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[Diagnosis] Round 2 Sleep Test
#61
RE: Round 2 Sleep Test
(03-31-2022, 12:17 AM)Geer1 Wrote: Pearlpearl if you look at those initial tests you will see that during the first 4 nights with 3 EPR your AHI was the worst of the bunch at 20-22 most nights (I am guessing first night was only lower due to being awake a bunch at the beginning of the night). The first days of data aren't very relevant right now though and what is more important is seeing your recent 3 EPR results. Posting your OSCAR settings tab including the "Changes to Prescription Settings" section would help interpret recent averages quickly. Here is a screenshot of the section I am mentioning.



On Jan 16th you tried one day of 1 EPR at a lower pressure and you had your best results of the bunch, these results were also similar to your recent 1 EPR results. 

Then you tried EPR 0 with a few pressure settings but your flow limitations (I am assuming FL but potentially could be snore, can't see the data) kept maxing out pressure so all you effectively tried was fixed pressures from 9-12 cm with 0 EPR. You suffered with leaks, 0 EPR makes it harder to breath out and you were most likely opening your mouth because it was difficult to breath out against the pressure and then leaking out mouth. AHI was mediocre (better than 3 EPR though) and I am not a fan of the flow limitations/snore driving pressure up.

Then you tried EPR 1 for a couple more nights at higher pressure (13 cm) and had moderate results (better than 3 EPR and 0 EPR data but not as good as lower pressure 1 EPR). You still had leak issues for the same reason (high exhalation pressure of 12 cm causing discomfort). 


In summary your 3 EPR data is riddled with central apnea and if it hasn't improved since then you are arguably making your sleep quality worse not better with those settings. Treatment emergent central apnea can get better with time but it can take up to 6 months. You are only 2.5 months in so it is still possible it could improve but both of your sleep studies indicated central apnea without CPAP so not all of your central apnea is treatment emergent. I expect you will always have central apnea present unless you use an ASV to treat it, the question is if we can we keep it to an acceptable level without ASV. 0 EPR doesn't get along with you and 1 EPR was the golden spot in January/February and also recently. Higher pressure doesn't obviously help but 13 cm with 1 EPR wasn't as bad as I would have thought it might be. I am sticking with my previous prediction that your best results will come with a fixed pressure somewhere between 6 and 9 cm with 1 EPR. There is also a chance a small range like 6-9 cm with 1 EPR might be best but I would try slowly increasing fixed pressures first to get an idea of how your apnea responds to pressure before considering a range.

Hi Geeri,

Here the statistics chart.  Please also find below my datalog from 20 Mar 2022 to 30 Mar 2022 for your review in my goggle drive https://drive.google.com/drive/folders/1...sp=sharing.
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#62
RE: Round 2 Sleep Test
Please find my last night 30 March 2022 result.  CSR events at 4am was exactly when i woke up and couldn't get back to sleep after.  I have been having this 4am thingy.  Either I woke to pee or i woke and couldn't get back to sleep.  I was just lying on my bed and wait for the morning to go to work.  Today i feel a bit tired, the past few nights my hours of rest were shorter.  Please note, rest hours not my sleep hours hahaha.  I need at least 7 to 8 hours rest including sleep lol. 

I plan to take a 3 days off from the machine and see how i feel.  I will switch the setting to 6/EPR1 next week to see how i feel!  I look forward for further input.  Thanks!

https://drive.google.com/file/d/1m--aETM...sp=sharing
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#63
RE: Round 2 Sleep Test
I think a break is an absolutely great plan.  There was a lot of questions about data validity in the sleep study and most of the events were in supine REM.  If you're not sleeping on your back tho, then one could certainly make a case that your OSA is in the not necessary to treat range.

Besides IMO you have a sleep problem, and not necessarily sleep apnea problems.

That said there are a couple more things we can try if you decide to continue therapy.

How many times do you wake up during the night?
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#64
RE: Round 2 Sleep Test
(03-31-2022, 06:52 AM)Rubicon Wrote: I think a break is an absolutely great plan.  There was a lot of questions about data validity in the sleep study and most of the events were in supine REM.  If you're not sleeping on your back tho, then one could certainly make a case that your OSA is in the not necessary to treat range.

Besides IMO you have a sleep problem, and not necessarily sleep apnea problems.

That said there are a couple more things we can try if you decide to continue therapy.

