Need guidance for complex sleep apnea and leaks follow-up

[jmayer180]

Another try at zoom.  

   

   

[SarcasticDave94]

I'm no expert at all on the charts, but the flow rate shouldn't like anything like an EKG trace.

Me thinks of pumping into the lungs, something akin to air stacking or similar. Inhale and exhale traces aren't symmetrical.

Just to note, but not suggesting action right now, that PS Max of 19 is odd, as in seemingly set too high.

Certainly if it is needed, the gurus can just tell me I'm barking at the wrong tree again. I've been known to bark at leaves blowing in the yard for no apparent reason lately.

[Geer1]

That is the idea but not of right duration or area (although breathing looks weird and a zoom or two of it is worthwhile as well).

See above the flow rate chart where it says duration 00:18:15, that is the length of zoomed area (18 mins), sleeprider wants 2-3 minute zooms and wants them to show areas of hypopnea (see the window where it shows current zoom is 1:05 to 1:26, adjust that to a position where hypopnea events are present like 2:20, 3:30 or 6:00). You can reorganize charts by swapping mask pressure with the pressure graph and then you only have to post the first image (flow rate, mask pressure and leaks). Post a couple examples of the hypopnea periods and one or two of what looks like "regular breathing".

To answer your question about leaks any large leaks (grey bars) are bad and you want leaks to be as non existent as possible. Your near constant leaks are horrible as are the regular large leaks, the goal is to try and understand why you have such bad leaks and to figure out how to improve them.

My gut feeling is you have an untreated obstructive issue, potentially a central apnea issue and a mixture of mask and mouth leaks due to inadequate comfort/setting and constantly trying to mouth breath to account for poor settings. First step is trying to confirm what we can from the requested zooms and to find more comfortable/adequate settings to minimize the leaks and get better data.

[Sleeprider]

Respiratory rate and volume and chaotic. There is simply no pattern, and I'm sure the Resmed ASV struggles with that. I don't see a lack of spontaneous effort consistent with central apnea, but breath timing and effort show no predictable pattern or volume. I don't really know what to do with this because the automated algorithm of the Resmed ASV gives us no control over pace and volume.

[Sleeprider]

I remember some years ago you were on a Philips System One Auto SV and had similar results, but fewer leaks.  I'd like to get a chart on your current machine that looks, as much as possible, like this one with events, flow, mask pressure, Tidal volume and Leaks. This chart showed you had hyperventilation episodes with 4 or more large breaths, followed by more normal breaths which were flagged as hypopnea. I suspect the same thing is still happening that is shown in this 4-minute view.

[Sleeprider]

Just for the sake of contrast, I'll offer a 4-minute view of my charts that I think represent a normal respiratory pattern.  Notice how steady respiration rate, volume, tidal volume, minute vent and leaks are.

[cathyf]

A tip on the zoom thing -- right above the orange bar with your AHI there are 4 tabs -- Details, Events, Notes, Bookmarks. Click on the "Events" and look down at the bottom. There is a "View Size" slider which snaps your zoom to that number of minutes.

When you are trying to develop an intuition about what the graphs are showing you -- in other words, you are eyeballing it -- you need to zoom to a particular level every time. Otherwise your eyes are showing you that your breaths look longer or shorter, when what's really happening is that the breaths look twice as long at a 2-minute zoom than a 4-minute zoom. And that's about the width. The heights of the graphs are draggable, and the spacing on the y-axis is settable by right-clicking on the y-axis. You need to make sure that when you are comparing graphs of different time slices that you have the axes set up the same on both sides of a comparison.

OSCAR is an extremely adaptable tool that can show you the data in a lot of different ways, and different people have different stuff going on and so they need different "views" according to what they are looking for. It takes some time and practice to get the hang of keeping that all under control otherwise it just makes your head spin. (Of course the sleep deprivation that comes when your apnea isn't under control sure doesn't help, either!)

[jmayer180]

cathyf

All this time and I had no idea this feature existed...and I thought I had been tthrojugh the Oscar guidance pretty well. Now I have less excuse to dismiss chart evaluation as totally incomprehensible.
Thank you.

