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Newbie. One Week In... poor AHIs
#11
RE: Newbie. One Week In... poor AHIs
OK, Let's turn off VS2 because we don't use it and it is providing a lot of clutter on the charts.

How do you feel?  This is important if we want you to get an ASV machine.
Here is a list of symptoms, which if any apply to you

Symptoms
Note that these are not all specific to Central/Mixed/Complex apnea. They are symptoms that impact our sleeping, arousals, and yes apnea too. Think of these, but do not limit yourself to these when you are asked "How do you feel?"

  • Daytime hypersomnolence;

  • Excessive fatigue;

  • Morning headache;

  • Cognitive dysfunction;

  • Dyspnea, etc.;

  • Fatigue;

  • Insomnia;

  • Difficulty going to sleep;

  • Difficulty falling asleep;

  • Wakening during the night;

  • Daytime Sleepiness;

  • Excessive Daytime Sleepiness (EDS);

  • Poor concentration;

  • Difficulty with balance;

  • Shortness of breath;

  • Dry mouth;

  • Restless Sleep;

  • Non-Restorative Sleep;

  • Snoring;

  • Obstructive Sleep Apnea;

  • Restless Leg Syndrome;

  • Nocturnal Leg Cramps;
I would like to see a new sleep lab study, a split study, specifically to see if Central/Mixed/Complex apnea is present without CPAP to be followed with an ASV Titration study.  The initial portion should be able to determine if the Central Apnea is treatment emergent or not.  

It looks like we are not going to decrease the Obstructive Apnea by manipulating the Max Pressure so we will work with you minimum pressure.  
Fact, EPAP/Exhale pressure, the green line on the pressure graph is what splints open the airway to prevent apneas so we are going to raise it.

note that the first step to possibly justifying an AS is to Titrate to minimize OSA, that is the obstructive AHI to less than 5 per hour.  You are currently at 6.99

My suggestion is to set the minimum pressure to 10. 

Fred
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
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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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#12
RE: Newbie. One Week In... poor AHIs
Per your latest recommendation, Fred, here's last night's result with min = 10, max = 13.   I turned off VS2 as well.

Interesting results...   OA was down to below 2.  H was 3.5, and CA a bit north of 6, for a total AHI of 11.6

I read thru the wiki link you provided a couple of days ago, "Justifying Advanced CPAP Machines", and I'm wondering if I'm doing myself any favors by trying to optimize my current results.  My total AHI is still well above 5, and my CA events are greater than 50% of the total, so I think these results would still meet the definition of Complex or possibly Central Sleep Apnea as defined in the wiki... so perhaps no harm in continuing to tweak my settings...?

As to the list of symptoms...  I can answer yes to several, but certainly not all.

Non-Restorative Sleep - Yes
Waking During the Night - Recently, Yes. A relatively new symptom for me.
Snoring - Oh, gosh, yes - when not using cpap
Daytime Sleepiness - Yep.  When I tell my wife I feel tired, she invariably replies, "You're always tired"
Poor Concentration - Sometimes.  I drink a lot of coffee (mornings) and diet coke (afternoons) at work to counteract this issue.
Restless sleep - my wife tells me emphatically yes (when not on cpap, and reduced but not eliminated with cpap)

But... no insomnia, no difficulty falling asleep, no trouble with balance, no shortness of breath/dyspnea, morning headache, dry mouth, restless leg, leg cramps.  And while I listed Daytime Sleepiness above, I wouldn't characterize myself as having the more extreme-sounding versions of sleepiness: hyper somnolence, EDS, or cognitive dysfunction.

Also... I'm starting to seriously question whether I chose wisely with regard to my sleep doctor.  I can't get them to call me back after two days of leaving voicemails.  So I take your point regarding the wisdom of an in-lab sleep study, but may have to find a new provider.  At this point I feel like the facility I chose made their money on me and have lost interest in follow-up care. 

Epsan


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#13
RE: Newbie. One Week In... poor AHIs
We are trying to drive just the Obstructive to under 5 to show that the obstructive can be managed.
We will now raise both min and max by 1 to lower obstructive events which are currently at 5.52.
New range 11 to 14

Fred
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

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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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#14
RE: Newbie. One Week In... poor AHIs
For your consideration (as Rod Serling used to say...), last night's results, with min=11, max=14.

From yesterday's discussion, Fred, I gather that you're defining Obstructive Events = OA + H + FL.  If so, last night I scored 4.83, which is definitely less than 5, though just barely!

I'm a bit confused about including Flow Limitations in that score, since Sleepyhead doesn't include FL in its calculation of AHI, which was 13.52.    My CA from last night was 9.24, or 68% of the AHI.

I realize I'm posting rather late tonight... if I don't hear back from anyone this evening (which I wouldn't expect, given the hour) I'll just stick with the same settings again tonight, and post again tomorrow evening.

thx!
Epsan

   
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#15
RE: Newbie. One Week In... poor AHIs
I want no doubt about the under 5

1 more time, if you please.  

Range 12 - 15

I don't hear any complaints, complaints are important.

After this if you are ok with it lets hold for a few days to show that it's no fluke.
than rest to a previous setting that you are comfortable with.