How many times do you wake up during the night?

Thank you for your encouragement.  I usually woke up just once and around the same time at 4am regardless what time i go to bed.  It has been like that for a while prior use of CPAP.  Having say that, in a few occasions, CPAP help me to overcome this.  This is one of the reason i am reluctant to ditch CPAP away hahaha

If anyone can possible do a findings if my sleep problem is resulted by sleep apnea or sleep apnea resulted my sleep problem will be awesome.  I am not certain if i will need to go for Round 3 sleep test which i feel may not be any use if there isn't a good technician or good doctors here have the ability to do a good job and read the result.  Anyhow i will put this problem behind me temporary.  I am going for my rest Smile Good Night everyone who read this thread!
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#65
RE: Round 2 Sleep Test
I think one of your issues on CPAP may be this thing:

[Image: x0F447k.jpg]

If you have a Phillips screwdriver and a hammer we can adjust it.
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#66
RE: Round 2 Sleep Test
Ok I took a look. First thing to note is that you need to share all SD card data, not just the datalog folder. If you only provide the datalog folder then machine settings and statistics page will be incorrect. For example this data of yours says you were using an ASV and the pressure settings are not correct. This is because I had to merge your datalog with some other data to be able to import it into OSCAR and this makes it tougher to interpret. 

   

We ask that members post screenshots as per the following wiki link because it helps with diagnosing. If another member (Rubicon) takes it on to help review data and post screenshots on behalf of the member they should do the same and post a full night screenshot and then zoomed in examples of interesting tidbits worth viewing. This ensures that all members can see the information necessary to help interpret the data.  

https://www.apneaboard.com/wiki/index.ph...ganization

The reason I bring this up is because Rubicon has been picking and choosing what he wants to post leaving other members in the dark on a lot of information. We cannot draw complete conclusions when things like the high level of flow limitations in that first screenshot have gone unnoticed and not been discussed. 

Flow limitations are restricted breaths caused by partially obstructed airways, they are the first indicator of an obstructive breathing issue. Sometimes they are not an issue but sometimes they turn into apnea, hypopnea or cause RERAs. Flow limitations this significant along with your two sleep study findings strongly support an obstructive/restrictive aspect of sleep disordered breathing. 

Treating flow limitations is a two step process. First you try and find the pressure required to hold an airway open. If increasing pressure doesn't help stop the flow limitations (like how your 0 EPR data just maxed pressure out) then you need to try and increase flow through the restricted airway using higher EPR (or PS on a bilevel). Even at 11 cm pressure and 3 EPR your breathing still shows signs of obvious flow limitation although it wasn't getting scored as such (these machines struggle to score round top flow limitations like this but it is obvious the breaths are flattened/restricted. 

   

The biggest problem is that the treatment for these flow limitations aggravates your central apnea. As you can see by this screenshot of the same day your tidal volume and minute ventilation are fluctuating constantly and significantly 75% of the night. Rubicon has been ignoring this data claiming it is mostly SWJ and if you are only sleeping 25% of the night then I am really surprised you don't have more symptoms of tiredness etc. I do agree that some are probably SWJ but I am fairly sure that some of the central apneas and periodic breathing are real, some of them even appear to be being caused by flow limitations/RERAs (triggering an arousal which sets off the central apnea).

   

Just like your two sleep studies indicated your data provided shows signs of pretty much every kind of sleep disordered breathing (obstruction, restriction, central). Unfortunately none of the settings tried have come close to treating your breathing issues in a combined sense. At lower pressures/EPR your flow limitations run rampant and at high pressures/EPR your centrals run rampant. This is not an uncommon situation but it is a somewhat unfortunate one in that is tough to treat with PAP. Machines like ASV can allow you to use a higher PS and keep the centrals in line but as earlier discussed it would be tough for you to get one and without obvious SDB symptoms it is tough to warrant its use, in people without symptoms it could also potentially cause more issues than it fixes.

Discontinuing for a few days (maybe even up to a week) would be an interesting test now because what often happens is that patients slowly improve while using PAP and they don't even notice the gradual changes in their symptoms. Often it is when you try to discontinue PAP that the symptoms (tiredness etc) come back and you realize PAP was indeed helping. This test will hopefully confirm if you sleep better with or without PAP which will help decide on how to proceed.

