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Need help with Aerophagia
#51
RE: Need help with Aerophagia
(05-28-2019, 03:29 PM)KallyA Wrote: 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?

Let's take a look at a graph you called a 'good night'.  The minimum leak is a very solid line near the red dotted line, which I suspect is the default large leak threshold of 24.  Your median leak rate is 31 L/min, so that is the most frequent leak rate, somewhere above your minimum and well below the maximum.  I suspect your median leak rate is NOT a large leak.  You seem to maintain a leak rate of about 24 L/min at very quiet times when there is almost no pressure support (00:45), as well as when there is a lot of pressure support (02:30). No matter what, you seem to return to this leak rate as the base-line.  I am calling that "your" zero line.  The period around midnight (00:00) has some leak above that level, and that may be a real, low-level leak, but your minimum is very close to that dashed line.

If your minimum leak is 24 L/min, then a "large leak" threshold would be approximately 24 L/min above that, thus my suggestion of 50. Now, let's focus on that nice stretch of flow rate around 4:30 where a large leak is not flagged. The height or amplitude of the flow rate is the same as the rest of the chart. That means you machine is still able to fully detect your breathing rate and volume during all the periods flagged as a large leak. If it was not able to detect your respiratory flow, the flow rate line would be much smaller (closer to zero). So let's look at chart #2 where a "real" large leak happened at 23:00. Notice how the flow rate is contracted during that leak. That is a sure sign that the machine has lost control due to a large leak. Around 00:40 is some of the lowest leak rate we have seen in your results, but somewhere above 50 L/min is where the machine has an impaired capability to treat your apnea and detect your respiration, so that is the basis of using that as an alternative threshold for flagging.

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Sleeprider
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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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#52
RE: Need help with Aerophagia
Thank you so much for the explanation, Sleeprider. It is very important to me to be able to see what it looks like on the graphs when the machine is not responding well. I have blown up the second chart to see the "real leak" area better and included the other graphs. I see straight lines across all of them. Do these also confirm what you were thinking. You would expect to see the other graphs like this too? And where everthing starts to squiggle is where the machine is responding well again? And also, during this period might I have had events that don't show up at all or no? Thank you so much for educating me on this!
   
   
   
   
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#53
RE: Need help with Aerophagia
In the period you focused on, your respiration rate went to a very high breaths per minute. These were shallow breaths that reduced tidal volume.

Minute vent was near average, but it is likely that you were re-breathing most of your exhaled air with the shallow volume. Your chart is not zoomed enough to count breaths per minute, and you did not include that chart, so hard to say, but I would be surprised if your maximum respiration rate of 20 reflects this period. My guess is it was inefficient breathing, and I can't say whether this is an artifact of the leak, or just a hyperventilation. There are no events, but I would focus on breaths per minute to learn more about his segment, or zoom into the flow rate at no more than 2-minutes to actually view the wave form.

I am less concerned with the leak, than interpreting what was going on with respiratory flow, which appears to be recorded. The leak may reduce the accuracy of the actual flow volume, but it should be accurate for BPM.
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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#54
RE: Need help with Aerophagia
Let me try again. Here is the full night chart and the rest of the charts zoomed into a two minute period in the middle the "real leak."   I hope this the right information for a good interpretation.
Following your comments, I see about twenty breaths per minute, fairly shallow compared to the rest of the night. I see the low tidal volume, below the median. I see the minute vent near target. Re-breathing exhaled air? Aargh!! It doesn't look like hyperventilation, but you are saying the flow volume shown here might not be accurate? What would it look like if it were accurate? 
I am on oxygen if that's is pertinent - 3 L/min.
Again, thank you so much for helping me understand what is happening here. I'm a new newbie and I feel an urgency to get a handle on things. More comments welcome! And thank you so much!
   
