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High pressures but no events?
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MastiffMom Offline

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Post: #1
High pressures but no events?
[attachment=900]I really hope my first attempt to post this comes through because I won't remember everything I typed and it was good <idiot>

I'm attaching a report. about every hour or so something makes hubby wake and take the mask off. He leaves it off for a while, puts it on and it happens again. When he first went to sleep he had a cluster of OCA but then none the rest of the night (same the night before) but the pressure remain running close to max (12). He says the mask is not leaking. if you look around 1 am the pressures are close to max but no events are showing. He took the mask off for a while and when he put the mask back on the pressure pretty much climbed immediate to the 10ish range. After his experience with over inflated lungs and having a worthless doc we are both terribly gun shy.

Shouldn't the pressure drop back to minimum until it senses an event? Any idea why it constantly remained higher? I thought maybe snoring was the problem but it doesn't seem that high most of the time.

What does flow limitation mean?

He is a slow deep breather with a long exhale (his description) can that be causing this?

We are thinking about lowering the max pressure a bit to see what happens. Even if it doesn't keep him from having some events if it helps him overcome his fear of getting his lungs over inflated again it will be worth it. Then hopefully we will have a better doc and we can go from there.

If there is anything else you need to see I'll try to get it for you.
As always, thanks for your help.
06-28-2014 09:19 AM
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justMongo Offline

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Post: #2
RE: High pressures but no events?
Well, there are excessive leaks at the start of the night. He is snoring.
Flow limitation is a scoring of the inhalation wave form.
It flattens on top due to limitation -- and the machine increases pressure in response to flow limitation as that's a precursor of obstructive apnea.

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06-28-2014 09:44 AM
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robysue Online
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Post: #3
RE: High pressures but no events?
(06-28-2014 09:19 AM)MastiffMom Wrote:  if you look around 1 am the pressures are close to max but no events are showing.
The machine is detecting serious snoring and a significant amount of flow limitations at the same time a that pressure spike right at 1 am. Those two things explain the pressure increase: The S9 responds very aggressively to snoring and flow limitations so as to proactively prevent OAs and Hs from happening. You can see this is what is happening by comparing the activity in the Snore and Flow Limitation graph to the activity in Pressure graph

Quote:When he first went to sleep he had a cluster of OCA but then none the rest of the night (same the night before) but the pressure remain running close to max (12). He says the mask is not leaking.
The S9 is very quick to INCREASE the pressure, but it decreases the pressure rather slowly. AND between 0:00 and 1:00 when there are no events, but the pressure remains close to 12cm, the machine is continuing to pick up quite a bit of Flow Limitation. (Look at how jagged the FL graph is.) At this scale it looks like every time the S9 tried a test decrease in pressure, the machine detected more flow limitations, which then drove the pressure right back up to the max setting of 12.

Quote:I'm attaching a report. about every hour or so something makes hubby wake and take the mask off. He leaves it off for a while, puts it on and it happens again.
Hubby needs to work on NOT doing this. I know it's hard, but he is unconsciously fighting the need for the mask, and that makes the adjustment more difficult.

Quote:He took the mask off for a while and when he put the mask back on the pressure pretty much climbed immediate to the 10ish range.
As soon as hubby put the mask back on at 2:00, machine detected serious snoring and a significant amount of flow limitations. Those two things explain the pressure increase at 2:00: The S9 responds very aggressively to snoring and flow limitations so as to proactively prevent OAs and Hs from happening. You can see this is what is happening by comparing the activity in the Snore and Flow Limitation graph to the activity in Pressure graph

My guess is that hubby woke himself up with snoring, realized the mask was off, put the mask back on, but the snoring and flow limitations continued just long enough for the S9 to detect them and respond pretty aggressively to them.

Quote:After his experience with over inflated lungs and having a worthless doc we are both terribly gun shy.
A lot of us have had bad experiences with docs. The answer is fire the doc and get a new on.

Also, the feeling of "over inflated lungs" is not uncommon at the beginning of PAP. Sometimes it just takes a bit of time to get used to the pressure. Sometimes it takes figuring out whether the therapeutic pressure setting can be safely lowered.

Quote:Shouldn't the pressure drop back to minimum until it senses an event? Any idea why it constantly remained higher? I thought maybe snoring was the problem but it doesn't seem that high most of the time.
No the pressure does NOT drop back to the minimum setting as soon as the apneas/hypopneas are over.

The way the machine is designed to work is this: After a cluster of 2 or more OAs or Hs that occur very close to each other, the machine will raise the pressure to prevent additional events from happening. The machine will keep the pressure at its new setting until the breathing pattern is very stable---as in NO snoring and NO flow limitations. Once the breathing is very stable, the S9 will gently and slowly start lowering the pressure back down towards the minimum. But if snoring or flow limitations are detected, the pressure will be increased once more.

Quote:He says the mask is not leaking.
The leak graph says other wise. Between 0:00 and 1:00 there is an hour long middle-sized leak. While it's well below the Redline that indicates Large Leaks, it still looks like an hour of mouth breathing. If hubby is also complaining of a dry mouth, that's more evidence of mouth breathing. It could be that these middle-sized mouth breathing type leaks are disturbing hubby's sleep enough to cause him to wake up. And the dryness of his mouth may be (part) of what's causing the discomfort and leading him to take the mask off.

