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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.
Here are the results from last night, using an Aircurve 10 VAuto with motor whine issues (5000 hours). 

Part 1: (Min Epap 6, Max IPAP 12.6, PS 4)

   


Part 2: (Min Epap 6, Max IPAP 12, PS 4)

   


Let me know if you'd like to see any closeups.
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RE: I've been using my APAP for a week, symptoms wors V2e.
The Resmed S9 VPAP Auto and VPAP S are equivalent in therapy to the Aircurve 10 Vauto and S models. In addition to the differences Dave mentioned, the S9 models must have the SD card locked before inserting into a computer to prevent index files from being written, and unlocked before putting the card back in the VPAP. We also have a batch-file tool you can run to prevent your computer from writing these files, and that removes the need to lock or unlock the SD card.

Your most recent screenshots use the same settings with an IPAP set 0.6 cm higher. I would not think that difference should logically result in a significant therapy difference, but August 1 has lower flow limitation, but a more ragged looking flow rate. I think you may have to decide which "feels" better.
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RE: I've been using my APAP for a week, symptoms wors V2e.
Neither feels distinctly better. I still feel pretty awful no matter what. I'm trying to decipher whether these flow limits are positional in nature, or the cause of additional obstruction when using higher pressures. I have more examples of apparent flow limits at higher pressure that may give some indication that there is a correlation between high pressure and more inspiratory flow limitation. Also, the Autoset "Ipap" was 14cmH2O as opposed to 12 or 12.6. Sleep-deprived me probably thought 0.6 of a difference would help to reduce the high pressure induced flow limitation.

My hypothesis is that due to my collapsable nasal valve at higher flow rates, I'm experiencing more obstruction when inhaling when pressure, and therefore airflow is higher. Not sure what steps to take in Pap therapy to address this possible issue, especially since I can't get a nasal reconstructive surgery until at least another 6 months, which is too long to wait when experiencing these symptoms.
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RE: I've been using my APAP for a week, symptoms wors V2e.
Have you considered raising PS rather than just IPAP max? It is the pressure support that will relieve flow limitation in general, however the periods of snore and FL in your graphs show an episode clustering, which does suggest positional.
Sleeprider
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____________________________________________
Download OSCAR Software
Soft Cervical Collar
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Organize your OSCAR Charts
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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.
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RE: I've been using my APAP for a week, symptoms wors V2e.
At the moment I can't raise PS since I'd rather not use a faulty BiPAP machine. That raises the question, why would PS help flow limitation when the issue is during inspiration and not expiration. 

Positional limitation has been considered, but my concern with that is that there are moments where flow limitation rises significantly with pressure increase, without any noticeable arousal beforehand that would've resulted in a position change. I can't discount that possibility though, but when many results have shown that flow limitation has risen simultaneously with pressure increase, I'm skeptical. (Correlation doesn't equal causation is still in the back of my head)

Here's a view from another night presenting the same thing:

Whole view:

   


Evidence of no prior arousal:

   


It seems that flow limitation from high pressures ultimately results in Obstructive apneas, which temporarily clears flow limitations until they start to rise again.
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RE: I've been using my APAP for a week, symptoms wors V2e.
Why does PS help flow limits? Because it creates a differential between EPAP and IPAP.

Positional apnea doesn't need an arousal to set anything off. Kinking the air hose is a physical blockage that the physical aspects of the cervical collar prevents.

Flow Limits with any person results in hypopnea or apnea if the pressure isn't enough to prevent it from blocking the airway.
Dave

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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RE: I've been using my APAP for a week, symptoms wors V2e.
I'm still failing to see how PS helps with the inspiratory flow limit. I understand that it reduces breathing-related effort by allowing the patient to exhale more easily. What I don't get, is how PS would support flow limitations during inhalation.

In the case where positional apnea isn't an issue, and I could use a Bilevel pap device, would you suggest I increase my max IPAP and pressure support, say by 1cmH2O and 0.6H2O. respectively?
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RE: I've been using my APAP for a week, symptoms wors V2e.
You don't need pressure. Pressure treats obstructive apnea by holding your airway open and you don't have obstructive apneas. Your airway does not close and more pressure has not appeared to hold your airways any more open then when using lower pressure (would notice improvement on ahi, flow limitations and other stats if it was helping). Higher pressure is going to give you more issues like aerophagia and if anything is more likely to make your sleep quality worse rather than better.

