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OSCAR data review - Low AHI Still tired
#41
RE: OSCAR data review - Low AHI Still tired
(09-11-2019, 08:33 AM)cwbolton Wrote: Thank you, the bit i dont understand is, the flow limitations are occurring because my EPAP level is too low or high? and a BiLevel would alter EPAP pressures whilst maintaining IPAP pressure, and my resmed device EPR does this but on a smaller scale and its not enough to prevent flow limitations? is that correct? so increasing overall pressure we do on a CPAP as that is the only way we can alter the EPAP levels? im just a little confused because in my head EPR is a bad thing because having negative 3 on the exhale means that its more likely to cause my airway to close than having an IPAP/EPAP of 13 instead of 10/13 Because of EPR

(09-11-2019, 08:28 AM)mper6794 Wrote: Hi, cwbolton
UARS (and PLM's) are essentially my single focuses in this blog; those were (almost used to be) my two 50-year sleep drawbacks. After suffering ALL that long with "inmsonia"; when retired, surprisingly with rather good healph (luckly, whithout knowing, blindly, my PLM's was partially treated with clonazepam and like),  two years ago a damn Doctor asked me a PSG; life started changing!
Two-year therapy now; 6 months with Oscar. Good and great experience acquired. CPAP and BPAP are magic. However, for UARS, don't believe in CPAP or APAP; It  would be traps in the middle of the road; don't not work in the absolute majority of times, ending up either in aerophagia or resilient untreated flow restrictions. I think you are trapped in persistent only slightly treated UARS. Repeatitively scrutinizing this blog; I have  seen the very same thing so many times!
You went right on the Mark, above: remaining disturbed sleep often would mean either wrong machine and/ir wrong parameters!
UARS, in particular, is a very serious sleep disturbing issue, even more serious than apneas themselves; used to being harder to treat! Why? UARS always leads to very sensitized brains (more than in apneas), therefore easily arising/awakening/wakening you up, leading to very low sleep efficiency.
Good luck

I have been doing some reading into flow limitations and UARS does come up, do you think it could be that i have UARS? Or can i have OSA and UARS at the same time? Or does UARS cause apneas as i have an AHI of 34 when untreated as demonstrated by a sleep study. I am seeing the hospital on friday, so i will voice my concerns about flow limitations and UARS.

First off, EPR = IPAP - EPAP. It's what we call pressure support. It's the same on a bilevel but there is no max value of 3. This value determines how much additional ventilation the bilevel will provide you. So if your EPR is set to 3 and your EPAP is set to 10, it's mean your IPAP is equals to 13.

You titrate yourself on a bilevel by raising the EPAP high enough to prevent full apneas. This is done in order to prevent your airways from totally collapsing since the EPAP is the lowest pressure. You don't want this to happen because the machine is only strong enough to prevent apneas not opening up the airways after it has already collapsed. Once it's done, you keep the EPAP to that value and raise the IPAP (and therefore pressure support) to deal with the remaining stuff (hypo, rera and flow limitations).¸

In you case, since you can't increase the pressure support with your machine, your only solution is to increase EPAP and hope it fixes your problem.
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#42
RE: OSCAR data review - Low AHI Still tired
(09-11-2019, 08:46 AM)alexp Wrote:
(09-11-2019, 08:33 AM)cwbolton Wrote: Thank you, the bit i dont understand is, the flow limitations are occurring because my EPAP level is too low or high? and a BiLevel would alter EPAP pressures whilst maintaining IPAP pressure, and my resmed device EPR does this but on a smaller scale and its not enough to prevent flow limitations? is that correct? so increasing overall pressure we do on a CPAP as that is the only way we can alter the EPAP levels? im just a little confused because in my head EPR is a bad thing because having negative 3 on the exhale means that its more likely to cause my airway to close than having an IPAP/EPAP of 13 instead of 10/13 Because of EPR

(09-11-2019, 08:28 AM)mper6794 Wrote: Hi, cwbolton
UARS (and PLM's) are essentially my single focuses in this blog; those were (almost used to be) my two 50-year sleep drawbacks. After suffering ALL that long with "inmsonia"; when retired, surprisingly with rather good healph (luckly, whithout knowing, blindly, my PLM's was partially treated with clonazepam and like),  two years ago a damn Doctor asked me a PSG; life started changing!
Two-year therapy now; 6 months with Oscar. Good and great experience acquired. CPAP and BPAP are magic. However, for UARS, don't believe in CPAP or APAP; It  would be traps in the middle of the road; don't not work in the absolute majority of times, ending up either in aerophagia or resilient untreated flow restrictions. I think you are trapped in persistent only slightly treated UARS. Repeatitively scrutinizing this blog; I have  seen the very same thing so many times!
You went right on the Mark, above: remaining disturbed sleep often would mean either wrong machine and/ir wrong parameters!
UARS, in particular, is a very serious sleep disturbing issue, even more serious than apneas themselves; used to being harder to treat! Why? UARS always leads to very sensitized brains (more than in apneas), therefore easily arising/awakening/wakening you up, leading to very low sleep efficiency.
Good luck

