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Need guidance for complex sleep apnea and leaks follow-up
#91
RE: Need guidance for complex sleep apnea and leaks follow-up
John,

The data you sent me includes Feb 24th to Mar 9th. It looks like you were using a nasal mask until Mar 5th and then switch to the F10 on Mar 6th (that is when machine setting changed from nasal to FFM).

While using the nasal mask I see you were using min EPAP 8 cm, max IPAP 26 cm, PS 5-12 cm. Leaks were definitely an issue with that mask and settings and it appears there are periods of mouth breathing with large mouth leaks. Below is an example of one of the worse nights. Some of the leaks and mouth breathing that night were so bad they reduced your flow enough your machine shut off because you have smartstart on (1:45 -2:00), I would turn this setting off.

   

After you changed to the FFM you tried min EPAP 6 cm, max IPAP 30 cm, PS 4-15 cm. This was your best night of data.

   

The next night you tried limiting max PS to 9 cm (same min EPAP and min PS) and this was your worst night AHI wise. 

   
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#92
RE: Need guidance for complex sleep apnea and leaks follow-up
The next night you tried increasing EPAP minorly to 7 cm and changing PS range to 1-10 cm. AHI was still high. 

   

Then on the 9th you tried increasing min EPAP to 12 cm with PS range of 1-10 cm. AHI on mid to high range of the data you sent me. The high pressure caused mask leaks to occur.

   
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#93
RE: Need guidance for complex sleep apnea and leaks follow-up
Your breathing is the most consistently inconsistent breathing I have ever seen. It appears that as soon as you fall asleep it starts to vary breath to breath but not obviously because of obstruction, central apnea or restriction. It just appears to be inconsistent all of the time for some unknown reason. If I had to guess based on the limited knowledge I have I would say it is due to your weight affecting your bodies ability to take consistent breaths. Do you have any known medical conditions or symptoms that might support a medical condition that you believe could be affecting this (other than weight)? 

   

Some of this breathing does seem to trigger apnea to occur at times and then you can get into odd looking repetitive apnea/hypopnea that isn't clearly obstructive or central in nature (almost looks like a mix at times). One thing to note about complex apnea is that it is often the case that obstruction occurs during the relaxation during initial central apnea and I wonder if that is what is happening here.

   

Because of the different settings you trialed before (my last two posts) it appears that the higher pressure didn't help and that limiting max PS made things worse. Both of these are supporting a central apnea issue more than obstructive. I want to go back to similar settings to what was used on Mar 6th to see if we can replicate that data. I also want to try turning off auto EPAP to remove one variable from your data which will help understand if these are primarily central in nature.

So new proposed settings are. 

Change mode from ASVauto to ASV. 
Turn off smartstart.
EPAP 8 cm
Min PS 4 cm
Max PS 15 cm
Max IPAP becomes 23 cm

Post a screenshot of data after your first night with these settings and then as long as they aren't noticeably bad for some reason I think try them for a few nights to see how much results vary night to night.
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#94
RE: Need guidance for complex sleep apnea and leaks follow-up
(03-12-2022, 12:06 PM)Geer1 Wrote: Is that from the OP or just some random image...

Well, I wouldn't necessarily call this completely random as it's from a current discussion on the accuracy of machine calculations in the face of LL.

Manually calculating exhalated tidal volume, it shows an essentially complete loss of exhalation (it has passed through the mouth, this is not the OP, this is from a patient with a nasal mask).  The reason that exhaled VT = 0 (or perhaps even less) is that a significant portion of what is obviously inhalation exists below -0- and therefore is counted as exhalation.

If you have examples of "negative flow rates that are often seen" please post them that we can properly analysis them.

Although your explanation of prolonged exhalation if this were the OP is incorrect it is off topic so I won't debate that (yet).

You are correct in that this is probably an example of palatal prolapse but the image title tends to give a clue.

However, keeping this relative to the the OP's plight, it offers consideration that the OP's apneas are twice as long as the machine thinks they are.  Indeed, the first event in the clip, although an obvious apnea, is completely missed.  The second event is not 10 seconds long, it's 20 seconds long,

If VT is incorrect, then MV is incorrect, and since ResMed ASV relies on MV to calculate Target then the Servo Attack is probably locally inappropriate.
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#95
RE: Need guidance for complex sleep apnea and leaks follow-up
Here finally is at least a taste of oximetry for Mar 11.  




To my knowledge I have nothing scary except the obesity, severe DJD, and well controlled BP.  

I've changed to last recommended settings and will wait for some day's data.
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#96
RE: Need guidance for complex sleep apnea and leaks follow-up
My editing failed in getting a FWIW Oximetry sample.  At least I don't seem to be smothering.  


.pdf   Mar 11, 2022 pO2 Summary.pdf (Size: 357.13 KB / Downloads: 16)


.pdf   Oximetry Report Mar 11, 2022.pdf (Size: 358.26 KB / Downloads: 14)

Will get couple more days & post Oscar data then.
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#97
RE: Need guidance for complex sleep apnea and leaks follow-up
Yeah your average O2 is decent, just bounces around a lot because of the inconsistent breathing.
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#98
RE: Need guidance for complex sleep apnea and leaks follow-up
Of the ASV downloads the worst AHI is 17.88

The oximetry shows 246 desaturations for an index of 25.5 using the 4% criteria.  This would be more reflective of your actual AHI (which in fact could be higher because events that resulted in arousals (but not not desaturations) are not counted).  It also offers additional evidence that many events are missed in the ASV calculations.
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#99
RE: Need guidance for complex sleep apnea and leaks follow-up
Hello JMayer,  I noticed your lowest heart rate for the night reached 26 beats per minute.  My lowest is usually in the 30's at night.  My father uses atenolol (beta blocker) as has been fine and is doing well today at age 88 (had heart attack at 65).  He can manipulate his heart rate (and blood pressure) just about anywhere he wants to based on how much atenolol he takes.  His old Cardiologist retired 2 years ago.  The new Cardiologist has some concerns when heart rate gets really low at night (the heart could actually stop and go into cardiac arrest).  
I don't want to scare you or anything.  Have you mentioned this to your Cardiologist?  What does he or she think?  I fainted after an angiogram in February.  Mine may have been too low.  My Cardiologist said to watch out for fainting spells or "seeing stars" when standing up from sitting too quickly.  
I am not offering medical advice.  None is offered here.  Just suggestions.  Just trying to help jmayer.
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RE: Need guidance for complex sleep apnea and leaks follow-up
The lowest his heart rate went was around 60, his heart rate actually surprised me by being so consistent.

The few readings below 60 (and definitely the 26) are artifacts (false readings). You can tell that because the graph is nice and smooth and then all of a sudden has a momentary drop. If yours is the same it is also due to artifacts. These artifacts are often due to movement which messes up oximetry readings, if you want to test it try wiggling the finger you put oximeter on and see how it fails to provide consistent readings.
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