Hello Guest, Welcome to Apnea Board !
As a guest, you are limited to certain areas of the board and there are some features you can't use.
To post a message, you must create a free account using a valid email address.

or Create an Account


New Posts   Today's Posts

No Flow while awake
#1
No Flow while awake
Attached is a 20 minute segment of last night. I am laying there awake trying to go to sleep. I did not go to sleep for several hours and that was after discarding the mask in frustration.

The second  attachment is the entire night.

Please, why do I have apneas and no flow and high pressure while I am awake?

TIA


Attached Files Thumbnail(s)
       
Post Reply Post Reply
#2
RE: No Flow while awake
I assume you have had at least one sleep study done. Can you post redacted versions so we can get a better understanding of your situation?

The first thing I think that likely needs to change is increasing PSmin up to 3. That might stabilize breathing a bit so that the machine isn't working so hard (current pressure fluctuations).

I have some other thoughts but need to see some sleep study data or OSCAR data from another machine (CPAP or Bi-level) first.
Post Reply Post Reply
#3
RE: No Flow while awake
(02-29-2020, 12:51 PM)Bugbitten Wrote: ...Please, why do I have apneas and no flow and high pressure while I am awake?
If you are awake then they are not really apneas.  You are simply breathing at a slow rate and holding your breath for longer than 10 seconds between breaths.
The machine doesn't know you are awake and so it reports anything longer than 10 seconds as an apnea.

If you have an ASV machine, whenever the machine thinks you are overdue with a breath it will start blowing air at you to encourage you to breathe.
However, if you are awake and don't want to take a breath that can feel annoying and strange.

When I am awake, if the machine starts forcing air at me too strongly, I blow back hard against the machine and that makes it back off and settle down.
Usually that buys me some time and I can fall asleep before the machine starts forcing air at me again.

Make sense?
Post Reply Post Reply
#4
RE: No Flow while awake
I would agree that action 1 to take is edit PS Min to 3. I think that looking at the red pressure graph, I see that the settings are artificially capping IPAP Max. I would suggest addressing that by adding 2 to EPAP Max for now. We may need to redo it again if results aren't good.

Can you check pressure settings and tell us what you have now? You are showing as being on ASVAuto mode; this means you should have numbers for EPAP Min and Max and PS Min and Max.

IMO you want EPAP 8-12 and I think you have now 8-10
I think PS is now 0-12 and I think you need 3-12
this means you currently have IPAP of 8-22, ranges like this in my experience are less effective than a more narrow, but higher number values

Recap: I suggest editing EPAP Max to 12 and PS Min edit to 3. This results in IPAP increasing to 24 Max.
Use and report back with OSCAR chart and your answer to "How do you feel compared to prior settings?".
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
Post Reply Post Reply
#5
RE: No Flow while awake
(02-29-2020, 02:41 PM)Geer1 Wrote: I assume you have had at least one sleep study done. Can you post redacted versions so we can get a better understanding of your situation?

The first thing I think that likely needs to change is increasing PSmin up to 3. That might stabilize breathing a bit so that the machine isn't working so hard (current pressure fluctuations).

I have some other thoughts but need to see some sleep study data or OSCAR data from another machine (CPAP or Bi-level) first.

Home study done before this!

Pertinent History:
Bugbitten is a 65 y.o. male with a Body mass index is 36.29 kg/m².  Concurrent medical history includes hypothyroidism, DM, obesity, Polycythemia.  Concurrent medications include Synthroid in AM.  Patient presented for a home sleep study for complaints of snoring/nocturnal awakenings/nocturia/EDS w/ dozing/elevated BMI, neck circumference, MP/OSA/gasping - all in the setting of polycythemia.  HST, Dec 19: pAHI: 55 / hr; SpO2 Nadir 69%; 26 min <=88% through study.  Now presents for PAP titration.
 
Polysomnography:  
The patient's sleep was evaluated for one night at the Sleep Disorders Center.  Sleep was monitored in accordance with recommended AASM guidelines.  The recording also included oral/nasal airflow, chest and abdominal respiratory effort, nasal pressure, single channel EKG, intercostal EMG, bilateral tibialis EMG, and oxygen saturation (by pulse oximeter).
 
Technical Comments: Technically adequate study.  
 
 
EEG & Sleep Architecture:
The patient had a 10 Hz posterior dominant rhythm when awake with eyes closed.
 
Sleep onset occurred after 19 minutes, unremarkable. Sleep efficiency was 32%, significantly reduced and fragmented.  Total sleep time was 138 minutes.  Wake after sleep onset was 280 minutes.
 
Sleep architecture was notable for an absence of REM sleep and NREM stage III.  
 
