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[Equipment] Stumped. Please help.
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AllenM Offline

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Joined: Jun 2014

Machine: ResMed S9 AutoSet
Mask Type: Nasal pillows
Mask Make & Model: ResMed Swift LT
Humidifier: ResMed h5i
CPAP Pressure: 9-12
CPAP Software: ResScan

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Sex: Male
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Post: #31
RE: Stumped. Please help.
(06-27-2014 11:10 PM)retired_guy Wrote:  That might work very well. Remember, don't put it on too tight. The idea is to "encourage" the jaw to stay forward when you get super asleep, not to force it so much that your upper and lower dentures trade places.

This isn't the kind of elastic stuff that gets tighter the longer it's on is it? Probably not.

Anyhow, let us know how this works out for you.

Two questions and an answer.

Perhaps informative details on my performance last night. 95% pressure was 11.2 (normal). Indices were also the new normal (argh) ... AHI=7.0, AI=5.9, and centrals =4.3.

So what may be informative? I got this data with leaks at 2/min for the night. I had the elastic strap on for the first 4 hrs of sleep, went to the bathroom, and checked the leak rate, seeing it was 3/min. I took the strap off for the next 3.25 hrs sleep, and because the leak rate for the night was 2/min, that means the next 3.25 hrs had a rate of around 1/min. Still lots of centrals, but this time with low leaks and pillows not feeling tight at all.

The questions:

1. I understand that if I have started to sleep with my mouth open, that can cause increased centrals. Would my mouth being open make the leak rate increase, or not necessarily? I don't quite get how mouth being open would affect leak rate.

2. What is the anatomical goal of the chin strap? You wrote to make the "jaw stay forward." I've looked at the the straps at Supplier #1, and aside from strapping across the back of the head, they all seem to have the strap under the chin to be slightly forward of the part on the top of the head. Is this "slant" what applies both 'up' and 'forward' pressure under the chin?

The strap I rigged up is just a loop, under the chin and atop the head. Since I cut the thing in half, I now have two pieces of this stuff. So I'm wondering if I should try and emulate the commercial straps, and take the extra piece and wrap it around the back of my head, attaching to the loop around my temples.

The answer -- Not to my knowledge, this gauze material does not tighten on its own.
06-28-2014 09:14 AM
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Sleepster Offline
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Joined: Feb 2012

Machine: ResMed AirCurve10 VAuto
Mask Type: Full face mask
Mask Make & Model: F&P Simplus
Humidifier: HumidAir and SlimLine Hose
CPAP Pressure: MaxI 13.6 | MinE 5.2 | PS 4.4
CPAP Software: ResScan SleepyHead

Other Comments: Diagnosed Nov 2011. Conquered aerophagia.

Sex: Male
Location: Houston, Texas

Post: #32
RE: Stumped. Please help.
(06-28-2014 09:14 AM)AllenM Wrote:  Perhaps informative details on my performance last night. 95% pressure was 11.2 (normal). Indices were also the new normal (argh) ... AHI=7.0, AI=5.9, and centrals =4.3.

First and foremost, please don't freak out over this data. To score an AHI of 7.0 simply means that your breathing rate fell below some amount for a period of at least 10 seconds on an average of 7.0 times per hour.

It will drop as you adapt to CPAP therapy. If it doesn't then we can make adjustments, but you should be celebrating the fact that your data looks as good as it does, and that you are able to sleep at all with the CPAP machine. You are doing extremely well, and it will get a lot better soon as you adapt to the machine and also as your brain adapts to the new ability to breathe and sleep at the same time. The human body's ability to adapt is nothing short of amazing. We just have to give it the time it needs to do its thing.

Quote:So what may be informative? I got this data with leaks at 2/min for the night. I had the elastic strap on for the first 4 hrs of sleep, went to the bathroom, and checked the leak rate, seeing it was 3/min. I took the strap off for the next 3.25 hrs sleep, and because the leak rate for the night was 2/min, that means the next 3.25 hrs had a rate of around 1/min. Still lots of centrals, but this time with low leaks and pillows not feeling tight at all.

