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New AirCurve 10, same results as AirSense 10
#11
Interesting. I am never surprised anymore to find someone that responds differently to pressure and pressure support. I think your results on fixed pressure actually did what I expected with CA, and the resolution of OA would come with higher pressure like 8.5, 9.0 etc. It's a trial and error process. I still think you will reduce CA with lower pressure support, but you need to find an EPAP high enough to prevent OA. So if you want to optimize, I think your next step is EPAP min 8.5, PS 2, IPAP max 11.0 to prevent the machine pressure from rising too high. This will keep pressure in a narrow range of 10.5/8.5 to 11/9

I think the bottom line is you're heading towards ASV, which would give you a comfortable bilevel with auto-adjusting EPAP and a variable pressure support that can resolve CA when they occur. You are currently doing your job of failing at BiPAP, and the next step will be titration to ASV. To speed up the process, talk to your doctor and let him know the number of CA events are becoming intolerable.

With regard to posting images, it is a lot more informative if you just take screenshots of the Daily Details in Sleepyhead, rather than print a report. Screenshots are taken with a simple F12, and are stored in My Documents/Sleepyhead/Screenshots. The first links in my signature describe the organization and posting of the screenshots.
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#12
(05-05-2017, 10:27 AM)Sleeprider Wrote: Interesting.  I am never surprised anymore to find someone that responds differently to pressure and pressure support.  I think your results on fixed pressure actually did what I expected with CA, and the resolution of OA would come with higher pressure like 8.5, 9.0 etc.  It's a trial and error process.   I still think you will reduce CA with lower pressure support, but you need to find an EPAP high enough to prevent OA. So if you want to optimize, I think your next step is EPAP min 8.5, PS 2, IPAP max 11.0 to prevent the machine pressure from rising too high.  This will keep pressure in a narrow range of 10.5/8.5 to 11/9

I think the bottom line is you're heading towards ASV, which would give you a comfortable bilevel with auto-adjusting EPAP and a variable pressure support that can resolve CA when they occur.  You are currently doing your job of failing at BiPAP, and the next step will be titration to ASV.  To speed up the process, talk to your doctor and let him know the number of CA events are becoming intolerable.  

With regard to posting images, it is a lot more informative if you just take screenshots of the Daily Details in Sleepyhead, rather than print a report. Screenshots are taken with a simple F12, and are stored in My Documents/Sleepyhead/Screenshots.  The first links in my signature describe the organization and posting of the screenshots.

Ok, We'll give that a shot. I think at EPAP 9 the machine is pushing me into an obstruction though. I have a lot of data that supports I need to be over or under that, but one more data point won't hurt. 

I have issues with sleepy head and my high resolution laptop display. This  is what the screen shots look like....

http://imgur.com/a/08jrr

Is that ok?
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#13
...and my NP broke up with me this morning for going rogue. She didn't feel comfortable treating a patient that was treating themselves.  Unsure  

Funny I don't feel comfortable being treated by someone who doesn't listen and ignores the data. I have an appointment with a pulmonoligist next week that's not associated with this office.
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#14
I can deal with the high res screen shot. Just vertically shrink some of the graphs. A couple good things to note are the tidal volume and respiratory I:E.

You say at EPAP 9 you think the machine is pushing you into obstruction. I think in some cases an OA may not be an OA and is a CA disguised by the pressure. When you set your pressure higher at 10-16 the number of CA is very high. I take this to mean that for you the OA is more uncomfortable than the CA? In your case, the period where OA occurred, your flow rate volume was not typical for you, but is extremely compressed, and that persists through that short session between 2:15 and 2:25. From 2:30 to 3:30 looks pretty good. You might compare a close up of the flow rate from 3:15 to the breathing pattern at 06:45 and see what's going on that gives you so much more volume with the higher pressure.

I want to emphasize, that I think you're affected by complex apnea and ASV is where you're headed. Whoever your NP is (not familiar with that acronym), is blindly applying the therapy without any perspective of what is really going on, and why you are compelled to experiment with alternate settings. It really doesn't matter because BiPAP without a backup or ASV function isn't likely to work anyway.
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#15
Sleeprider Wrote:I can deal with the high res screen shot.  Just vertically shrink some of the graphs.   A couple good things to note are the tidal volume and respiratory I:E.
Ok, I'll give it a shot when I get back to my laptop.