PS is what treats flow limitations and restricted breathing. PS creates a pressure differential and this pressure difference occurs during both inspiration and exhalation (albeit a faster transition during exhalation). The pressure rises as you are inhaling and then falls after you start exhaling. This pressure differential creates more flow through a restricted airway which is why it helps, if you read Resmed or PR titration protocol you will see that increasing PS is what is recommended after obstructive apneas have been dealt with by increasing EPAP. If your issues are due to a restricted airway PS is the only CPAP adjustment that is likely to help you and you can't do anything more with your autoset so will have to wait for vauto and then use minimal EPAP and try adjusting PS.

I believe I have said this multiple times already but will say it again, both pressure and PS only help if they help. If they don't help they make things worse. Based on all the information given it appears that pressure does not help and perhaps makes things worse, PS/EPR appeared to make things worse but now may be helping. I would use less pressure (because you don't need it) and try to use higher PS if you feel it is needed. You need to focus on how you feel because you don't have high AHI or any other data that shows an obvious issue or clear improvement/worsening as settings are changed. 95% flow limitation, median TV and median MV are the only stats that may be slightly helpful to you, you want lower flow limitation and higher TV and MV (within reason, both can be too high if you go overboard on PS) but I am not sure you can draw much of a conclusion on those numbers based on what has been posted.

Your periods of high flow limitation may be due to positional effects but they could also be caused by the full face mask and mouth breathing which I have already explained a few times. If you research the topic and you will see that mouth breathing is inefficient and that full face masks can be less effective then nasal masks, this is because they apply pressure in the mouth which pushes tongue/palate back negating some of the positive effects of CPAP treatment, the lower strap can also apply pressure pulling chin back/down. If this is the issue you are having then higher pressures would make things worse by collapsing airway rather than helping hold it open. If your issue is due to restricted breathing it may not be possible to find effective treatment using CPAP and a FFM alone which is why I have recommended chasing other avenues that could have a potential effect and could cause significant improvement. So now the question is have you tried a dairy free diet yet? Have you continue to follow up with ENT? Have you attempted to correct your circadian rhythm? Have you reduced stress and anxiety? Have you researched and applied sleep hygiene and CBT-i principles? Or are you choosing to delay these potentially effective treatments while spending all your effort on trying to find a unicorn CPAP setting? You can't do anything more with autoset right now so focus on the other things you can try.
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RE: I've been using my APAP for a week, symptoms wors V2e.
I have a CT scan booked for next week, so I'm hoping to get a more detailed assessment as to how to deal with nasal obstruction. In the meantime, are there any nasal dilators you can recommend to avoid my tendency to have nasal valve collapse? My issue with taking medication for my enlarged turbinates is that I'm now quite sensitive to the corticosteroid medication I'm prescribed. I will ask my primary care physician to prescribe nasal spray in the meantime.

In tandem with nasal dilators, I'd like to try to use a nasal mask alongside either tape to close my mouth, or a chin strap to eliminate the chance of mouth breathing. It looks like I might ask to receive the P10 nasal mask, but want to know if there are any better options.

Additionally, since I have a recessed jaw (around 0.5-1cm), I will attempt to get a MAD device prescribed by a dentist. I have an appointment with a sleep apnea-specific dentist this Wednesday.


In regards to non-CPAP treatments... 

I'll be honest by saying that I haven't been doing the dairy elimination diet yet, but plan to do so soon, once I've got a better bearing on how to meal prep. I've reduced my stress by in-completing my difficult class, which means that I don't have to work on it till I start to feel better. In regards to my circadian Rhythm, fixing it has been rough, but I am planning to (and have already done) sleep 15-20 mins earlier than usual each night till I reach a good schedule. I use 1.5mg of quick dissolve melatonin to help make me sleepy.

PS: Aerophagia doesn't seem to be much of an issue anymore, but mask discomfort and leaks are.
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RE: I've been using my APAP for a week, symptoms wors V2e.
Dymista is the best nasal spray, it is a combination antihistamine and steroid. Decongestants can provide more obvious short term benefits but create more long term issues.

Regarding meal prep for dairy free diet it is a bit of a pain but not that bad. Use almond or oat milk instead of milk and use dairy free margarine or oil (olive oil etc) instead of butter. The biggest frustration is that dairy is included in a lot of prepackaged meals and in lots of restaurant meals but if you make more homemade meals and look at restaurant allergy menus finding dairy free options isn't that hard. I am currently on a dairy and gluten free diet which sucks a lot but dairy free only isn't that bad.

As you note mask leaks etc all get worse at higher pressure and can create more issues then the higher pressure helps. After my most recent sleep study tech commented how 11+ cm of pressure helped but I tried that for a while and found I had worst quality sleep then sticking with lower pressures. The only way to really know is try different settings and see if it causes improvement or not.
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