Not sure how good your coverage is for sleep studies but one option is called a titration study. It is similar to the previous studies you have done but you use a CPAP machine and a technician adjusts the settings to try and optimize them. If indicated a good sleep clinic will even try a other machines (like ASV). If discontinuing CPAP brings back symptoms you didn't realize you had then discussing this option with your doctor may be worthwhile to investigate why your AHI has never been adequate on CPAP. At a minimum this study would help quantify the real events and indicate if CPAP appears to help (because they have EEG data and know which events to ignore whereas Rubicon and myself have to guess). Ideally it would indicate settings or a machine that help treat your apnea successfully.
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#67
RE: Round 2 Sleep Test
(03-31-2022, 07:34 AM)Rubicon Wrote: I think one of your issues on CPAP may be this thing:

[Image: x0F447k.jpg]

If you have a Phillips screwdriver and a hammer we can adjust it.
Huhsign Do you mean to hack my CPAP machine or to "cut out" the mask to fix it? 
I am thinking when i resume my cpap treatment next week, shall we deal with the pressure setting first?  I think that's probably the key to fix.  On another note, lol i didn't know removing my mask without switching off the machine will result a large leak!  I usually hook on the machine way before i sleep to enjoy the "breeze" and i will walk away to attend to thing without switching off the machine.  Does this really matter to the data?
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#68
RE: Round 2 Sleep Test
(03-31-2022, 12:10 PM)Geer1 Wrote: Ok I took a look. First thing to note is that you need to share all SD card data, not just the datalog folder. If you only provide the datalog folder then machine settings and statistics page will be incorrect. For example this data of yours says you were using an ASV and the pressure settings are not correct. This is because I had to merge your datalog with some other data to be able to import it into OSCAR and this makes it tougher to interpret. 



We ask that members post screenshots as per the following wiki link because it helps with diagnosing. If another member (Rubicon) takes it on to help review data and post screenshots on behalf of the member they should do the same and post a full night screenshot and then zoomed in examples of interesting tidbits worth viewing. This ensures that all members can see the information necessary to help interpret the data.  

https://www.apneaboard.com/wiki/index.ph...ganization

The reason I bring this up is because Rubicon has been picking and choosing what he wants to post leaving other members in the dark on a lot of information. We cannot draw complete conclusions when things like the high level of flow limitations in that first screenshot have gone unnoticed and not been discussed. 

Flow limitations are restricted breaths caused by partially obstructed airways, they are the first indicator of an obstructive breathing issue. Sometimes they are not an issue but sometimes they turn into apnea, hypopnea or cause RERAs. Flow limitations this significant along with your two sleep study findings strongly support an obstructive/restrictive aspect of sleep disordered breathing. 

Treating flow limitations is a two step process. First you try and find the pressure required to hold an airway open. If increasing pressure doesn't help stop the flow limitations (like how your 0 EPR data just maxed pressure out) then you need to try and increase flow through the restricted airway using higher EPR (or PS on a bilevel). Even at 11 cm pressure and 3 EPR your breathing still shows signs of obvious flow limitation although it wasn't getting scored as such (these machines struggle to score round top flow limitations like this but it is obvious the breaths are flattened/restricted. 



The biggest problem is that the treatment for these flow limitations aggravates your central apnea. As you can see by this screenshot of the same day your tidal volume and minute ventilation are fluctuating constantly and significantly 75% of the night. Rubicon has been ignoring this data claiming it is mostly SWJ and if you are only sleeping 25% of the night then I am really surprised you don't have more symptoms of tiredness etc. I do agree that some are probably SWJ but I am fairly sure that some of the central apneas and periodic breathing are real, some of them even appear to be being caused by flow limitations/RERAs (triggering an arousal which sets off the central apnea).



Just like your two sleep studies indicated your data provided shows signs of pretty much every kind of sleep disordered breathing (obstruction, restriction, central). Unfortunately none of the settings tried have come close to treating your breathing issues in a combined sense. At lower pressures/EPR your flow limitations run rampant and at high pressures/EPR your centrals run rampant. This is not an uncommon situation but it is a somewhat unfortunate one in that is tough to treat with PAP. Machines like ASV can allow you to use a higher PS and keep the centrals in line but as earlier discussed it would be tough for you to get one and without obvious SDB symptoms it is tough to warrant its use, in people without symptoms it could also potentially cause more issues than it fixes.