You say at EPAP 9 you think the machine is pushing you into obstruction.  I think in some cases an OA may not be an OA and is a CA disguised by the pressure.  When you set your pressure higher at 10-16 the number of CA is very high.  I take this to mean that for you the OA is more uncomfortable than the CA?  In your case, the period where OA occurred, your flow rate volume was not typical for you, but is extremely compressed, and that persists through that short session between 2:15 and 2:25.  From 2:30 to 3:30 looks pretty good.  You might compare a close up of the flow rate from 3:15 to the breathing pattern at 06:45 and see what's going on that gives you so much more volume with the higher pressure.  
So there's a couple things going on here. If my OA is bad enough, the mask gets ripped off. From that perspective OA is intolerable. I don't have that problem once the EPAP goes to 10.  CAs are tolerable from a sleep through the night perspective, but I've yet to quantify the effect on SpO2. I have that sensor showing up today. It would appear that in autoset I can deal with the OA and H first at the expense of CA, and then the machine has some success of lowering keeping the OA in check and dropping the CA. Kind of a top down approach instead of steady state. I ended up asleep with a better AHI at a lower EPAP than I would have if I started at that same level. This is some what shown in the Auto BiPAP data set as it averaged an EPAP under 8, and I think if I recall it correctly there was some good data as low as 6, but it would need to rise a little to deal with 1 off OAs. It might be interesting to run this same profile with a PS of 2. Something like an EPAP of 6.4 and IPAP max of 15. I'd expect the result to be an AHI under 5, but a rather nasty start with CAs.    

I want to emphasize, that I think you're affected by complex apnea and ASV is where you're headed.  Whoever your NP is (not familiar with that acronym), is blindly applying the therapy without any perspective of what is really going on, and why you are compelled to experiment with alternate settings.  It really doesn't matter because BiPAP without a backup or ASV function isn't likely to work anyway.

She's an APRN or Nurse Practitioner. Thanks for somewhat confirming my conclusion as well. I'm sure the board established process they are following work the majority of the time and I'm just an outlier. I'm sure it also predates the ASV therapy, which is why it's tacked on last. I guess I get that some people will have their centrals disappear, but there should be a protocol around this other than let's throw something at the wall that's counter to the data collection and see if it sticks. I'm not sure they are following the therapy guidelines by ignoring the centrals and continuing to drive pressure. I suppose the branch in the decision matrix to go to ASV could be after they do that though.

Switching docs will put water under the bridge, and I can get the treatment I need. In the mean time, I think there's some benefit to be had by doing what I can with what I've got... To include the often handed out advice of diet and exercise.
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#16
Here's a short data clip to see if the format is acceptable.

http://imgur.com/BevtJ2W
http://imgur.com/51OXs7N
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#17
The format is perfect. If you think 9 is your magic number for OA, set EPAP min there, and keep the machine from running away. Less PS is better than more in your case. I think you know what we're trying to do, and I'm not Nurse Ratchet. Go for it.
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#18
so are you going to do EPAP min of 8, IPAP max of 11 and PS of 2 for a night and see those results as compared to your EPAP min of 10, IPAP max of 16, with PS of 0?

Those seem widely variant from each other.

If you feel that anything below about EPAP min of 10 will set you into OA, it seems like you would not pick 8 as minimum.  Sleeprider originally suggested 8.5 but might be convinced by your latest post on feeling below 10, to go with:

1) EPAP min of 9 IPAP max of 11 with PS of 0
      or
2) EPAP min of 9 IPAP max of 13 with PS of 2

both would limit EPAP to a band of 9 cm to 11 cm.

Anyway, whatever you decide, I look forward to seeing some more charts.

Now that those charts are adjusted, will you post a 5 minute long chart for MAY 4 at each timeframe Sleeprider was interested in?  3:15-3:20 and 6:45-6:50
(and do you believe you were asleep at those times?)

Thanks,

QAL
Dedicated to QALity sleep.
You'll note I am listed as an Advisory Member. I am honored to be listed as such. See the fine print - Advisory Members as a group provide advice and suggestions to Apnea Board administrators and staff concerning Apnea Board operation and administrative policies. Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment.
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#19
(05-04-2017, 06:06 PM)Jrw1 Wrote: 1-2) Yes, Immediately. 4 of them at a CPAP of 4; 0 @ 5;0 @ 6; 13 @ 7
So the titration study showed CAs right away. What about the diagnostic study--i.e. the study (or part of the study) before they slapped a CPAP mask on your face?