Quote:What does flow limitation mean?
A flow limitation is a change in the shape of the inhalation part of the Flow curve that indicates the airway is partially collapsed or in the process of collapsing. The reduction in airflow in a flow limitation is not severe enough for the event to be scored as a hypopnea or an apnea. But studies have shown that significant amounts of flow limitation are strongly associated with an increased risk of airway collapse. So flow limitations are often regarded as "precursor" events to hypopneas and apneas. And that's why the S9 responds pretty aggressively to them by increasing the pressure. The idea is that if the pressure is increased enough to minimize the flow limitations, then the chance that the airway will actually collapse goes way down.

Quote:He is a slow deep breather with a long exhale (his description) can that be causing this?
. Unless his exhalations are consistently longer than 6 seconds or so, this is NOT likely to be the source of the problem. The usual source of the flow limitation problem is labored inhalations.

Quote:We are thinking about lowering the max pressure a bit to see what happens. Even if it doesn't keep him from having some events if it helps him overcome his fear of getting his lungs over inflated again it will be worth it. Then hopefully we will have a better doc and we can go from there.
Does hubby have EPR turned ON? If not, that's actually the first thing that I'd suggest trying. And counter intuitive as it sounds, increasing the minimum pressure a smidge may help because that will help prevent the flow limitations and snoring that are triggering the sudden increases of pressure in the first place.

If you do decide to change the pressure settings, go slow. Only change one setting at a time, and only change it by 0.5-1.0 cm at a time.

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06-28-2014 10:11 AM
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zonk Offline

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Post: #4
RE: High pressures but no events?
Flow limitations (FL) don,t meet the '10 seconds or more' criteria for scoring an apnea but nevertheless are sort of mini-apnea. The machine increase pressure in response to FL but cannot go any higher than maximum set pressure
Yellow colored apnea are 'unknown apnea', when high leak is detected, the machine cannot identify type events accurately and such events are shown in yellow colored flags, good idea to switch off the machine when removing the mask

The second part of the night tells us better story, no apnea are scored, just 1 hypopnea, leak is excellent, the pressure stayed at the maximum 12 for most part but FL persisted

For a starter, if hubby sleep on his back, let him sleep on his side, some people place a tennis ball in a sock attached it to pyjama top so become uncomfortable to roll on the back and maintain side sleeping position

Washing the cushion after each use helps with seal also replace the cushion when get worn out
I've always find humidity level is important, i don,t sleep too good if the air feel too warm or too cold, everyone is different
06-28-2014 04:21 PM
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MastiffMom Offline

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Post: #5
RE: High pressures but no events?
(06-28-2014 10:11 AM)robysue Wrote:  Also, the feeling of "over inflated lungs" is not uncommon at the beginning of PAP.
That is what doc called it. It took 9 days before day time breathing felt normal again.


.
Quote:Does hubby have EPR turned ON?
Yes. EPR is 3 fulltime

Mask is brand new. Used only last 2 night. He is new to machine
(This post was last modified: 06-28-2014 04:52 PM by MastiffMom.)
06-28-2014 04:49 PM
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MastiffMom Offline

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Post: #6
RE: High pressures but no events?
(06-28-2014 10:11 AM)robysue Wrote:  [quote}Unless his exhalations are consistently longer than 6 seconds or so, this is NOT likely to be the source of the problem. The usual source of the flow limitation problem is labored inhalations.

I asked him about this. one day he timed his breathing while he was very relaxed and calm and he took 8 breaths in a minute and he said that he inhales quicker than he exhales.

Oh-jeez
06-28-2014 07:07 PM
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robysue Online
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Post: #7
RE: High pressures but no events?
(06-28-2014 07:07 PM)MastiffMom Wrote:  
(06-28-2014 10:11 AM)robysue Wrote:  [quote}Unless his exhalations are consistently longer than 6 seconds or so, this is NOT likely to be the source of the problem. The usual source of the flow limitation problem is labored inhalations.

I asked him about this. one day he timed his breathing while he was very relaxed and calm and he took 8 breaths in a minute and he said that he inhales quicker than he exhales.

Oh-jeez
Unfortunately this "test" is pretty meaningless for two reasons:

1) Whenever we are concentrating on our own breathing (i.e. "counting our own breaths"), it changes the breathing patterns. Usually the breathing slows down when we count our own breaths. This is why the nurse who takes your RR at the doctor's office does NOT tell you when s/he is counting breaths vs. your pulse rate. The nurse wants to get the RR when you're NOT focusing on your breathing pattern.

2) Sleep breathing is quite different from our normal wake breathing, even when we are very relaxed. In some people, the normal sleep RR is faster than the normal wake RR. In others, it's slower.

But even with an RR = 8, that means each breath cycle lasts about 7.5 seconds. If the exhalations are longer than the inhalations, the exhalations are still probably only 4.5-5.0 seconds, which the S9 ought to be able to follow without misscoring.

And as a final comment, flow limitations are scored on the shape of the inhalations as they show up in the Flow Rate graph: Flow limited inhalations are more jagged and less round than a normal inhalations and sometime FL inhalations also show multiple "humps" or "chair shaped" humps.

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06-29-2014 07:58 AM
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