   
   
   
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#55
RE: Need help with Aerophagia
Update ... saw the dr. yesterday. Here is what he had to say...
He can't reduce the pressures as I really need them to keep the apneas and hypopneas down and our lesson is don't change them!
He hopes I can find a way to cope with the aerophagia, and to stay away from using the cervical collar if it is associated with more aerophagia. He looked at the median for leaks since he put the pressure back up and said yes, it was running between 25 and 35 which was ok, that yes he knew it sometimes went higher but not to worry about it. When asked whether the ASV would work properly at the high leak levels he said oh yes, yes, do not worry. It is bringing down your events overall and that is what we care about.


So here is my take away. My doctor is never looking at graphs and flow patterns and doesn't usually even care if I have a "bad night" unless I bring it to his attention as a concern for me. He is just looking at statistics and how I am doing overall with the treatment settings he has chosen. He is very comfortable with the leakage median of about 30 (as am I), and has not taken the time to see how high the leakage gets or just doesn't know what else to do about it (take your pick). He is unaware of or doesn't care that the ASV might not be working properly at the high leakage levels part of the time.

I do care about the large leaks that cause equipment failure. I am willing to watch the graphs and do what it takes to keep leak below ineffective treatment level, whatever it is. I need to be certain of how to spot this. So let's start with the observation by Sleeprider. Please clarify if I am not understanding something about this.

When the leakage is over 50, the pressure and tidal volume are below the medians, and the respiration rate is around 20, we are assuming the flow graph may be inaccurate and the ASV is not working well to control events. There may be events happening that are not being recorded. I may be re-breathing air. Is this correct? Have I missed anything?

I also notice that inspiration and expiration are below the medians. Does this also fit the explanation given?

Now, I am attaching another instance where I think this is happening --from last night's chart. 
First chart is the whole night. Second and third are the section where leakage is high/pressure low, etc, ...notice it is dropping and recovering several times.

Please verify if you think this also reflects the equipment not responding appropriately.
When I feel confident I can identify these failure periods correctly, I will check below the 50 L/min leak line and see if I can verify that I can keep the leak flag at 50 in OSCAR. If not, it can be reset. In spite of what my doctor will settle for, I am not content to live with leakage that allows for inadequate treatment and I believe I have more work to do to stop this, but like Sleeprider, for the pressures I am at, it is doubtful I can consistently keep it below the ideal 24 L/min level. 

I hope you can continue to advise me on this, Sleeprider, and anyone else who understands it is welcome to comment. I am working for a treatment level my doctor can not (or will not) help me with. Thanks to all for your support and for sharing your time and experience.
           
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#56
RE: Need help with Aerophagia
Update ....
Went against Dr. orders and used the cervical collar last to prevent chin drop. Leakage stats: med 25.2, 95th 33.6, max 45.6. Looks like the machine responded well through it all. This is a great improvement for me and I thank you all for the idea of using the collar.

I hope I didn't lose my advisors. I would still like answers to my questions in the last two posts. Need verification if I'm on the right track with seeing when the ASV is failing with high leakage. Thanks ahead!
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#57
RE: Need help with Aerophagia
I'm glad to hear you went ahead and used the soft cervical collar. There really is nothing that should contravene its use. Your doctor has an autocratic approach to your therapy, and you probably know we are not in agreement that you should fully compromise comfort with respect to aerophagia in favor of resolving every possible apena with high pressure. It seems the collar helped with leaks and brought things back to where we expected given your pressure and mask model.

To gain more understanding of the UA and H events, we are going to need to consider your therapy in both whole-night perspective, as well as zoomed in enough to see what is going on with your respiratory flow and mask pressure during the events. That means closeups need to be about 2-minutes total in length where the flow wave is clearly visible. The previous screenshots are not helpful because they cover about 30 minutes, and in the previous post, the 2-minute zooms show what I believe is representative of your normal breathing when there is no event. It looks pretty good at about 23:00, but respiration rate is very high at about 22 BPM, and breathing is relatively shallow. We need to learn more about what becomes of your respiratory flow rates and the machine response during the H and UA events. For the zoomed charts, I think we should see Events, Flow Rate, Mask Pressure, Respiration Rate and Tidal volume.
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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#58
RE: Need help with Aerophagia
Thank you for your response, Sleeprider.