Those are entirely acceptable leak rates. It can go as high as 24 L/min with no problems. CPAP machines are designed to leak!

Quote:1. I understand that if I have started to sleep with my mouth open, that can cause increased centrals.

That's not my understanding at all. The machine can't even reliably measure centrals or any other kind of event if you're mouth-leaking. The danger of mouth-leaking is that the machine can no longer maintain the pressure splint needed to keep your airway open and it will collapse just as if you had no CPAP machine at all.

Quote:Would my mouth being open make the leak rate increase, or not necessarily? I don't quite get how mouth being open would affect leak rate.

Not necessarily. If your mouth is open so far that the pressurized air hisses out it shows up in the data as a too-large leak rate.

Quote:2. What is the anatomical goal of the chin strap? You wrote to make the "jaw stay forward."

No, in fact one of the unwanted side effects of a chin strap can be that it may force the jaw backwards.

When you fall asleep the jaw-closing muscles relax and the jaw may drop far enough that the passageway above the back part of your tongue opens up and air hisses out. What the chin strap can do is prevent this from happening. That's its purpose.

Sleepster
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
06-28-2014 10:33 AM
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retired_guy Offline

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Posts: 2,744
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Machine: ResMed S9 Autoset
Mask Type: Nasal pillows
Mask Make & Model: Resmed Airfit P10
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CPAP Software: ResScan SleepyHead

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Post: #33
RE: Stumped. Please help.
I agree completely with Sleepster. I believe that the centrals especially will calm down rapidly as you adjust to the therapy. Often they seem to come up a little when you make changes, such as pressure increases. You might need to increase pressure a little bit to bring the OA's down a little more, but not right now. Right now you're doing just great, so focus on being comfortable and relaxed and enjoy some quality sleep for once.

What Sleepster says about the jaw falling back is what I experience when I put my chinstrap on too tightly. That, and I get a super bad pain in the whatever gland between my ear and my mouth. So gently works for me. Like I say, a reminder, not a commandment. And, it doesn't have to be perfect. When I look at my leak stats I mentally smooth away the high peaks and visually note that most of the night I was happily under 20. So I'm good with that.

Love your little cpap 'cause it's lovin you.
(This post was last modified: 06-28-2014 12:40 PM by retired_guy.)
06-28-2014 12:39 PM
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AllenM Offline

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Posts: 14
Joined: Jun 2014

Machine: ResMed S9 AutoSet
Mask Type: Nasal pillows
Mask Make & Model: ResMed Swift LT
Humidifier: ResMed h5i
CPAP Pressure: 9-12
CPAP Software: ResScan

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Sex: Male
Location:

Post: #34
RE: Stumped. Please help.
(06-28-2014 10:33 AM)Sleepster Wrote:  First and foremost, please don't freak out over this data. To score an AHI of 7.0 simply means that your breathing rate fell below some amount for a period of at least 10 seconds on an average of 7.0 times per hour.

It will drop as you adapt to CPAP therapy. If it doesn't then we can make adjustments, but you should be celebrating the fact that your data looks as good as it does, and that you are able to sleep at all with the CPAP machine.

The danger of mouth-leaking is that the machine can no longer maintain the pressure splint needed to keep your airway open and it will collapse just as if you had no CPAP machine at all.

Thank you for helping me. That said, I am confused.

Re adapting to CPAP - I have been using CPAP for >10 years. Until 6 months ago, I was on an older CPAP-only machine. In January, I got the S9 and H5i, and started using the S9 as APAP, and looked at my night's data every morning. My AHI has consistently been below 5, averaging 2.8 with centrals 1.8. Then, something changed, and for the past month, I have averaged AHI of 7.1 with centrals 5.6.

I understand many people would be pleased with my recent (worse) data, but it seems something has to account for the rather sudden increase in my centrals. I'm not freaked out, at all. Yet I would like to see if I can determine what happened to account for the lesser performance, to be able to get back to AHIs <5.

There have been no environmental changes to my knowledge -- no new bed, no new pet, etc.

