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I've been using my APAP for a week, symptoms wors V2e.
RE: I've been using my APAP for a week, symptoms wors V2e.
I'd like to add that, while I was looking at my results, I noticed that my tidal volume for my height seems to be relatively low. I'm a 5'7 male and should have a tidal volume between 397 and 529, yet my data consistently shows medians of 320-340. Not sure what the clinical significance of this is, but I definitely think there's an issue here. Higher min/max pressures increase my tidal volume to a normal level but end up causing respiratory effort, even at an EPR of 3. My minute vent is also on average lower than the supposedly reasonable MV of 6, averaging around 5.6-5.8. 

I'm not sure what the clinical significance of this is, but as I've said before, my symptoms are still terrible while my numbers are decent. I'm going to urge my doctors to order the Resmed Aircurve 10 Vauto, which I can use as an APAP with PS < 3 if a higher PS doesn't seem to benefit me. I'm just trying to exhaust all options to feel better.
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RE: I've been using my APAP for a week, symptoms wors V2e.
MV and TV also depend on weight.

Imo part of the reasons your TV and MV are higher at higher pressure/EPR is because you are sleeping worse and having more awake, arousal and recovery breathing all of which are large amplitude.

Good luck with your doctor, I will be very surprised if he considers bilevel. You might be able to talk him into to doing an in clinic titration study which will use CPAP and test your sleep quality to determine ideal settings and to see if you are in fact having any RERA's like you think you are. Potentially with the right technician/clinic they would bump you up to bilevel if indicated although lots end up wasting time trying different pressures.
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RE: I've been using my APAP for a week, symptoms wors V2e.
While I am overweight, I'm nowhere near obese and shouldn't have a tidal volume median that's 80% of my lowest predicted tidal volume at 5ml / Kg. Again, I'm not sure what the clinical significance of this is, but even after good numbers last night I still feel awful. Here are my results from last night with settings of 8cmH2O to 12cnH2O at EPR 2.

Part 1:

   

Part 2:

   



Another example of unreported flow limit:

   



My numbers, excluding the first few apneas, while awake, should be pretty good, but my sleep quality is still terrible. Not sure if Resmed / OSCAR doesn't report flow limitations due to a baseline level of chronic flow limitation.

In regards to the bilevel, I'll try and make the case that breathing against the machine is unbearably uncomfortable and is causing poorer sleep quality.
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RE: I've been using my APAP for a week, symptoms wors V2e.
You have smaller TV but higher RR so overall MV is probably reasonable. These numbers have not changed significantly based on CPAP settings tried so far and I too don't know that there is any clinical relevance.

We have tried pretty much everything you can try with this machine, it is clear there is no setting that is going to make your symptoms go away overnight. The question is what is the BEST setting. What setting leaves you waking up feeling the most refreshed and gives you the most energy through the next day? If you can't answer that you need to step back and restart the titration process focusing solely on how you feel. I would go as far as recommending you stop using OSCAR, it is too easy to tell yourself you think you feel better just because your TV is 0.1 higher (because you slept less so had more awake breathing) than if you just focus on how you actually feel and use that to drive your settings.  

With the best settings possible you will get the best sleep possible while you focus on the next steps to take whether that is a vauto, sleep study, ENT visit etc. I highly doubt your doctor will consider bilevel. Probably 90+% of the bilevel users on this forum gave up on their doctors and bought out of pocket, mainstream medical does not use bilevel to treat UARS even if there is anecdotal evidence that it can be helpful in some cases (which is why it gets used more so on this forum). If it is clear your doctor won't consider bilevel (likely) you are best to change tact and ask for a better quality sleep study/titration study that actually monitors your breathing and sleep status. The watchpat study you had done measures arterial tone and movement instead of breathing and EEG, it is considered good enough for a home study but I believe it can be influenced by other things especially in cases like this where your RDI isn't that high. A PSG is the golden standard and imo warranted in your case although you would probably have trouble sleeping and getting good data because of your messed up circadian rhythm and anxiety. You could learn a lot from a PSG like how I learned that one of my main issues appears to be bruxism related.
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RE: I've been using my APAP for a week, symptoms wors V2e.
The thing is that only 2 nights have made me feel somewhat refreshed in the morning. The reason why I think I felt better after the night of June 25th, was because I only slept for 4 hours, which made me avoid the harsher sleep I get during the 2nd half of the night. As well as that, the night of July 1st wasn't too bad either, but despite not changing any settings for the next nights of sleep, I felt awful yet again. Like you've said, I've been primarily driving how I am adjusting to my settings by how I feel, but since there are no settings that have made me feel good, I've been using the data to try and find the underlying issue with why I'm feeling so awful. The only reason I'm so data-hungry is that it is clear to me that I'm always feeling awful.


