC
5min - http://imgur.com/p9HDufe

Let me know what you think the next changes are and thanks again for all the help!

-Casey
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#47
Casey,

The obstructive stuff is still plenty low: The OAI + HI = 1.48. Even the OAI + HI + RERA = 2.85, which is quite acceptable.

If a lower max pressure eliminates most of the CAs while increasing the obstructive stuff marginally, you are better of with the higher number of obstructive events and the lower overall AHI.

In other words, if you could find a pressure setting that reduced or eliminated almost all the CAs, but the overall AHI = 3.5ish, all of which is obstructive, you might be better off than you are now.
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#48
Thanks for last nights data. Screenshot http://imgur.com/PGJIKzC pretty well confirms that at low pressures you are having more Central Hypopnea type events. As robysue points out you can probably return to your best compromise settings. Also continue testing with and without EPR and look at bringing your EPAP and IPAP settings closer together to see how that looks. You could also get a recording Pulse Oxymeter to check for desaturations. Your best AHI numbers were in the 3 range. A Doctor would have a hard time prescribing an expensive ASV machine with numbers like that. If you were having significant desaturations it would be a different story. Continue with seeking a sweet spot in your settings.

Rich
Apnea Board Member RobySue has posted a Beginners Guide to Sleepyhead Software here:  http://www.apneaboard.com/wiki/index.php...SleepyHead

Download Sleepyhead
Organize your Sleepyhead Charts
Post from Imgur


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#49
(12-05-2016, 09:48 AM)robysue Wrote: Casey,

The obstructive stuff is still plenty low: The OAI + HI = 1.48. Even the OAI + HI + RERA = 2.85, which is quite acceptable.

If a lower max pressure eliminates most of the CAs while increasing the obstructive stuff marginally, you are better of with the higher number of obstructive events and the lower overall AHI.

In other words, if you could find a pressure setting that reduced or eliminated almost all the CAs, but the overall AHI = 3.5ish, all of which is obstructive, you might be better off than you are now.

(12-05-2016, 10:23 AM)richb Wrote: Thanks for last nights data. Screenshot http://imgur.com/PGJIKzC pretty well confirms that at low pressures you are having more Central Hypopnea type events. As robysue points out you can probably return to your best compromise settings. Also continue testing with and without EPR and look at bringing your EPAP and IPAP settings closer together to see how that looks. You could also get a recording Pulse Oxymeter to check for desaturations. Your best AHI numbers were in the 3 range. A Doctor would have a hard time prescribing an expensive ASV machine with numbers like that. If you were having significant desaturations it would be a different story. Continue with seeking a sweet spot in your settings.

Rich

RobySue and Rich,

I'm definitely seeing a drop in CAs, but still quite a few. I'm thinking that if my pattern shows a drop in pressure causing a problem that EPR off might be better. The only days that I really had below 4 AHI are days that I wore the mask for long durations while awake. When I look at the actual number of CAs has been pretty similar until just last night.

I'm honestly not sure what happened on the 1st, but here are the numbers.
Dec 1st - 110 CAs
Dec 2nd - 54 CAs
Dec 3rd - 41 CAs
Dec 4th - 32 CAs

I'm quite optimistic with these results so far and I'm thinking that tonight I'll raise the EPAP and keep the IPAP making it 7-8CM range. I'm going to leave the EPR setting at 1 for tonight and depending on results I'm thinking of EPR off with the same 7-8CM range for the following night. If the pattern continues I'd expect to see lower CAs and higher Hypopnea/Obstructive events.

What do you guys think of that plan? Would a 6-7CM range make more sense?

Also I've ordered the CMS-50D+ pulse oximeter recording device and that will be here Wednesday.

Y'all are always so responsive and I really appreciate it.

~Casey
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#50
I like the idea you have. "I'm quite optimistic with these results so far and I'm thinking that tonight I'll raise the EPAP and keep the IPAP making it 7-8CM range. I'm going to leave the EPR setting at 1 for tonight and depending on results I'm thinking of EPR off with the same 7-8CM range for the following night. If the pattern continues I'd expect to see lower CAs and higher Hypopnea/Obstructive events." My hope is that at slightly higher pressures you will see a very minimum number of Obstructive events and as you tighten up the pressure range you will see less in the way of Central events. If I had to characterize your condition right now I would suggest that you have mild Obstructive Apnea complicated by mild Central Hypopnea. This would be classified as mild Mixed apnea. Your machine can pretty well handle the Obstructive events at somewhat higher pressures but those same higher pressures can turn the Hypopnea to Central Apnea. Pressure differentials may be responsible for some of the increase in Central events especially at higher pressures. You now know that at low pressures your Centrals revert to Central Hypopneas and Periodic Breathing. Thus you had that condition all along. It was not caused by the machine it was only changed by the machine. You also know that at lower pressures you have more Obstructive events because the pressures are too low. You are essentially doing a self titration to find the sweet spot. If you can find that sweet spot where Obstructive and Central events are controlled an an AHI under 5 with few if any desaturations your present machine will probably be satisfactory. If your AHI cannot be brought consistently under 5 you should be a candidate for an ASV machine. Most insurance requires that you fail at CPAP/BiPAP before they will authorize an ASV machine.

Rich
Apnea Board Member RobySue has posted a Beginners Guide to Sleepyhead Software here:  http://www.apneaboard.com/wiki/index.php...SleepyHead

Download Sleepyhead
Organize your Sleepyhead Charts
Post from Imgur


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