Retired_Guy suggested two things (I've posted some ResScan graphs earlier in the thread) -- to reduce my pressure range from 9-14 to 9-12, and a chin strap. I've made those changes for the past 4 or so nights, and nothing has improved so far. The past two nights, my leaks were 3-4/min, and last night, my AHI was 16.6 with centrals still dominating, at 12.9. I'm content to give it m,ore time, to see if these changes can reduce centrals, but from what I've read, 3-4 nights may be a reasonable length of trial.

Throughout this whole time, during good and bad (i.e., past month), my actual pressure (95%) has remained unchanged and without much variation - always averaging somewhere in the 11-2 range.

I've used the chin strap to test whether there is mouth leaking that may account for the statistical increase in centrals. That is why I wonder if the past two nights of rather low leak rates could possibly indicate that mouth leaking is not the reason for the change.





(06-28-2014 12:39 PM)retired_guy Wrote:  I agree completely with Sleepster. I believe that the centrals especially will calm down rapidly as you adjust to the therapy. Often they seem to come up a little when you make changes, such as pressure increases. You might need to increase pressure a little bit to bring the OA's down a little more, but not right now. Right now you're doing just great, so focus on being comfortable and relaxed and enjoy some quality sleep for once.

What Sleepster says about the jaw falling back is what I experience when I put my chinstrap on too tightly. That, and I get a super bad pain in the whatever gland between my ear and my mouth. So gently works for me. Like I say, a reminder, not a commandment. And, it doesn't have to be perfect. When I look at my leak stats I mentally smooth away the high peaks and visually note that most of the night I was happily under 20. So I'm good with that.

Love your little cpap 'cause it's lovin you.

See note above to Sleepster.

I am comfortable going to bed, and don't have pessimistic views about how I'll do on any one night. I go to sleep with an open mind, not expecting anything in particular.

Thank you for hanging in there with me.
(This post was last modified: 06-29-2014 09:20 AM by AllenM.)
06-29-2014 09:17 AM
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Sleepster Offline
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Posts: 4,994
Joined: Feb 2012

Machine: ResMed AirCurve10 VAuto
Mask Type: Full face mask
Mask Make & Model: F&P Simplus
Humidifier: HumidAir and SlimLine Hose
CPAP Pressure: MaxI 13.6 | MinE 5.2 | PS 4.4
CPAP Software: ResScan SleepyHead

Other Comments: Diagnosed Nov 2011. Conquered aerophagia.

Sex: Male
Location: Houston, Texas

Post: #35
RE: Stumped. Please help.
(06-29-2014 09:17 AM)AllenM Wrote:  Re adapting to CPAP - I have been using CPAP for >10 years. Until 6 months ago, I was on an older CPAP-only machine. In January, I got the S9 and H5i, and started using the S9 as APAP, and looked at my night's data every morning. My AHI has consistently been below 5, averaging 2.8 with centrals 1.8. Then, something changed, and for the past month, I have averaged AHI of 7.1 with centrals 5.6.

Sorry. Somehow I thought you were new.

When I switched from CPAP to BiPAP I had a rise in my CA index that put my AHI way over 5 and no one could explain it at the time. Since then I found out it's a documented phenomenon.

In your case, I know of no cause but I suspect the APAP algorithm. Lowering the EPR or switching to CPAP mode are the only things I can think of to try.
[/quote]

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
06-29-2014 09:37 AM
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diamaunt Offline

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Joined: May 2012

Machine: S9 VPAP Auto 36006
Mask Type: Full face mask
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Humidifier: none
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Post: #36
RE: Stumped. Please help.
Several things,

1) just for ease of understanding, could you put resmed s9 autoset (I assume it's an autoset?) in your profile for future reference, there are a LOT of different s9 machines.

2) what kind of machine did you have before, and what settings was it using, pressure, pressure relief.