Yes, using the cervical collar definitely reduces the large leaks with the Amara mask, where LL is defined as anything over 50 L/min. It seems like the machine responds well with leaks under this level. 

About the last charts posted, I was framing what appeared to be drops in pressure during high leakage from 22:25-23:15.  I was wondering if the ASV might be missing events during those times. There are no events shown at all during the times the pressure drops there. Here I will post the full night again, and then zoom into some two minute windows where the leaks are particularly high. Here is the full night:
   

The next two are from 22:48-22:50. I am not sure whether the ASV is showing accurate wave pattern here because we have fairly low pressure/high leakage/high respiration rate. What do you think? This is my main concern .. can you tell (or do you suspect) the ASV is unable to show events at this leakage rate? Is this what it would look like if it were missing events?
       

The next two are from 22:51:15-22:53:15 with an event. Though the leak rate is high, pressure is high/variable and the respiration rate has declined.  Here the ASV appears to be able to see the event in spite of the large leakage. This looks like a normal response from the ASV. Do you agree?
       

I have more to learn about breath rate, tidal volume, minute volume. In particular, I don't know what constitutes shallow breathing vs. normal. I see the breath much more constricted during A&H. I see a lot of breathing around 20 bpm in my charts. What does shallow and fast breathing represent?

Thanks ahead for your response. You've been very informative.
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#59
RE: Need help with Aerophagia
It's good you are using the collar again, it seemed to help earlier. Working with your DME on mask fit or a more suitable mask, would still be a worthwhile exercise. If the mask is adjusted properly and they can't get one to seal, because your facial features preclude propper mask fit. The doctor could order a mask made to suit your face shape and may be an option.

Above a 24lt leak messes up the feedback loop on the ASV, I wouldn't trust any event or charts. It would be on a curve and not a cliff, that you drop off over 24. I wouldn't try to work out what is going on. The one with the H is showing about 20Lm peak flow rate, It would be more than that and not that weak.

You have CSR, so you will get a large variation in the stats on resp rate, as you cycle. REM/sleep states can also make the resp rate swing. As can o2 levels.

If you want to reassure yourself, that your basic treatment is Ok. I would get the overnight recording SPO2 meter, cms50f for around $60-$80. It may be worth peace of mind.
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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#60
RE: Need help with Aerophagia
Thanks for your reply, Ajack. It's good to hear from you again.
Yes, my doctor is full of beans when it comes to using the collar. My charts for the last two nights look so much better with it. leakage is much lower. It's definitely worthwhile. I am not eligible for a new mask for a couple more months. At that time I will be willing to try a different one. I have a pulse oximeter that records. My doctor requested I wait about a week after turning down my oxygen concentrator (from 4 L/min back to 3) and then run the oximetry, so that will be forthcoming. Here are my last two nights, turning down the oxygen on the second one. I don't see any major difference turning it down. Not sure if leakage is affecting anything, but I moved the leak line back to 24 so you can eyeball it easier.

Here is the night on 4 L/min oxygen
       

Here is last night on 3 L/min oxygen
       

I purposely selected these graphs as they are reflected in a study I found titled "Estimation of adaptive ventilation success and failure using polysomnogram and outpatient therapy biomarkers." It has a couple of sleepyhead charts in it indicating effective vs. poorly effective ventilation and tells how relying only on AHI can be misleading, particularly for issues with complex apnea and high loop gain (that's me). Fortunately, excessive cycling of the machine can be readily seen on the sleepyhead graphs, as well as the other biomarkers they discuss. The study can be found here if you are interested:  https://academic.oup.com/sleep/article/4...33/4868556

In comparing my graphs to the ones in the study, I would say both these nights are pretty good. Looking back, not so good. Lots of cycling and extremes in the inspiration/expiration time graphs. I still have a lot to learn.

Thanks for your interest and comments.
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