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Need help with Aerophagia
#41
RE: Need help with Aerophagia
Excessive indeed! But doctor doesn't seem to think that matters as much as getting the apneas to stop.
As far as accuracy goes, I think the AHI is about right because I do feel better and the wave pattern through the night is so much better too. Here are a couple of shots showing both high leakage and low leakage. The ASV is seeing every breath and responding. It factors in the minute ventilation as well as the leakage and flow pattern. I don't see any difference in it's responsiveness during high leak vs. low. I don't doubt that the ASV could respond a bit better with leaks less than 24 L/min, but here we are in the real world with less than perfect conditions and the machine just keeps purring away. It's getting the oxygen in me and that is stabilizing my system and stopping the high loop gain issues that lead to periodic breathing and long apneas. It will be interesting to know what Dr says about the data on Wed. I wish he would answer all my questions.

   
   

Thanks for all the support!  I will keep you all posted.
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#42
RE: Need help with Aerophagia
Your doctor is treating a person and not a number. He is juggling a few things and has your total history. However I think you took him too literally when he said, not to worry about leaks. The manufacturer Resmed say they need to be below 24lt for the machine to work properly. I understand that you loosened the mask for more comfort, but if you could fit it a bit better, it really will help.

o2 does help, my dad is on 2lt 24/7

In the first chart, I think you woke up, the masked sealed as you took some recovery breaths, A lot of movement on the flow chart. You can see the rise in the tidal volume in the time it was sealed. The pressure returning to you epap and min PS
The second chart looks like an arousal with increased breathing and high flow, that then led to a H on the machine. I wouldn't count anything after increased breathing and high flow and just ignore it.
mask fit http://www.apneaboard.com/wiki/index.php...ask_Primer
For auto-cpap, from machine data or software. You can set the min pressure 1 or 2cm below 95%. Or clinicians commonly use the maximum or 95% pressure for fixed pressure CPAP, this can also be used for min pressure.
https://aasm.org/resources/practiceparam...rating.pdf
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#43
RE: Need help with Aerophagia
Thanks for your reply, Ajack. I am interested in learning how to interpret the graphs. Your comments were helpful.

My doctor was pretty adamant about letting it leak, and he specified all leaks, even large ones. But of course when I got home I realized you can't do that. You can't have the mask wide open blowing off your face! I agree that the goal should be to at least keep it under the 24 L/min level. I'm sure the doctor would not disagree if I could accomplish it. My mask is fairly tight right now in spite of having loosened it a bit. I don't feel or hear any leaks when I am awake and the mask fit feature tells me it's fine. Sometimes it's fine at night when the pressure tops out and other times not. I think it has to do with the mask sliding up a bit, as I check for this every time I awaken and usually have to pull it back down into place. I can keep it in place better by loosening the top strap and tightening the side straps, but that leaves deep marks on my face in the morning. I made some strap cushions two nights ago to help with the marks, so I could try tightening them again. I don't have hopes for a different mask as I have been through so many and I had the same trouble with the F30 they put on me during the sleep study in February. I thought the cervical collar worked pretty well in keeping my chin up (and the mask in place better), but Dr. told me to quit using it. We will certainly be having a discussion about all this when I see him Wednesday. Did you agree the ASV seemed to be responding appropriately breath by breath regardless of the leakage? You did not comment on that.

I used a mouth guard last night during the last segment. You had suggested it earlier for another reason, but l thought it might increase saliva and reduce dry mouth. It did! Unfortunately it caused the mask to slide up more and the aerophagia increased, so it's a no go for me for now.

I bought a strap for hard hats with a chin cup on it and fooled around with it yesterday trying to make that work to hold my chin up during sleep. It has elastic straps that would have to buckle over the top side straps of my mask. When I got it all together, it seemed like it might work, except that the dimensions of the chin cup were large enough to push the mask up out of alignment. Still it gave me some ideas. I won't give up yet.