3) are you using epr now?

could you load a copy of sleepyhead and import your data into that, and then post a page with the
events, flow, pressure, snore, flow limitation and leak graphs? (you can autoscale and resize the graphs by dragging. click the little ^ by the calendar to turn it off and thus present more of the stats info on the left (you'll see what I mean when you see the daily page)
06-29-2014 02:09 PM
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robysue Online
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Machine: PR Dreamstation BiPAP Auto
Mask Type: Nasal pillows
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CPAP Pressure: min EPAP = 4; max IPAP = 9;
CPAP Software: SleepyHead EncoreBasic EncorePro

Other Comments: Papping since September 2010

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Location: Buffalo, NY

Post: #37
RE: Stumped. Please help.
(06-29-2014 09:17 AM)AllenM Wrote:  Re adapting to CPAP - I have been using CPAP for >10 years. Until 6 months ago, I was on an older CPAP-only machine. In January, I got the S9 and H5i, and started using the S9 as APAP, and looked at my night's data every morning. My AHI has consistently been below 5, averaging 2.8 with centrals 1.8. Then, something changed, and for the past month, I have averaged AHI of 7.1 with centrals 5.6.
So you've been using the S9 for six months or so, but centrals didn't show up until about a month ago.

May sound silly, but I'll ask anyway: When do the seasons change in your neck of the woods? Did summer (or spring or winter) arrive about a month ago??

Quote:Yet I would like to see if I can determine what happened to account for the lesser performance, to be able to get back to AHIs <5.
The problem is: There's no obvious way of "self treating" a slight rise in centrals: Pressure increases don't treat them and can make them worse.

Quote:There have been no environmental changes to my knowledge -- no new bed, no new pet, etc.
Have you been more restless at night during the last month? Sometimes wake breathing gets misscored as centrals. Also if you're doing a lot of dozing---in other a lot of transitioning between light sleep and wake, the number of "sleep transition centrals" can increase and more of them may get scored by the machine.

Sleep transition centrals are a normal phenomenon: They can occur when the control of breathing is switched from the voluntary nervous system to the autonomic one and the CO2 trigger for inhalation is reset. When sleep transition centrals are seen on a PSG, they're typically not even scored because they are not considered part of sleep disordered breathing unless the number of them is so great as to make it difficult for the person to transition to sleep.


Quote:The past two nights, my leaks were 3-4/min, and last night, my AHI was 16.6 with centrals still dominating, at 12.9. I'm content to give it m,ore time, to see if these changes can reduce centrals, but from what I've read, 3-4 nights may be a reasonable length of trial.
How much time did you spend sort of half awake or half asleep while masked up?

Quote:Throughout this whole time, during good and bad (i.e., past month), my actual pressure (95%) has remained unchanged and without much variation - always averaging somewhere in the 11-2 range.
This is NOT a surprise. The S9 will NOT increase the pressure setting in response to CAs since the airway is already open.

Questions about SleepyHead?
See my Guide to SleepyHead
06-29-2014 04:08 PM
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retired_guy Offline

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Post: #38
RE: Stumped. Please help.
(06-29-2014 04:08 PM)robysue Wrote:  Have you been more restless at night during the last month? Sometimes wake breathing gets misscored as centrals. Also if you're doing a lot of dozing---in other a lot of transitioning between light sleep and wake, the number of "sleep transition centrals" can increase and more of them may get scored by the machine.

Sleep transition centrals are a normal phenomenon: They can occur when the control of breathing is switched from the voluntary nervous system to the autonomic one and the CO2 trigger for inhalation is reset. When sleep transition centrals are seen on a PSG, they're typically not even scored because they are not considered part of sleep disordered breathing unless the number of them is so great as to make it difficult for the person to transition to sleep.

This observation really resonates with me Allen. I think Robysue may have an answer her for you. Which, of course, is why we pay her the big bucks.

At season change, with warmer weather, later lasting daylight and all that our sleep patterns can change a little. Maybe you aren't sleeping near as deeply as when you were "hibernating," and the transition effect Robysue is describing is occurring.

Your environment hasn't noticeably changed, but is it warmer at night? Less covers? Go to bed a bit later? Sleep indoors instead of out on the porch? Or vice-versa?
06-29-2014 05:14 PM
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me50 Offline

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Post: #39
RE: Stumped. Please help.
maybe check your pillow cushions to make sure they don't need replacing. What robysue said.
06-29-2014 07:54 PM
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