[jmayer180]

Plan: Reset my ASV pressures to defaults (min EPAP-4 Max EPAP-15 Min PS-3 Max PS-15).  Get several days’ data and then try to post some meaningful Screenshots.  Meanwhile post this (more than anyone will care to read) to keep me sitting on my hands and stop punching buttons.  

Sleep Apnea Timeline 

July 2009: OSA symptoms became increasingly obvious, prompting evaluation.  Sleep study 9 Jul 2009, resulted in prescription for Respironics BiPAP Plus M Series at 20/24 and O2 at 2 L/min via concentrator.  First few years treatment supervised by FP physician 

High pressures and mask leaks were challenging but with good compliance and at least some decrease in SX’s and partial decrease in AHI for next few years – various pressures and masks experimented with - little objective change 

2012 – switched to Respironics BiPAP Auto, persistent high AHI – tried different settings/pressures with persistent high AHI – perhaps marginally improved tolerance

2015 – Began care with newly available Pulmonologist/Sleep Specialist – O2 no longer indicated per new Medicare rules 

Switched to ResMed AirCurve 10 VAUTO July 2016 - ? dates – little change - Due to persistent high AHI’s and increasing SX’s had repeat sleep study – poor quality study due to severe sleep fragmentation, but due to increasing CA’s recommendation by sleep doc 20 Sep 2016, was for trial of Respironics BIPAP AVAPS - done from 4 Oct 2016 to 14 Nov 2016 with persistent high AHI and more presumed central events 

Due to lack of progress with AVAPS, on 30 Oct 2016, sleep doc gave ‘script for Respironics BiPAP Auto SV Advanced for diagnosis of G47.33, E0471 Complex Sleep Apnea; machine supplied 14 Nov 2016 

Circa Oct-Nov 2016, Sleep Apnea Forum gave a great deal of time, discussion, and assistance – Sleeprider and RonnySue in particular – with consensus that an ASV machine might be indicated.   Oct-Nov-2016, Thread: RE: New User Problem with BiPAP AVAPS – Part 1

– After some experimentation and adjustments with the Auto SV Advanced, overall got much improved symptoms and satisfactory OA’s, no more CA’s with persistent though better tolerated Hypopneas (AHI’s often <5; seldom over two digits) for next 2 ½ years when machine broke.  Under Medicare rules and lease/purchase agreement, I had become owner of the machine.  In absence of any confidence in (local DME) to respond in a timely fashion, I sent the Respironics BiPAP Auto SV Advanced to a private repair center on my own 

Meanwhile, I purchased out-of-pocket a ResMed AirCurve ASV (valid under sleep Dr.’s prescription - E0471).  The ASV was recommended as more efficacious for the central apnea component but (local DME) would not provide this ResMed machine.  It was put in service Jan 2019.  With supervision from sleep doc, I remained fairly comfortable and getting good scores for effectiveness with very low OA’s and only marginally elevated AHI mainly due to Hypopnea component.  Doc had spaced my routine follow-ups to annually, and encouraged mid-term or as needed interval email contact over the years.  

No dramatic recent changes, but AHI perhaps creeping up, higher leak rates even with same mask system, and PM nap-attacks increasing.

[Geer1]

It is always best to review available data and make one change at a time. Although going back to default settings can be used as a starting point it is multiple changes and it won't be clear which one is affecting your data the most. PSmin is the better first change because it will not make any significant negative changes to either obstruction or central, the only potential negative of PSmin is oxygen levels hence my recommendation to use your oximeter. Lowering your min pressure from 8 to 4 as you did can cause obstructive apnea to worsen and frankly that is the main thing I will be looking at your data for at these default settings.

The reason sleeprider wants to see hypopnea examples is because it can give us a good idea if this is obstructive or central in nature. The old hypopnea example posted by sleeprider appears central for example. If we can determine what the main problem is it will be far easier to dial in ideal settings, seeing these examples now is more helpful than trying new different settings.

Data is the only thing that can help us figure this out better so don't be stingy, post up lots of examples.