Thanks for also posting the titration studies' stats. It's important to note that those 13 CAs @7cm were scored in about 4.25 hours of sleep time. So while the whole AHI @7cm was 5.2, the CAI was about 3.1ish. It's high enough to raise a flag about pressure induced centrals being a potential issue, it's probably not high enough to immediately jump to a diagnosis of complex sleep apnea without data from your xPAPs.

It's also worth pointing out that on the Bi-Level titration, they didn't have you at IPAP = 11, EPAP = 7 for very long (19 minutes), and you were awake most of that time since the actual sleep time listed for 11/7 is only 2 minutes of non-rem sleep. That's why one CA at 11/7 results in a whopping AHI = 60. There's not enough data here to be useful in terms of saying whether that one CA at 11/7 is or is not important in terms of what's going on with your sleep.

Quote:3) I'll post some sleepy head data in a sec, but I had a clean report from a centrals perspective with 4-7 In terms of EPAP awhile back. The AHI was 4.4 all Obstructive. 
Can you clarify what you are saying?

Are you saying when the EPAP is restricted to 4-7 cm (using what settings?), you don't get CAs showing up in the AirCurve data, but the AHI is usually in the 4-5 range and made up of obstructive events?

Or are you saying that you have one day of data when you had the machine set so that EPAP stayed between 4 and 7 with an AHI = 4.4, all of which is obstructive.

And were those events OAs or Hs?

Quote:4) I've stayed at 10/13 for a bit. I'd have to back track through sleepy head, but at least 3 weeks. I sit around AHI 5-7, only got the AirCurve Tuesday.
The data you posted shows an IPAP range of 10-13, not VPAP settings of IPAP = 13, EPAP = 10. The 10/13 notation is usually used for EPAP/IPAP when you're using fixed bi-level pressures. The data makes it look like your PS = 4. That means your EPAP ranges from 6-9.

The pressure increase at the start of the night also makes it look like you may be using the ramp, with the Starting Ramp EPAP = 6, which induces a starting ramp IPAP = 10 since PS = 4. It looks like the pressures may ramp up to a Min EPAP = 6.5 or 7cm, which would induce a Min IPAP = 10.5 or 11.

Can you confirm your machine's therapeutic settings by looking at them in the clinical menu? In VPAP Auto mode, you should have the following settings:

Min EPAP (or a Min IPAP, but not both on a Resmed VPAP)
PS
Max IPAP (or Max EPAP, but not both on a Resmed VPAP)

Quote:A-B) February. I however have  been dancing around the EPAP 9 issue for awhile. The changes were minor as the machine has been left to auto adjust within a narrow range and the results don't change as long as 9 is not in the range.
So you've been on PAP for at least 2 months. Yeah, it would be reasonable to expect that if those CAs were going to disappear on their own, they ought to be noticeably decreasing by know.

But again, can you clarify what you mean by "I have been dancing around the EPAP 9 issue for a while."?

The VPAP Auto data for May 2 that you posted shows that your EPAP stayed well below 9cm for most of the night. Indeed, the only time the EPAP > 9 is between 3:20 and 3:40, and there is maybe one or two CAs scored during that time, but not enough to worry about. But there are two nasty cluster of CAs on the night you posted.

The first nasty cluster of CAs occurs between 1:30 and 1:45 at the beginning of the posted data. It looks to me like this is during a ramp period (judging from the way the pressure curves are increasing in a linear fashion). The EPAP when this first cluster happens is really low---as in it looks to my eyes that the EPAP stays below 7, and possibly below 6.5 for this whole cluster. If you said that you took about 15 minutes to fall asleep, I'd say this cluster was sleep transitional. But you also say:
quote='Jrw1' pid='203740' dateline='1493939888']2) How long do you estimate it takes you to get soundly asleep at the beginning of the night?
I'm out the second my head hits the pillow and I find a spot for the hose and fix any leaks.And in that case, we have to consider that the CAs are real, and occurring at EPAPs that are as low as 7.0 or 7.5cm of pressure.

The second nasty cluster of CAs in the data you posted occurs just before 2:40. Again, the EPAP pressure is not exceptionally high here: During the cluster, the EPAP is around 7.0-7.5. Notably the machine is actually working on decreasing the pressure after the pressure spike caused by what looks like a couple of OAs around 2:25.