This is ultimately why I'm considering purchasing a bilevel so that I can have more room for titration since higher pressures seem to be too tough to breathe against, and lower pressures don't address flow limitations and OA's and hypopneas very well. I'm not sure if you'll agree with me, but I think there's merit in trying a higher max pressure of 12-14cmH20, and a minimum pressure of 7-8cmH2O by using pressure support from a bilevel. I'm aware that my central apneas will almost definitely be an exacerbated issue, but with time they should be resolved.

I'm hoping, but not betting, that I can resolve my SDB using surgical and non-surgical long-term solutions, but in the meantime, I'll just have to get used to breathing with a mask.

One other thing to note, I've been prescribed the corticosteroid, Flonase, for congestion and it has a very weird effect on my body which ultimately keeps me up for longer and further ruins my circadian rhythm. My congestion, even without taking Flonase, seems fine when I'm going to sleep but during my brief awakenings, I notice my congestion is noticeably worse. I've set my climate control to Auto and ramped up my ClimateLine tube to the max temperature to try and deal with that, but to no avail. 


To the sleep study comment:

While my circadian rhythm will likely affect my PSG study unless I take a sleeping aid, my anxiety shouldn't be too much of an issue, as it primarily originates from my brain fog and how my symptoms have affected my ability to function in school and life. I'm not concerned about being observed while sleeping and having wires strapped to me.


I have an appointment with a sleep nurse this week, and am hoping she can address my issue to a doctor in an attempt to replace my machine, but if that doesn't work out, what are some recommended suppliers that'll sell Aircurve 10 VAuto for a reasonable price (couldn't find anything good on Craigslist).
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RE: I've been using my APAP for a week, symptoms wors V2e.
No help here, sorry. Just observations you or others might be able to use, explain or dismiss for our benefit.

Your third graphic, IMO, does show a local baseline level of unflagged flow limits that are witnessed by mainly deformed I-peaks. But such a dense series of tip deformities without trigger-level drops in flow rate have been ignored in my FL curves, too. I think it is marked change of pattern among RR, wave shapes (including flatness), as well as the key driver, TV drop , that drive FL flagging. It seems static irregularities, to be oxymoronic, tend to be (or become) ignored.

The 1.5-minute view is in a notch of the FR curve with high amplitude bursts at either side. At first sight what caught my eye is how the  ending of exhalations were not nearly as asymptotic to the 0-axis as I would expect--except for the latest one at right.  It seemed, guessing here while trying to breathe that way, that you were almost panting--no hesitation between the exhale and inhale breath phases. But not so with 21 breaths in your 89-second view. Surprising to me is not seeing an obvious higher I/E---time to time---ratio in the breathing. Also, your exhalation seems slower after the peak exhalation flow. But, overall, the view is in a short gap between widely varying breaths so maybe it is just part of your normal variations. 

I can't find my link but want to find and send it to you. It, writtten by and MD or other medical provider, dealt with mouth breathing, which I must artificially seal off myself, and an unusual way to clear the nose passages. I don't make light of what you know or have tried. But it struck me as being little known. lt may be useless to you, but worth a scan. I may start a new thread with it so others will see its discussion and approval of a mouth taping product. Further, I'm happy I was "forced" to use (and could use) P-10 nasal pillows with mouth sealing after sleeplessly hating leaking FFMs with their lengthier perimeters to seal over variant contours.

The article is in depth about mouth breathing, how it develops in children and how it leads to later sleep and breathing problems and to bone, nasal and oral deformations.

I just saw Geer1 has already commented on RR and MV accounting for the two different, more stable TV levels.
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RE: I've been using my APAP for a week, symptoms wors V2e.
Please send the article as soon as you find it. Considering my dry mouth and halitosis that I've experienced every morning since at least adolescence, I'm sure I've been mouth breathing for a while. I have my ENT appointment scheduled for this Wednesday, and will correspondingly report my Doctor's observations that day. Initial observations of a large tongue leading to a crowded mouth, and a deviated septum have been made, but I wouldn't be surprised if enlarged turbinates and facial-skeletal abnormalities are also an issue. 

I can post more photos of 2-4 minute views of my flow rate patterns throughout sleep since it seems that breathing irregularities occur fairly frequently without being flagged by my machine. Flattened tops, while not long in duration, seem to be a frequent occurrence, as well as double/triple peaks for many waveforms, which I believe indicates some form of flow limitation. 

