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[Diagnosis] Round 2 Sleep Test
RE: Round 2 Sleep Test
OK, send me the link and we'll do a deep "drive".
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RE: Round 2 Sleep Test
So when your sleep is disturbed, you tend to take a deep breath (or 2 or 3).  Consequently you have no need to take another breath for a few extra seconds (Try this at home-- take 3 big breaths, and you'll note that you don't feel like taking another one for a bit).  In sleep, this is a post-arousal central.  The red boxes indicate the extra large breaths that will force the central:

[Image: mKscfJf.jpg]

Mas importante:  The problem here is not the central-- it's the arousal that caused the central.  Those centrals need to be left alone cause it's the body just doing what it's supposed to.

The blue box shows a little less aggressive breathing, but IMO the ensuing event is probably arousal-related too.

So scratch all these off.
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RE: Round 2 Sleep Test
In this area there's some stuff.  IMO the most important event isn't even tagged as an event.  In the first box, flow limitation leads up to an arousal (the suddenly larger breath or 2).  That's a break in sleep continuity.  Box 2 has sort of normal breathing preceding it (but see how they are not evenly spaced?  That's probably a lighter sleep stage as a result of the FL arousal), but then an apnea occurs in Box 2 (I think that's really a central).  With large breaths following the event, that one further disturbed sleep.  3, 5, 6 and 7 are all post-arousal so scratch those.  4 and that little drop following it looks like the body trying to get back to stable breathing.

[Image: WzfMR2B.jpg]

In summary, while most of the events in that area are benign, that flow limitation started havoc and instability.  I would reduce the number of scored events here from 6 to 2 (one apnea and one RERA) but they are significant in that sleep took a big hit.  WAG in that sleep went from Stage 2 > Stage 1 > Wake.

Is raising the pressure the answer?  This is a balancing act.  Higher pressures can mean more leaks, discomfort and sleep instability so you may lose more than you gain.
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RE: Round 2 Sleep Test
This is the continuation of the previous screen. Although it looks a little ugly, I'd leave it alone because I think it's just some Wake > Sleep instability and bludgeoning it to death with an ASV would probably be counterproductive.

[Image: 0xdyDoO.jpg]
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RE: Round 2 Sleep Test
Take these out. Post-arousal, don't count.

[Image: Irya651.jpg]
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RE: Round 2 Sleep Test
Quick note then I gotta watch the game.

So we went to 5.0 cmH20 for desensitization purposes including conquering leaks. Overall not a bad result, although there's some significant FLs.

I really like March 11 with therapy 11/8 but the leaks were like tonnage. Probably gonna end up a little more towards that (IDK what actual settings were see note).

Will post a few more images but hopefully you're getting the hang of meaningful stuff vs junk.
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RE: Round 2 Sleep Test
Rubicon I can tell you like data like I do but you but 95% of beginner patients will not grasp the details you are trying to convey especially in tricky situations like this where I feel your interpretations are only partially correct. 

Although many of those apnea are post arousal I do not believe you can ignore all of these examples. Many of those arousals are RERAs (or at least a decent change of being RERAs) or caused by obstructive apnea so even if the apnea occurring post arousal can be ignored it doesn't mean that apnea/restriction isn't part of the issue. 

She clearly she has a central apnea aspect especially during sleep transition. Some of these sleep transition central apnea end up turning into and being reported as obstructive apnea because they are mixed apnea (start as a central during which obstruction sets in during relaxation). The one example you dubbed SWJ appears to be sleep transition central apnea/periodic breathing.

Imo there are enough indications that both the obstruction and central aspects present in this data are real and not just false events. Especially when you take into account the supporting PSG reports and previous thread. If these were all false events caused by arousal she would have to be tossing and turning like a windmill to cause these results.