The data for May 4 when you were using CPAP @8 for part of the night and APAP at 10-16 for the rest of the night shows a lot of pretty serious leaking going on. (Interestingly, your leaks were quite well controlled on the VPAP night. Were you using a different mask?) While only the stuff between 1:30 and 2:00 is flagged as a large leak, there's a lot of smaller leaks that are flirting with the 24 L/min "red line". Is mouth breathing an issue for you? I bring this up because in the presence of a lot of leaks, the FOT algorithm for determining whether an apnea is a CA or an OA becomes less reliable. Some of those CAs may be misclassified OAs. (or vice versa).

But assuming that the data is reasonably reliable, it looks like if you could tame the leaks, you might do better with straight CPAP rather than APAP or VPAP. In terms of the OAs and Hs, you might need a bit more pressure than 8cm, but in terms of the CAs it could be that you do better with a more constant pressure.

In looking at the titration study data that you provided, it looks to me like the best (semi)extended data came from 76 minutes of sleep with straight CPAP @5 and 6cm of pressure. You had no events of any sort during those 76 minutes, but you also had no REM sleep. They also had you at bilevel at 12/8, 13/9, and 14/10 for extended periods of time. At 14/10, the centrals were not too bad and the obstructive stuff was very well controlled and you did get some REM sleep. At 12/8, the obstructive stuff wasn't as well controlled and the total AHI was still too high. At 13/9, the central stuff was pretty pronounced. Does your report have an event table that shows when the events occurred along with a pressure graph that shows when each pressure was tried?

Finally, as someone else pointed out earlier, some people's CAs react badly in the presence of a pressure support (PS). When you used the machine as an APAP and CPAP, did you have EPR turned on or off? And if it was turned on, what setting did you use?

As for where to go from here:

Given that it's been two months and CAs are still an issue, it could indeed be that the idea of complex sleep apnea needs to be raised with the sleep doc.

But it's not a clear, slam dunk case that you need an ASV in my (nonmedical) opinion. If this were my data, I'd be inclined to think seriously about the following things:

1) Just how much pressure is needed to get the OAs and obstructive Hs under control? If OAI + HI stays consistently below 5.0 at a given pressure setting, then there is no point using a whole lot more pressure if the additional pressure triggers a lot of CAs.

2) Is the CA data better when you use fixed CPAP? Or fixed VPAP? If so, then the variable pressures may be something your body is having trouble dealing with. There's nothing wrong with using fixed CPAP or fixed VPAP, and some people do indeed do better without varying pressures.

3) Is too much PS a potential cause of the CAs? The test here is to see if you can tolerate a very low PS---you could try setting PS = 0, 1, or 2 in VPAP mode and see if the number of CAs drops, stays the same, or gets worse. (This essentially changes the VPAP mode into CPAP with EPR set to 0, 1, or 2.)

4) Is the leaking a real problem night after night, or only a periodic problem? Does switching masks or mask types help the leaks? And if it does, does controlling the leaks help bring the AHI down?

5) Assuming the problem is complex sleep apnea, what kind of documentation does my insurance company require before authorizing a switch from bilevel to ASV? Is my current sleep doctor willing to provide that documentation?
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#20
(05-05-2017, 06:23 PM)quiescence at last Wrote: so are you going to do EPAP min of 8, IPAP max of 11 and PS of 2 for a night and see those results as compared to your EPAP min of 10, IPAP max of 16, with PS of 0?

Those seem widely variant from each other.

If you feel that anything below about EPAP min of 10 will set you into OA, it seems like you would not pick 8 as minimum.  Sleeprider originally suggested 8.5 but might be convinced by your latest post on feeling below 10, to go with:

1) EPAP min of 9 IPAP max of 11 with PS of 0
      or
2) EPAP min of 9 IPAP max of 13 with PS of 2

both would limit EPAP to a band of 9 cm to 11 cm.

Anyway, whatever you decide, I look forward to seeing some more charts.

Now that those charts are adjusted, will you post a 5 minute long chart for MAY 4 at each timeframe Sleeprider was interested in?  3:15-3:20 and 6:45-6:50
(and do you believe you were asleep at those times?)

Thanks,

QAL

I loaded the profile Sleeprider wanted to see this afternoon, as well as tested the new spoo sensor. We'll see what we get in the AM. 

I'll catch up on the charts tomorrow too.

Thanks,
Jay
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