[Diagnosis] Periodic breathing

[DavePaulson]

Lots of people would like to see better results for you. Good luck and good night.

Dave

[quiescence at last]

yep. see you in the AM. the last posted screenshot did not show anything definitive about exhale resistance. good try.

QAL

[bigtonio]

well that was a very different nights "sleep".  I usually drop off immediately.  whether it was nerves or whatever i found myself looking at my watch periodically and can say that although i may have dozed for a few minutes at a time i was not asleep until after 2am. similarly for my second session i was awake (no dozing even) until after 5:06. 

full night screenshot attached hot off the press i haven't even looked at anything yet! - what closer selections would help? - i think I can post a link to an imgur set of snaps (as I have now over 4 posts) but i haven't managed to master the way they are put into a post - is that OK to do (or try to do)?  (to send this attachment i had to delete the original one but i think we have moved on from there - sorry if it was the wrong thing to do - but.....)

T

[attachment=3688]

[quiescence at last]

well this was partially successful, since it showed that the CA score can drop significantly with control of flex - CAI of 17.0 to 7.3.  we did not expect much change in overall score, but did drop from AHI of 43.6 to 27.1.  you cut the periodic breathing by two and a half times from 44% to 17%.

[imgur for 19 Jul]

[imgur for 18 Jul]

[imgur for 10 Jul]


perhaps we can suggest slowly raising the fixed pressure to attack the obstructive events that now almost tripled.

sorry your night was so disruptive.

QAL

[bigtonio]

Thanks QAL - hopefully sleeprider may have an idea of revised pressure or other alternative settings as it has certainly proved that it is not right yet.  We need to be a little careful of comparison with 18th because of the horrendous number of events that occurred when I used CPAP when i was asleep in the chair (as an experiment).  my AHI 7 day and 30 day averages were 26.8 and 23.8 the day before (generally creeping slowly up).  PB averages the day before were 21 and 17 (7 & 30).  I would say therefore that changing to CPAP (8cm) has not made things worse but not significantly better overall.  it was certainly different!  Hopefully it will reveal things to others that it doesn't to me as to the way forward.  

I have had a scan through  and found the "CSR" waveform as expected and the changing respiration rate wave form at the same time. Unless I am told otherwise i intend to exclude the pressure graph from other scans of the day as it just shows 8 all the time the machine is active.

[Sleeprider]

Bigtonio, I would continue increasing pressure without Flex and see if we can get some better results. I would have no problem trying a 2-cm increase to 10. The idea is to get as comfortable as possible, but you are on the wrong machine or have underlying health issues that need prompt attention. Unfortunately, I have seen this pattern several times before, and getting significant improvement using CPAP is unlikely. Getting ASV will require you to demonstrate cardiac health evaluation that shows your left ventricular ejection fraction is more than 45%. If your LVEF falls below that threshold, you should be evaluated for congestive heart failure and obtain appropriate treatment for that. These problems suggest there should be a high concern for your health, and there is a high correlation to the complex apnea with Cheyne-Stokes respiration that you are exhibiting in these reports. I encourage you to express some urgency to your doctors so you may be evaluated sooner than later.

It can be difficult to pursuade health professionals of a problem unless you give them something they understand. In your case, the sleep specialists will be looking for results in the format provided by Philips Respironics Encore software. You cand get a copy here: http://www.apneaboard.com/forums/Thread-...hines-only

Philips writes the reports in PDF (Acrobat) format, and anyone familiar with these macines will respect what that report contains. I think you should get a copy of the software (free), and create a few reports to get in the hands of your sleep specialists ASAP. I think that should get their attention.

[bigtonio]

Thanks very much SR my GP appt is 31/7 - with a new GP as my normal GP has just gone on maternity leave - great timing!  it is just over a year since they did every test there was on my heart etc multiple ECG's, Echocardiogram (result "normal left ventricular size and systolic function, estimated EF = 55-60% normal RV size and function. No significant valvular pathology,") and finally a cardiac angiogram which found "minor coronary atheroma only" this was done because i had had chest pains after climbing 7 stories in the hospital to visit my wife (lifts weren't working).  Since then the assumption has been that my heart is A-OK. As it is derived from an echocardiogram i assume "estimated" is normal.   I also assume it could have had a significant change in a year but I may have some difficulty in getting the tests repeated?