Then you need to complete the list
  • Titrate to minimize OSA, that is the obstructive AHI to less than 5 per hour. This typically is raising EPAP or pressure until obstructive AHI is less than 5 per hour, we expect this to make the Central and Complex Apnea worse thus failing the current treatment
  • Record the central apnea-central hypopnea index (CAHI) (looking for greater than or equal to 5 per hour and greater than 50% of total AHI)
  • Document the presence of at least one of the following symptoms: These symptoms are specifically noted by Medicare. These are key symptoms that we look for by asking "How do you feel?". Do not limit your answers to the following and do not fabricate the answers.
  1. Sleepiness, "How do you feel?"
  2. Awakening short of breath, "How do you feel?"
  3. Difficulty initiating or maintaining sleep, "How do you feel?"
  4. Frequent awakenings, or "How do you feel?"
  5. Nonrestorative sleep, "How do you feel?" Nonrestorative sleep is defined as the subjective feeling that sleep has been insufficiently refreshing
  6. Snoring, Can be documented on Sleepyhead
  7. Witnessed apneas Both in your Sleep Study and recorded on your nightly charts
When are you scheduled to complain discuss with your doctor?
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

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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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#16
RE: Newbie. One Week In... poor AHIs
I think in future charts, turning off the VS2 flag will help the more important events to be highlighted. The results of reducing Flex and the pressure range are that your AHI and event distribution is unchanged. You have a complex apnea your current machine cannot treat. Call the doctor and have him setup a titration study. Tell him your apnea is mixed central and obstructive. You should read up on adaptive servo ventilation ASV so that you can start to advocate for a more effective treatment strategy.
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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#17
RE: Newbie. One Week In... poor AHIs
(01-22-2019, 11:15 PM)bonjour Wrote: 1) I don't hear any complaints, complaints are important.

2) After this if you are ok with it lets hold for a few days to show that it's no fluke.
than rest to a previous setting that you are comfortable with.


3) When are you scheduled to complain discuss with your doctor?

Thanks (once again), Fred & Rider -

I went to bed shortly after yesterday's post, so didn't see the recommendation to go to 12/15.  I slept last night on 11/14 for the second night in a row.  Results below.  Short version:  Obstructive events: 3.74   AHI 12.38  Central events: 8.77, which is 71% of AHI

I'm a bit confused about the points that I numbered above.
1)  You want to hear complaints?  I'm confused by that statement.  I'm just happy to be getting closer to figuring out what sort of apnea I have (complex) and what needs to be done next.  Here's my biggest issue w/ my current state: I wake up multiple times per night some nights (last night was particularly bad) but other nights I sleep clear through.  I'm still feeling tired pretty much all day long. But that's about it.

2) I'll go with 12/15 tonight and stay there for a few days, as you suggest. But then... go back to a previous setting?  What setting?  And why?

3) Discussion with doctor won't happen quickly, I'm afraid. I am fed up and have given up with the medical care (or rather, the lack thereof) that has been provided by the Sleep Wellness Institute.  I need to get a copy of my original sleep study results from them, but once that's done I don't intend to ever contact them again.  I'm going to start over again with a new doctor, and of course give him/her all the information that I have accumulated (original sleep study, Sleepyhead data) in order to expedite the titration study that you've shown me I need.

   
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#18
RE: Newbie. One Week In... poor AHIs
Epsan, you don't need a sleep specialist / quack at all, you just need good care. If your insurance is good, then the doctor, prescription, DME route makes sense. If you have a lot of out of pocket, we can help you figure out what your needs are and find the lowest price alternative. You are heading towards ASV. If you have a family doctor you trust, he might be willing to take over your care and run the scripts.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Optimizing Therapy
Organize your OSCAR Charts
How To Attach Images And Files to your posts
How To Deal With Equipment Supplier
Mask Primer
Beginner's Guide to Sleepyhead

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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#19
RE: Newbie. One Week In... poor AHIs
Your "complaints", or if you rather symptoms are the last piece of letting a doctor see that you need an ASV.  Things like your waking up multiple times demonstrate that this machine is not really working for you.  You have myself and SleepRider convinced already.  All we are trying to do is make it a slam dunk that you are getting an ASV which is the best machine for you.

All we seem to have done is trade central events for obstructive events which is what we expected and wanted.

Are you going to use Insurance or do you need to self pay?  And as Sleeprider pointed out your family doctor can do it, and by it we mean support you and write a prescription for the ASV machine.

Until then we want you to be as comfortable as possible.  All the combinations you have tried equate to very close to the same therapeutic value by the numbers.  Given that the best thing, until you get an ASV is to make you as comfortable as possible.  That can mean staying where you are at, increasing, or decreasing pressure.

ASV could lower your AHI to less than 2 with many users approaching zero.

Fred
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Mask Primer
Dealing with a DME
Organize Charts
Attaching Charts

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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#20
RE: Newbie. One Week In... poor AHIs
What usually works best in complex apnea is relatively low fixed pressure with no Flex or EPR. We're talking about a pressure of 8.0 cm. This allows us to see if the centrals drop without an increase in OA. Part of why this experiment is valuable is that it can begin to show us the minimum pressure at which OA is controlled which can be used later in titrating ASV. Your machine will improperly classify some of the apnea, so we're looking at so don't expect this to solve the problems, but it's worth a look, and might be more comfortable than letting the machine run up your pressure in auto mode.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Optimizing Therapy
Organize your OSCAR Charts
How To Attach Images And Files to your posts
How To Deal With Equipment Supplier
Mask Primer
Beginner's Guide to Sleepyhead

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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