There was no evidence of parasomnias (night terrors, sleepwalking, sleep talking, etc.) on study night.

No noted EEG abnormalities.

100% of sleep time spent supine.
 
 
Respiratory:
CPAP was titrated from a pressure of 5cm to 11cm, then transitioned to BiPAP 13/8 cm to 25/15cm.  Patient did report difficulties with BiPAP tolerance to sensation of air being "pushed in."  Ultimately, patient transitioned to ASV.
 
CPAP:
--5-8 cm: NREM w/ frank obstructive apneas.
--9 cm: NREM seen for ~14 min, no frank events, though blunting of respiratory signals indicative of airway resistance seen, in setting of elevated leak
--10 & 11 cm: NREM w/ development of frequent, frank central apneas
--Pt was then transitioned to BiPAP
 
BiPAP:
--At lower pressures of 13/8 cm & 15/13 cm only briefly seen (3 min & 2 min respectively) limiting data, though with blunting of respiratory signal and some obstructive hypopneas
--At 19/13cm less frequent events were seen, though primarily central hypopneas. Fragmented sleep.
--At 19/14cm infrequent events, scattered, residual events were seen with adequate SpO2 in the low to mid 90%s. Fragmented sleep.
--At the highest pressures of 25/13 cm & 25/14 cm, no events were seen, though limited timing and adequate SpO2 in the low to mid 90%s. Fragmented sleep.  
--Difficulties with BiPAP tolerance, as above.  Transitioned to ASV.
 
ASV:
--Settings of EPAP 8 - 15 cm; Pressure Support: 0-17 cm; Max Pressure 25 cm; Rate: Auto.  On this setting, good control of both obstructive and central events.  No sustained hypoxia.  At lower pressure support max of 10 cm, some residual events were see.  Sleep was more consolidated during the ASV portion of the study.  
 
Interfaces Used: Simplus medium
 
 
EKG/Cardiac:
Normal sinus rhythm with very rare premature atrial complexes of unclear clinical significance.  No periods of sustained bradycardia or tachycardia.   
 
 
Periodic Limb Movements:
The periodic limb movement index was broken down by titration type:
-CPAP during beginning third of night: PLMI 0/hr.
-BiPAP during middle third: 16 / hr with 12 / hr leading to arousals.
-ASV during final third: PLMI 142 / hr w/ 15 / hr leading to arousals. Normal index is < 15
The significance of periodic limb movements in the setting of sleep disordered breathing is unclear.
 
 
Study Conditions:
            --Head of the bed: flat
            --Supplemental oxygen: none
 
 
 
Assessment:  Bugbitten is a 65 y.o. male who underwent positive pressure titration with a wide range of pressures tested.
 
On CPAP at lower pressures, obstructive events were seen; at higher pressure, treatment emergent central events were observed.
 
On BiPAP, at lower pressures ongoing events were observed.  At middle (19/14 cm) and high pressures (25/13 cm & 25/14 cm), adequate control of events occurred but sleep was highly fragmented.  Mr. Berry also voiced difficulties with BiPAP tolerance.  
 
On ASV, at lower pressure support maximums events were seen, though at a pressure support max of 17cm, no events occurred.  Sleep was significantly more consolidated on ASV.
 
Overall, an adequate titration occurred, limited only due to lack of REM sleep.  
 
Moving forward, recommend ASV with settings of EPAP 8 - 15 cm; Pressure Support: 0-17 cm; Max Pressure 25 cm; Rate: Auto.  If ASV is not tolerated, may pressure adjustment with lower pressure support.  If need to consider BiPAP, would recommend 19/14 cm, though sleep was far less consolidated.  Of note, given no history of cardiopulmonary problems and no opioids, CSA may resolve in some individuals, and re-titration study could be considered.  
 
 
Recommendations:  
1) ASV with settings of EPAP 8 - 15 cm; Pressure Support: 0-17 cm; Max Pressure 25 cm; Rate: Auto.

Machine settings 2/29/2020 are
Min EPAP 8
Max EPAP 10
Min PS 0
Max PS 12
Ramp off
Humidity 4
Post Reply Post Reply
#6
RE: No Flow while awake
It seems the EPAP min of 8 is required for obstructive apneas. One thing I am not certain of is why your EPAP maxes out at the current max of 10 right off the bat. Move the pressure graph down out of view and replace it with the flow limitation chart, then post a zoomed in shot of roughly 4 minute duration at the beginning of the night where you can see that EPAP rises to 10 cm.

The sleep study comment on events still being present with PSmax was set at 10 and that is why they increased PSmax to 17. You have yours set to 12 now which might allow events to occur, we can wait until you try the new PSmin and actually get some sleep before increasing it though.