Here is the chart from last night ... not the best night

   
Thanks for all  your support Ajack.
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#44
RE: Need help with Aerophagia
Kally, every mask has a design leak or flow rate that changes with pressure. Your pressures go pretty high, and the Amara mask has a high design flow rate.  The image below shows the normal expected leak rate for your mask.  Note that at your therapy pressure, the default leak rate of 24 cm in OSCAR or Sleepyhead is wrong, and should be raised.  For your 90% pressure of 90/11, I think a leak rate of 60 L/min may be acceptable. The Resmed machines report a net corrected leak, and we don't really know what it is subtracting from the total leak in your case, and this is one reason we set the mask type. You can change the pressure at which a large leak is flagged in OSCAR under File/Preferences/CPAP, and change the threshold for flagging leaks to 50 L/min.   I am basing this on the appearance of your charts that don't appear to lose resolution in the flow rate when leaks are less than 50 L/min. I have doubts you can ever meet a leak rate of 24 L/min with this mask and pressure.


[Image: amara-pressure-flow-curve-512x384.jpg]
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
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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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#45
RE: Need help with Aerophagia
there's a bit of important info I'm not sure we'd ever hear about from our providers.

what is the relationship between this info, the differently defined leak flag and the machine mask setting? I assume the setting accounts for design variations in resmed masks, at least, if not others? and that the ffm setting in resmed machines is not appropriate for the amara (I did not check but assume amara is not resmed)? is this something to pay attention to - in this case - for all or some non-resmed masks or is the amara an outlier in this regard?
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#46
RE: Need help with Aerophagia
Thank you, Sleeprider. The graph you posted is very similar to the one in the users manual for the amara view (below). I saw it but didn't know what to  make of it in terms of leakage.
   

The 24 L/min leak rate seems to have come as a "standard" from Sleepyhead. As I view the info for the AirCurve 10 ASV, I don't see this limit listed. In the clinician's manual for the machine it says:
Leak management with VSync Using ResMed's VSync algorithm, the AirCurve 10 device monitors and compensates for leak by continuously and automatically adjusting the baseline flow. This enables reliable delivery of therapy pressure while maintaining patient-device synchrony

Under the part about the optional leak alert alarm, it says this:
When enabled, leaks >40 L/min (0.7 L/s) for >20 sec result in an audible alert and a high leak message is displayed.

In promo literature for the machine it says this:
Mask leakage is a common issue encountered by even the most diligent and conscientious sleep apnea patients. The AirCurve 10 ASV makes unintentional mask leakage a much less serious concern with its Vsync leak management system. Vsync will recognize instances of mask leakage and then make the necessary adjustments so that the issue is corrected.

My PS tops out at 25, so you're guess for the 50L/min leak flag is probably quite conservative, Sleeprider. Since I have been asleep during all these "large leaks", I can't verify how much actual leakage there is. Has it all been mirrors and smoke below 50, not really leaking to any extent that machine can't handle, as the close-ups graphs seem to indicate? Foolish as I feel, I pray this is so! Can I trust it? Does the data lie? More comments welcome!

PS Amara is from Phillips Respironics
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#47
RE: Need help with Aerophagia
I question whether that is the case.  I can put up my charts with 30cm and 0.0 leak rate. On the last page, I put up my dads chart that had a 1.2 leak rate at/under 95% @ 18cm . So it is obviously not the case.
The machine has a small selection on mask and hose choice. This will allow for pressure changes and intended leak. I wouldn't see this leak rate being acceptable. As it just being the natural mask venting. Kally has said that her mask leaks.

The 24lt is over and above the intended leak rate and adjusted for pressure. Resmed clearly state the 24lt requirement in the ASV titration guide page 33
excessive leak : Leak is greater than 24 L/min
https://www.resmed.com/us/dam/documents/...er_eng.pdf


Not applicable here. In sleepyhead/oscar settings, there are the leak rate at pressure settings and the software would adjust. You input the intended leak rate at two pressure settings 4 and 20cm. If the machine isn't presenting it, aka Philips..

   
mask fit http://www.apneaboard.com/wiki/index.php...ask_Primer
For auto-cpap, from machine data or software. You can set the min pressure 1 or 2cm below 95%. Or clinicians commonly use the maximum or 95% pressure for fixed pressure CPAP, this can also be used for min pressure.
https://aasm.org/resources/practiceparam...rating.pdf
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#48
RE: Need help with Aerophagia
Thank you so much for your input. You have both brought up a lot to consider. Here are my thoughts.