I do agree these results aren't horrible (better than PSG results without PAP) but nor are they good. I imagine a slightly higher pressure will help and maybe a higher EPR will help but it is more likely to aggravate her central apnea. I recommend a slow methodical approach of trying increased pressure while maintaining the current 1 EPR (set to 3 but only 1 effective) which will allow us to determine an ideal pressure range and see how it affects her obstructive apnea. Then can try effects of EPR if necessary to deal with remaining flow limitations although the central apnea may very well negate that. Due to her nightly fluctuations of results I recommend only making one changed every 3-4 days and averaging results to draw more accurate conclusions of the effects of the change.

pearlpearl I believe you are stuck in a bit of a pickle right now and have a few options. You can trial no PAP to see how you feel without it although I would say your apnea is significant enough (you had 21 AHI in rem and 33 AHI supine in your last sleep study) that if you aren't already having some symptoms you will probably start to have them as you age. Your other option is to continue trying these low pressures or try tweaking further if desired (you saw my recommendation above of how I would do so). If you go through all these options and aren't satisfied with the results trialing ASV is your only option remaining although your doctor is kind of right in that using ASV to treat what appears to have been bruxism findings (I assume tooth wear or muscle hypertrophy) by your dentist is questionable. Your dentist's recommendation probably should have been a mouth guard even though he is right that sleep bruxism could be the cause. Your apnea although it is not the cause of bruxism could be worsening it.
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RE: Round 2 Sleep Test
(03-27-2022, 03:06 PM)Geer1 Wrote:  95% of beginner patients will not grasp the details

No prob.  I've been told I'm an excellent instructor with the ability to adapt to any situation.

It'll take as long as it takes, and as long as pearl2 is interested, I am at her service.


"With the patience of Job."

Sorry, couldn't think of the guy...
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RE: Round 2 Sleep Test
(03-26-2022, 07:34 PM)Geer1 Wrote: Where are the other pages of that report? You can see at the bottom it says page 1 of 6 and lots of details are unknown from that summary page like the prevalence of central apnea.

Taking a look at your original thread central apnea was your biggest issue. Taking a look at your original sleep study it indicated that you had more central apnea than obstructive apnea before trying CPAP. Your central apnea is not all treatment emergent and I imagine your details for this second sleep study would indicate central apnea was present once again.  

This recent data at 5 cm pressure didn't aggravate your central apnea as bad but it shows signs of obvious obstructive apnea and flow restrictions. Your AHI in first study was 21 and in second study was 13.5, both of which are significant enough that treatment is recommended if you have any symptoms related to apnea (tired, unrefreshing sleep etc).

It seems obvious that you have both central and obstructive sleep apnea and this machine is not capable of treating the central apnea and in fact aggravates it once the machine starts treating your obstructive apnea. Rather than discontinuing CPAP your doctor should consider treating your central apnea... A basic APAP like yours is not capable of doing so and you require ASV.
Hi Geer1,

Thanks for your comment.  ASV is out of question.  Firstly, this machine is not for retail in Singapore.  Secondly, ASV machine is not in the approve list in our Health Authority.  If i am to purchase and import from other countries, i will still unable to get it clear from the Singapore Customs.  Thirdly, if i do manage to use a ASV, it will be use at my own risk as no doctor here has approved and assign me with one to use it.  Hence, it may end up in an unfavorable situation if other conditions develop and questioning the use of ASV.     

I will be interested to know how my CA is developed during my sleep.  Could it be my functional breathing problem? or some kind of weird gene in me that resulted this kind of breathing pattern.  I need some kind of direction whether i should seek other medical fields advice with my condition.  I need to also have some facts to speak to all these ENT doctors and Sleep physician.  Sometime i have a feeling that their comments were not very logical.  Hence, that's why you are seeing me here in the forum hahaha
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RE: Round 2 Sleep Test
I think your AHI on 3/26 instead of 7.64, once all the junk is removed is actually <1.0.  However, there's a lot of flow limitation.  Last night (3/27), your AHI was 10.19, but after removing junk it's more like 5.1.  3/11 is another good night AHI listed as 3.09 while on 11/8 but more like AHI<1.0 again.

However, on 3/11 there's a lot of waxing and waning:

[Image: y3aTBJD.jpg]

[Image: exlMwO0.jpg]

While not actually periodic breathing it's getting close, but more important, darn near to starting treatment-emergent central apnea.  IMO, we need to stay away from 11/8, whether it's the PS, the pressure or both.  So I'm thinking we're going to end up somewhere between 5/2 (you're using EPR) and 11/8, probably closer to 5/2.

Recalling how we got here, this is CPAP Desensitization, you had horrid leaks, and these are clearly resolved during these low pressure sessions so this is going well.  A few events are acceptable, especially when there's few leaks and good compliance.
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