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Flat Topped Flow; Help With Chart Please
#1
Flat Topped Flow; Help With Chart Please
Hello I would like some help analyzing my chart please. 

I have been noticing some flat topped flow; and would appreciate some input please as to what exactly is going on, and the best way to approach it. 

I am feeling pretty tired despite what my AHI says, and the fact that the flat topped flow ended with some big flows makes me think that it was some sort of respiratory arousal.

I wear a N20 resmed nasal mask, and I tape my lips up. I fully tape them up, and press the tape in pretty good. (I noticed I would blow a puff of air through the tape if it was only a postage size piece, or if the tape was not pressed in well or if I pulled it off and put it back on.)

Is increasing my max IPAP the best way to stop this from happening? I see the machine went to max IPAP almost immediately, which made me wonder if more pressure would help. I also feel like I have read a lot that increasing pressure support is good for flat topped flow, so I am not sure if I should slowly increase both my max IPAP and PS.

I have been slowly increasing my max IPAP because I had some treatment emergent central apneas when I first started treatment, and now if I increase my max IPAP too fast I do get more centrals for a bit. 

I also have my ramp on for 15 min because I also randomly get a bunch of central apneas when I am falling asleep. These are actually not from my CPAP I found out, because I have a CMS-50something and for a few days I didn't have a cpap but I had the pulse ox meter, and I even saw a cluster of oxygen desaturations early on that night. So i just don't like to add any chance of that happening with treatment. I really hate waking up over and over and it's some combo of freaky and exhausting. So while CPAP may not cause it all, it has the potential to make the CAs worse, and when I stay up for a bit after starting my machine, I do notice quite a few CAs right in the beginning of the night.

(If anyone was curious how my old post ended up my central apneas did actually mostly go away shortly after I posted. My clear airway index has been 1-3 ish range since then. An ASV may have provided me with better treatment, but it would have taken years to go through the system here, and it may have not really been needed at all. I did go through insurance and get the resmed aircurve vauto.)

Thanks for the input!!! Big Grin


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#2
RE: Flat Topped Flow; Help With Chart Please
It is also possible this is just how a chart looks when it has a bit of a leak... I am just SO tired today I wanted some extra input <3
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#3
RE: Flat Topped Flow; Help With Chart Please
With PS 6.0, we should not be seeing flow limitations, and indeed in your last full-night chart the mask pressure shows you're not getting significant pressure support during the periods of lower flow rate. I think in future charts, we should use the mask pressure chart to see how your machine is behaving. The problem with the Vauto is that it's pressure support follows spontaneous effort, and if for some reason inspiration is weak or flow limited, you often don't get the expected pressure support. I think your EPAP min of 4.8 needs to be closer to 5.4 or perhaps 6.0. Your closeup at 00:45:30 is clearly a RERA arousal, and the flow rate does not appear flow limited. What was going on with mask pressure leading into that event?
Sleeprider
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#4
RE: Flat Topped Flow; Help With Chart Please
Does this screenshot help for the events before the RERA? I am not sure why the mask pressure was doing this. I was kind of wondering why because I thought the pressure would have changed a bit with my breath, but I just figured it was something else reasonable that I just didn't understand. 

I see there was a bit of a leak proceeding the event, but I thought the machine could compensate for low leaks. Now that I think about that I don't know what is a "low leak" and is ok. I feel like this mask gives me the lowest leaks and fits the best. I do have a p30i I used for awhile, but then I thought it was leaking too much so i went back to this nasal mask, which is a really good fit for my nose.  I have been considering a diff mask to try, but that is a topic for another day all on its own =P 

I have been increasing my min EPAP every other day or so by 0.2, but when I get centrals all night it triggers migraines, so I don't like to do it too fast. I could prob do it every day and maybe even 0.4 a day (if it goes well) to get to 6 or closer to. Thank you for that =) I was slacking a bit now that I look through Oscar.

I was going to also increase the max IPAP a bit each day as well, since I was getting to max pressure for a bit. 

I added a screenshot of a diff time in the night where there is a 0.5 flow limit and some flat topped flow, since you mentioned you didnt think the first incident was, I thought I would add one that probably was due to flow limits =) 

Thank you very much for your help =)


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#5
RE: Flat Topped Flow; Help With Chart Please
Change trigger sensitivity to high and see if that helps. You are not getting the IPAP pressure support for some reason. This is not the machine behavior we expect to see because there is clearly inspiratory flow, but the machine is not backing it up with pressure support. I don't know if this is a machine defect, but it sure looks like one.
Sleeprider
Apnea Board Moderator
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____________________________________________
Download OSCAR Software
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How To Deal With Equipment Supplier


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.
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#6
RE: Flat Topped Flow; Help With Chart Please
I can change it to high, but I had it on high and I felt like my exhales were trying to be cut short. I had to constantly remind myself that i was the boss of my breath and I could exhale for as long as I wanted before I started inhaling. 

So I guess maybe this is a result of changing that setting? I didn't change it just because the setting was there, I did feel my breaths were wonky. 

I actually changed both trigger and cycle to very low. My tidal volume was around 260-280 and minute under or around 4, and I wondered if that was part of my problem. Maybe I should change both back to medium? When cycle was at very low and trigger high, that was when my breaths felt cut off the worst. Maybe this explains it, but if it's a machine defect (or possible) I will change any setting to see for sure lol. I have had this machine about 3 weeks now, so if it was a manufacturing issue I would love to take care of it as soon as possible. (It's also possible my setting changes now explain this, I am not sure)

Thanks for your help =)
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#7
RE: Flat Topped Flow; Help With Chart Please
Here is another night with less leaks and it looks like the same thing happening. I probably had both trigger and cycle very low here.

I am not going back to that mask because it was a horrible fit. (It was a liberty hybrid and the mouth part was way too wide so it kept leaking. I was too lazy to get out of bed to get a diff mask and tube part and change the machine setting, so I thought it would be easier to tape the mouth part of the mask to my face with tape I had handy to tape up my lips, lol. It was actually not easier and the tape was way harder on my chin skin than it is around my lips. I did think it was amusing that my 95% leak rate was 0. All it took was taping a full face mask to my face. The bleep does interest me, but that is also for another day, lol)

Thanks for your help


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#8
RE: Flat Topped Flow; Help With Chart Please
If the chart we looked at has the trigger setting at very low, increase it to low or medium until it properly triggers. I was not aware of the change in settings. I think you can see the impact of this on therapy. I'm sure we can get this to the point where your sleep is not disrupted by expiration being interrupted, but still keep a functional pressure support.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


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.
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#9
RE: Flat Topped Flow; Help With Chart Please
You can always experiment with trigger and cycle settings while awake, and see what feels more comfortable.
Caveats: I'm just a patient, with no medical training.
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#10
RE: Flat Topped Flow; Help With Chart Please
(09-12-2020, 09:45 AM)slowriter Wrote: You can always experiment with trigger and cycle settings while awake, and see what feels more comfortable.

That's a good idea, thanks!! I moved trigger to low last night, but I fell asleep before I hooked up my mask or taped my mouth (facepalm). I only have data from when I woke up to pee until morning, and with the mouth not taped everything is wonky as expected.  

My spouse works nights so I have to plan daytime pap tests carefully. Maybe later today in the evening.

I did previously find very low the most comfortable, but now I am wondering if maybe that was a bad idea lol. Higher trigger settings felt like I was fighting the machine, but last night wasn't too bad I guess.

Maybe I have a day or two of old data from when I changed trigger down in levels. Hmmm

I will be back tomorrow, thanks everyone!
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