The setting for leak rate that sleep rider mentioned just resets the level of the red line on the graph as far as I can see. So we are actually telling it what to consider a large leak for the purposes of the graph data. It was at 24 by default.

When I said my mask is leaking, I was relying on that line to tell me when it was an unacceptable leak, a large leak. I have never been awake to tell what is actually happening. I have made a guess based on mask slippage which I have noticed when I wake up. As for wispy small leaks, I have felt them when I am awake, but they hardly even show up as a leak on the graphs, so I stopped worrying about them. My concern is large leaks.

The 24 L/min in the titration manual is an ideal standard set by the manufacturer of the titration equipment. I'm sure my technologist went by this when using their ResMed equipment, hence their concern that I had a large leak (which they could never locate). This was so even when they switched masks. Fortunately, they have much more data to score events than just flow and pressure and leaks. EEG, belly and belts, etc. come into play. I'm sure these young techs just follow the instructions and had their "large leak level" set on default. But when I asked my doctor if I should be concerned about my mask leaking at home, since the techs had told me it was leaking in the lab, he said they were just trying to get the best readings they could and not to worry about it. That was BEFORE I downloaded OSCAR and saw what appeared to be so much unacceptable leakage with the 24 L/min setting.

The 24 L/min may be a good conservative limit when estimating mask leaks for the average mask with the average treatment equipment. But when it comes to specific masks and specific treatment equipment, I believe we do have to look at the results (in wave form, if possible along with the AHI) and rely on the specifics from those manufacturers. Here is a quote from an article on titration in the Journal of Clinical Sleep Medicine titled "Clinical Guidelines for the Manual Titration of Positive Airway Pressure in Patients with Obstructive Sleep Apnea." (http://jcsm.aasm.org/articles/040210.pdf)

"4.4.3.2 There is insufficient evidence for what constitutes a clinically significant leak given mask fit and other factors; however, in general, an unacceptable leak for PAP is one that is substantially higher than the leak recorded at a given pressure from a well-fitted, applied, and secured interface. The acceptable leak will always exceed the intentional leak, which depends on the applied pressure and interface type. The intentional leak vs. pressure relationship is usually supplied by the manufacturer of each interface (consensus)."
and ...
"This recommendation is based on consensus agreement by the PAP Titration Task Force. The intentional leak of all inter-faces increases as pressure increases. The exact amount of leak also varies with the type of interface. This makes identification of what constitutes an unacceptable leak value very difficult. Clinical judgment based on laboratory-specific criteria or the leak vs. pressure relationship supplied by the manufacturer for a given interface is recommended."

Even setting the leak rate upper threshold at 50, I do see some large leaks flagged in my charts, but of course much much less than at 24. Even then the ASV seems to be responding appropriately breath by breath. I am wondering what would we see in the flow rate graph (or other graphs, or combination of graphs) that would clearly indicate the ASV is not working well enough? What does it look like when the ASV falters or fails?

Any comments welcome. And thank you for your support!
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#49
RE: Need help with Aerophagia
I think it would be great if your leak rate was zero, but it's not and we have had other members that adjusted the large leak threshold in OSCAR/ Sleepyhead and it does not affect therapy, it only removes the distraction of excessive leak flagging. It is relevant that you are not aware of leaks and that the flow rates are displaying in full resolutions (height). So the machine is not losing control. Your "zero" line, where leaks settle as a baseline is just over 40 L/min. We can clearly see where leaks are present well above that, and we can also see where the flow rate attenuates due to leaks. There may be more important matters to be concerned with than the leaks.

I'm not saying you should not keep an eye on the leaks, but I think it is fine to set the large leak threshold to a level that is reflective of your mask design and experience, and flag leaks at a higher threshold that actually do disturb the therapy. Kind of like turning off the VS2 flag on Dreamstation charts.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


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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#50
RE: Need help with Aerophagia
Sleeprider, I don't understand this part ...

" Your "zero" line, where leaks settle as a baseline is just over 40 L/min"
"we can also see where the flow rate attenuates due to leaks"

Could you show me what this looks like on the graph?
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