Discontinuing for a few days (maybe even up to a week) would be an interesting test now because what often happens is that patients slowly improve while using PAP and they don't even notice the gradual changes in their symptoms. Often it is when you try to discontinue PAP that the symptoms (tiredness etc) come back and you realize PAP was indeed helping. This test will hopefully confirm if you sleep better with or without PAP which will help decide on how to proceed.

Not sure how good your coverage is for sleep studies but one option is called a titration study. It is similar to the previous studies you have done but you use a CPAP machine and a technician adjusts the settings to try and optimize them. If indicated a good sleep clinic will even try a other machines (like ASV). If discontinuing CPAP brings back symptoms you didn't realize you had then discussing this option with your doctor may be worthwhile to investigate why your AHI has never been adequate on CPAP. At a minimum this study would help quantify the real events and indicate if CPAP appears to help (because they have EEG data and know which events to ignore whereas Rubicon and myself have to guess). Ideally it would indicate settings or a machine that help treat your apnea successfully.
Thank you so much for your input and your part to take time to analyze my data.  I am excited and looking forward to see the result of your recommendation setting of 6/EPR1 next week.  I hope it can constantly calm my CA down.  I am not asking or aiming for ZEROs but a good balance i am satisfy.

My experience and my observation i think, it will be a waste of my resources, my money to seek further help from the doctors in my country.  They simply rule me out that my conditions is serious enough for further treatment  I have consulted 3 doctors in total.  2 from the private practise which i paid full fees for their services and 1 from our public (government run) hospital, i was thinking engaging the government doctor will be more professional and my diagnosis will be more accurate but when i received my Sleep 2 report by the government doctor.  It left me with uncertainty.  I came to this forum is to seek someone like you to share some lights whether i should consider to continue to sleep with the machine despite what the doctors claim my condition is mild.  If my decision is to sleep with the machine for the rest of my life what will i gain or will it be worst.  However the final decision is I will need to make on my own obviously.  There is already a registered polysomnographic technician attached to me to titrate.  She is the one that insisted that i should/must on EPR3.  She brought my OA down but in my opinion she has no clue how to bring my CA down.  The whole team just does not care about CA, they felt it will go away on its own despite after my 68 days with CPAP, my CA does not seems to lower.  The doctor told me if i am really concern, he will order me to a neurologist and do a MRI for my brain and if found nothing to my brain, i will be discharged!  So my situation is like, there is a problem and there is a no problem but without a solution.    

Sorry for my rant above.  I am just frustrate with my condition.  How i wish i just need to hook on to CPAP and all the number just turn Zero!

I will continue to observe my condition and i am grateful to all the support and encouragement that you and Rubicon have provided to me and the rest of the guys in my first thread.

Between, i can send you the CPAP files if you don't mind i PM you.  I didn't want to share too many information here to annoy or confuse anyone who is as new as me to CPAP treatment.

My first night without the machine, not certain whether is psychological i couldn't quite able to sleep the whole time from 9pm to 6am.  I don't feel any difficulties in breathing nor feeling choked but my mind is like "engaging" something while i am not really sleeping.  Of course i don't feel refresh at all.

Looking forward next week with my CPAP!  Thanks
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#69
RE: Round 2 Sleep Test
(03-31-2022, 11:07 PM)pearlpearl Wrote: Huhsign Do you mean to hack my CPAP machine or to "cut out" the mask to fix it? 

Unfortunately, j/k because that's a feature called Forced Oscillation Technique that cannot be removed.  It could be felt as a vibration during the appearance of apneas.  In many people this disturbs sleep continuity, causing arousals, waking them up or making falling asleep difficult.

Give it some thought in re: this bothering sleep continuity.

It's not active during ramp so a workaround could be increase ramp to 45 minutes and do a restart whenever you wake up (a couple of other things happen in ramp that might need tweaking) so that might help a little.

Image showing end of ramp/initiation of FOT:

[Image: gacNkNf.jpg]

A
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#70
RE: Round 2 Sleep Test
(03-31-2022, 11:07 PM)pearlpearl Wrote: Do you mean to hack my CPAP machine ...

BTW there is a "hack" to unleash a number of functions in ResMed machines but from what I've seen it then kinda behaves like Skynet in Terminator.

And we all know how THAT turned out!
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