Part of the reason for the CPAP 8cm night was to find out if the CA events were being caused by excess pressure.  I certainly had a worse night partly because i couldn't get to sleep and significant time was spent lying awake particularly in the first part of the night.  normally i sleep immediately.  As AHI is an events per hour measurement reducing the sleep hours from 7.5 to 5 skews the results as worse than my normal auto doesnt it? I have certainly had a worse day in terms of daytime somnolence even though i felt less physically tired on waking. If a significant improvement is unlikely from stepping up CPAP how would that be likely to compare with reverting to auto with A-flex set to 1? (I dont understand how A-flex affects my situation).  i anticipate less of a problem with the doctors if I dont "play" with settings especially if the results are not going to show much improvement.  I can justify last nights attempt easily as a reversion to my CPAP prescription. I also feel i need something I am used to tonight as I have 2 hospital appointments tomorrow (unconnected) and I wouldn't want to feel as I have today.

I have loaded encore basic and will try to get to grips with that whilst still trying to understand my issues.  your point about things to get action moving is well made and i will get data into that software a s a p so I can see what examples are likely to have that effect. 

Thanks for your help - i feel more relaxed in one way - last night my pressure could not be excessive yet my AHI (adjusted) was worse than average this makes me hopeful that a change of machine will be the answer - I just have to see if there is anything that can expedite that.  I have been coping with AHI in the 20's and 30's for a few months now. The PB% has been increasing slowly at the same time.  If I can produce evidence to my GP and  get her to write when I see her there is a hope that I might get things moving sooner.

[quiescence at last]

I believe that if you change the pressure to 10 cm you will see a reduction in OA without any significant increase in CA from last night.  Estimating, based on past efforts, that your OA will be about 10 and your CA will be about 8, and H about 2 for a total of 20 AHI, which will show as better than last night and past weeks.  There is no reason to believe that you will be less comfortable than last night, and every reason to believe that you will feel less physically tired again and maybe better thru the day.  That is what we are hunting for until you get back to the doctor.

never fear.

QAL

p.s. regarding PB drop, I also see a definite difference between last night and the data shown on 10 Jul.  It was 27% on the 10th, and only 17% last night. You were right to point out that 18 Jul was a strange night, not typical.

[bigtonio]

I have made a very difficult decision.  I am in such need of the goodwill of the sleep clinic to resolve my problems as quickly as possible I cannot make what they might see as "playing" amendments to the settings.  It is clear from what many have said that CPAP is not the answer so all I would be doing is risking the expeditious provision of a permanent solution for a limited possible gain.

The surgeon I saw on friday said in no uncertain terms that he would not be prepared to operate on me until my apnoea is properly controlled.  This is what I feared would be the case.  I think that is must be difficult for you all to understand the situation here with the NHS.  Although private healthcare is available it is very small and fragmented.  My first two CPAP machines were private after I had had a private sleep study.  Once the Dr had had his percentage for the sleep study and his markup on the provision of my first machine he rather lost interest  there was no routine follow up or monitoring.  After my retirement my GP referred me again for NHS treatment and regular monitoring has taken place though all has seemed to be going OK until recently.  I do not want to return to private provision as not only am I retired but I have a number of other medical problems. 

Because of this decision (which some of you may find difficult to understand ) I have to accept that all I can do is try to identify what (apart from changes to the clinician settings) makes my problems worse or better.  I can of course change the Aflex setting (as I am 'allowed' to).

I have looked back at the charts to see when they started getting significantly worse and it may relate to a change in my sleeping position.  I used to sleep on both sides and my back.  this year I have been sleeping much more on my back (because of pain which is now better under control).  Is it possible that this could increase the number of events?  (in particular the CSR)?  i tried last night to sleep on my side far more and it seems it may be better - is this likely? 

I also dont understand A-flex I have set this down to 1 and it seems to have slowed the rise in my pressure (and it didnt get as high) - again is this just a coincidence?  Any help will be appreciated.  I trust that you can understand my position and the very difficult decision I have made and will still help me.

[DavePaulson]

Position can be a huge factor in obstructive events, not sure about CSR but it can cause your pressure to be higher. People will definitely respect your decision and continue to help you, it's your health your decision. I hope you can move the process along quickly and get good results. Most of the time flex is considered a patient comfort setting mess with it a bit and see if you see a trend.

Dave