My hypothesis for why my symptoms seem to persist at a severe degree despite some form of relief from APAP therapy is the current ongoing stress from very dire circumstances in my family. This in turn, along with a predisposition to sleep-disordered breathing has resulted in a kind of negative feedback loop, which affects my mental functioning in a very demanding course at a very demanding university, which in turn leads to increased stress. It is here that the feedback loop has started, which is why I'm actively looking for a crutch to break the loop so that I can begin recovery. My personality traits of persistence, drive for excellence, and a hint of unhealthy perfectionism backed by self-criticism in the context of academic and social scenes, have most definitely excarcebated my stress caused by my symptoms, and therefore further exacerbates my symptoms. 

I will not allow this disorder to take away my dreams, passions, and most importantly, my ability to take care of my mother. Hence, why I'm looking at every option including the purchase of a Bilevel Pap machine, which I believe will likely address some of my normalized flow limitations. 

I would like some recommendations as to what mask I should order next since there is the possibility of managing mouth breathing by getting a nasal mask and a chin strap, with the risk of increased flow limitation due to obstructions in my nasal passageways. Hopefully, this will become more clear after my ENT visit. 

I'd like to add one thing about my purchase of the ResMed Airsense 10 Autoset via insurance. Because I still have to pay an initial total out of the pocket of $300, I'm not getting a great deal on my device, and will ultimately have to pay a total of $1004 through the initial $300 payment, and 10 further monthly payments. I haven't done much research as to what the insured price of my device should be, but surely it shouldn't be that expensive. Let me know your thoughts on this. 

To anyone reading this, if you've found any good deals on the Resmed Aircurve 10 VAuto, please notify me either via this thread or by private message.
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RE: I've been using my APAP for a week, symptoms wors V2e.
You used the word "steroid" and I went *bing* -- steroids often screw up your body in very strange ways, and sleep is a prime thing that gets affected.

Speaking as someone who has not one but two! autoimmune diseases, steroids are a real mixed blessing. The can take away pain and itching, but also at the cost of just destroying your sleep (and making you fat, and making you really irritable, and topical steroids destroy your skin over time...) Some people are relatively unaffected by the steroid side effects, others are just slammed by them.

Do you have an apple watch or fitbit or other device that claims to do sleep stages? I have a fitbit, and I was extremely skeptical about how it could figure out sleep stages from my wrist. But I wore it to 2 sleep studies, and it was right on exactly what the PSG needed the 35,000 electrodes glued to my head to show!

You can buy a fitbit or AW (other people have experience with other devices and might chime in) at the store today, take it home, and go to sleep. Don't need any interaction with any doctor or DME or insurance company!
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RE: I've been using my APAP for a week, symptoms wors V2e.
I have looked at your data in detail and I see things that are not ideal and that may be related to sleep disordered breathing but I do not see obvious improvement in them when your settings are changed. If they are SDB related then I am not sure it is responsive to the current PAP treatment which is why I have given other recommendations that may be necessary in order to see improvement (being able to breath out nose, able to try a different mask etc). 

Could higher PS help like you think it might? Sure but if that is the case then so will an EPR of 3. If you can't sleep well and adapt to EPR of 3 then it is unlikely you will sleep well or adapt to a higher PS. Test the theory, run EPR of 3 (probably at a pressure range of 10-14) for a few weeks until you notice improvement or are certain it is a lost cause and doing more harm than good. If you start feeling better but still need more improvement then I would jump on the higher PS bandwagon with you. If there is no improvement or you feel worse then I have a hard time believing higher PS will help. I would focus on how you feel and not on your data, as mentioned before I would consider not even looking at the data.

The most reliable place for a used CPAP machine is secondwindcpap, I see their prices have increased since I last looked (probably due to current CPAP shortage) and a used vauto is now $1250. Given your other life stressors including financial situation I would be trying to prove to myself that higher EPR helps before considering spending that money.
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RE: I've been using my APAP for a week, symptoms wors V2e.
(07-11-2021, 11:26 PM)AmirKas Wrote: I'd like to add one thing about my purchase of the ResMed Airsense 10 Autoset via insurance. Because I still have to pay an initial total out of the pocket of $300, I'm not getting a great deal on my device, and will ultimately have to pay a total of $1004 through the initial $300 payment, and 10 further monthly payments. I haven't done much research as to what the insured price of my device should be, but surely it shouldn't be that expensive. Let me know your thoughts on this. 

Providers often charge an arm and a leg ($1000s in total) but you can buy for cheaper through some online stores. Top of the forum has a supplier list you can review some pricing at.

If you were to buy a machine from one of those sources I don't know if/what your insurance would cover though (would have to look into that).
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