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Choosing Quality over Quantity
#1
Choosing Quality over Quantity
Hi everyone,

First, I want thank you all again for your ongoing help.  Having only been on therapy for 2 months, your advice has been incredibly beneficial.  Many thanks to you all, particularly Gideon and SleepRider  

I've posted previously that I spent a few weeks working with a polysom tech to do what I would describe as an "at home titration."  We tested pressures from 9 to 16 with and without EPR turned on.  At higher pressures my OA and HA events virtually disappear, and I'm left with just CA events.  However I've never been more tired, even bordering on exhaustion.  I wake up feeling like I need to go right back to bed, and then I'm tired for much of the day.  

The tech reviewed each day's data and found that even at 16cm I still have subtle SDB events that look to be fragmenting sleep.  

So I'm at a crossroads.  At lower pressures I tend to have more events per hour, particularly centrals, but I generally felt better.  My question is this - would you personally solve for quality of sleep or for quantity of events?

Given how I feel at the higher pressures, and as long as my AHI and related metrics stay in good therapeutic ranges, I wonder if it make more sense to aim for feeling better than for 'ideal' therapy.

Secondly, would you expect there to be any long term physiological pitfalls to choosing better sleep at the expense of increased AHI? 

As a side note, I started wearing a sleep tracker a few days ago.  While I realize they are not entirely accurate, it's showing what I already suspected.  I have very little time spent in N3 (6% or so).  I don't yet have enough data to add it to my decision making, but it's still a metric pointing towards poor sleep quality issues.

What would your approach be?  I'm guessing you would encourage therapy that leaves you feeling better since several of you have hinted at that previously.  I figured I'd ask anyway because I'm willing to acclimate if the fatigue will eventually go away.

Again, thank you all for the ongoing support you bring to the community.  I can't imagine trying to go it alone.

An example of an average night @ 16cm, EPR=3
   

An example of an above average night @ 13cm, EPR=3 (typically 13cm shows more CAs, a few more obstructive events).
   
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#2
RE: Choosing Quality over Quantity
I should add a small postscript.  

Part of why I think my CAs diminish at higher pressures is that I'm fighting to exhale.  It's notably uncomfortable, and expiration feels short.  As such, I likely expel less CO2 thereby preventing CA onset.  I also suspect that 7 hours of increased expiratory effort plays a large part of my overall fatigue.
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#3
RE: Choosing Quality over Quantity
At least for now, comfort rules.
Set up for your best sleep subjectively at the sacrifice of numbers. Run that for at least a week then repost before and after charts and your critical opinion.
Of course if something looks like it's going south/bad post then and we will be more than happy to help.
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#4
RE: Choosing Quality over Quantity
I'll add that both of the above charts look awesome to me. Statistically the differences are insignificant.

Once you have achieved good numbers such as you have shown above both Sleeprider and myself favor comfort vs numbers.
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#5
RE: Choosing Quality over Quantity
Hi Near - You are two months into the process, and thus may be experiencing so-called "treatement-emergent" central apneas. Because you breathe more efficiently with CPAP, you blow off more CO2 which causes the centrals. As your body adjusts over a period of time, these will probably diminish or disappear in time, leaving you with a super duper AHI. In which case, comfort rules.

If you subscribe to the strategy of using the LOWEST pressures that will handle your obstructive events, as opposed to the highest pressure you can tolerate, the answer is pretty clear. Personally, I would try lowering the minimum to see if you still can have a low AHI. If you do, remember to keep a setting for several nights, maybe a week, because one night is not a trend.
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#6
RE: Choosing Quality over Quantity
Quick, 2 part update after 4 days at at 13cm.

I feel less tired than at 16cm.  Still tired, but not on the brink of exhaustion.  AHI is staying under 1 every day. 

My historical flow limit 95% at pressures 14cm and higher were always 0.00 to 0.01.  At 13cm it's hovering between 0.02 to 0.03.

I'll post the 3 days of 13cm charts and second posts zoomed in at the difference in inspiratory flows.


Attached Files Thumbnail(s)
           
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#7
RE: Choosing Quality over Quantity
Looking closer at flow rate in particular, I see at 13cm there are a large percentage of abnormal inspiration curves.  At 15cm and up the average flow tends to be more sinusoidal on average.

Typical curve shape @ 13cm leading up to what looks like a RERA to my untrained eye.
   


Typical mixture of inspiration curves @ 13cm showing various flow limitation patterns
   


Contrasted by 16cm which tended to look more sinusoidal on average.
   
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#8
RE: Choosing Quality over Quantity
I would say quality of sleep/how you feel.

With a big BUT, how long do events last, how low does oxygen get because this can cause health issues beyond feeling tired.

If you can handle EPR turned off, I would suggest Auto, 12 to 16.5. Then go up or down from there.
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