I actually missed the awake part the first time which is a key thing. Apneas and lack of flow when awake simply mean you aren't breathing consistently. If you were actually awake at the time of those apneas than it means you were taking a few deep breaths followed by shallower breaths. If you weren't awake and doing that then what might have been occurring is you being partially asleep, some people have sleep transition central apneas and you might have been having those.

I think increasing PSmin to 3 cm is a good enough change for now. Try to get a good nights sleep with those settings so we can get a better idea of how the machine works when you are actually asleep. Data while awake doesn't really help know how the machine is set up.

I don't know all the ramp settings available on an ASV machine but if your issue is not being able to fall asleep ramp settings are about all we can adjust that may help. If like the basic APAP units there is a on/off option, start pressure and time. Let us know what they are set to if falling asleep is the issue.
Post Reply Post Reply
#7
RE: No Flow while awake
interesting that your plm increased later into the night. due to different modalities, the hour, both or neither? hard to say. 142/hr is a lot, like every 5 seconds all night. 15 arousals/hr is a lot. asv raising ps repeatedly against plm induced flow limitations is exhausting even if you're unaware of it. I wasn't until I capped ps with a vauto. despite what the report said, the significance of plm is quite clear. frequent arousals, fragmented sleep & fatigue.
Post Reply Post Reply
#8
RE: No Flow while awake
(02-29-2020, 04:00 PM)Geer1 Wrote: It seems the EPAP min of 8 is required for obstructive apneas. One thing I am not certain of is why your EPAP maxes out at the current max of 10 right off the bat. Move the pressure graph down out of view and replace it with the flow limitation chart, then post a zoomed in shot of roughly 4 minute duration at the beginning of the night where you can see that EPAP rises to 10 cm.

The sleep study comment on events still being present with PSmax was set at 10 and that is why they increased PSmax to 17. You have yours set to 12 now which might allow events to occur, we can wait until you try the new PSmin and actually get some sleep before increasing it though.

I actually missed the awake part the first time which is a key thing. Apneas and lack of flow when awake simply mean you aren't breathing consistently. If you were actually awake at the time of those apneas than it means you were taking a few deep breaths followed by shallower breaths. If you weren't awake and doing that then what might have been occurring is you being partially asleep, some people have sleep transition central apneas and you might have been having those.

I think increasing PSmin to 3 cm is a good enough change for now. Try to get a good nights sleep with those settings so we can get a better idea of how the machine works when you are actually asleep. Data while awake doesn't really help know how the machine is set up.

I don't know all the ramp settings available on an ASV machine but if your issue is not being able to fall asleep ramp settings are about all we can adjust that may help. If like the basic APAP units there is a on/off option, start pressure and time. Let us know what they are set to if falling asleep is the issue.

Ramp available 0 to 45 minutes

See attached

Thanks


Attached Files Thumbnail(s)
   
Post Reply Post Reply
#9
RE: No Flow while awake
I missed that PLM stat, that is interesting although I am taking all of his titration study results with a grain of salt. Total sleep time was only 138 minutes in which they tried 3 different types of machines at different settings. He couldn't have had much time at those final settings and all it takes is a burst of PLM in a short time to throw the numbers out of whack like that.

A second titration, ASV only might tell you a lot more about that and hopefully give some information on REM sleep if a second titration is available (if you can't find relief self titrating).
Post Reply Post Reply
#10
RE: No Flow while awake
Definitely flow limits at least in the machines eyes, I want to see the flow rate chart and mask pressure chart as well though.
Post Reply Post Reply


Possibly Related Threads...
Thread Author Replies Views Last Post
  Flow rate kink at end of exhalation ahuman 3 41 5 minutes ago
Last Post: Sleeprider
  Awoken by air flow? ReclaimingMySleep 8 234 13 minutes ago
Last Post: ReclaimingMySleep
  [CPAP] Adjusting for flow limitations jane2911 10 305 03-25-2024, 01:24 PM
Last Post: jane2911
  [Equipment] HELP - BIPAP-ST Restricting Inhalation/Exhalation Air Flow / Tidal Volume PAPPER101 3 110 03-24-2024, 09:29 PM
Last Post: stevew168
  flow limitations acceptable levels yankees123 27 1,608 03-23-2024, 02:41 AM
Last Post: CPAPfriend
  OSCAR flow rate assessment -- mouth leaks, palatal prolapse? manders513 9 230 03-22-2024, 06:16 PM
Last Post: BigWing
  Fixed mask leak, but flow limit seems to be increasing AHI emile.leplattenier 3 142 03-19-2024, 11:00 AM
Last Post: staceyburke


New Posts   Today's Posts


About Apnea Board

Apnea Board is an educational web site designed to empower Sleep Apnea patients.