I have been doing some reading into flow limitations and UARS does come up, do you think it could be that i have UARS? Or can i have OSA and UARS at the same time? Or does UARS cause apneas as i have an AHI of 34 when untreated as demonstrated by a sleep study. I am seeing the hospital on friday, so i will voice my concerns about flow limitations and UARS.

First off, EPR = IPAP - EPAP. It's what we call pressure support. It's the same on a bilevel but there is no max value of 3. This value determines how much additional ventilation the bilevel will provide you. So if your EPR is set to 3 and your EPAP is set to 10, it's mean your IPAP is equals to 13.

You titrate yourself on a bilevel by raising the EPAP high enough to prevent full apneas. This is done in order to prevent your airways from totally collapsing since the EPAP is the lowest pressure. You don't want this to happen because the machine is only strong enough to prevent apneas not opening up the airways after it has already collapsed. Once it's done, you keep the EPAP to that value and raise the IPAP (and therefore pressure support) to deal with the remaining stuff (hypo, rera and flow limitations).¸

In you case, since you can't increase the pressure support with your machine, your only solution is to increase EPAP and hope it fixes your problem.

Can i not just reduce the EPR? which will raise my EPAP without further increasing my IPAP
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#43
RE: OSCAR data review - Low AHI Still tired
(09-11-2019, 09:12 AM)cwbolton Wrote:
(09-11-2019, 08:46 AM)alexp Wrote:
(09-11-2019, 08:33 AM)cwbolton Wrote: Thank you, the bit i dont understand is, the flow limitations are occurring because my EPAP level is too low or high? and a BiLevel would alter EPAP pressures whilst maintaining IPAP pressure, and my resmed device EPR does this but on a smaller scale and its not enough to prevent flow limitations? is that correct? so increasing overall pressure we do on a CPAP as that is the only way we can alter the EPAP levels? im just a little confused because in my head EPR is a bad thing because having negative 3 on the exhale means that its more likely to cause my airway to close than having an IPAP/EPAP of 13 instead of 10/13 Because of EPR


I have been doing some reading into flow limitations and UARS does come up, do you think it could be that i have UARS? Or can i have OSA and UARS at the same time? Or does UARS cause apneas as i have an AHI of 34 when untreated as demonstrated by a sleep study. I am seeing the hospital on friday, so i will voice my concerns about flow limitations and UARS.

First off, EPR = IPAP - EPAP. It's what we call pressure support. It's the same on a bilevel but there is no max value of 3. This value determines how much additional ventilation the bilevel will provide you. So if your EPR is set to 3 and your EPAP is set to 10, it's mean your IPAP is equals to 13.

You titrate yourself on a bilevel by raising the EPAP high enough to prevent full apneas. This is done in order to prevent your airways from totally collapsing since the EPAP is the lowest pressure. You don't want this to happen because the machine is only strong enough to prevent apneas not opening up the airways after it has already collapsed. Once it's done, you keep the EPAP to that value and raise the IPAP (and therefore pressure support) to deal with the remaining stuff (hypo, rera and flow limitations).¸

In you case, since you can't increase the pressure support with your machine, your only solution is to increase EPAP and hope it fixes your problem.

Can i not just reduce the EPR? which will raise my EPAP without further increasing my IPAP

Yes you can but you want the pressure support to be as high as possible in your case. The pressure support is what will help you solving your flow limitations but right now your limited to 3 with your machine. If you had a bilevel, you would keep the EPAP the same and raise the pressure support to increase your ventilation but since you do not, your only choice is to raise the EPAP to try to lower your airways resistance.
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#44
RE: OSCAR data review - Low AHI Still tired
Im getting really confused now, what do you mean by pressure support? If i LOWER my EPAP from 3 to 2, it means my EPAP will be HIGHER meaning a greater exhalation pressure without modifying my IPAP, that increased exhalation pressure will keep my airway splinted better thus causing less flow limitations will it not? Or am i missing something here, i thought my last comment explained how i understood it pretty well. 

Thanks
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#45
RE: OSCAR data review - Low AHI Still tired
(09-11-2019, 09:46 AM)cwbolton Wrote: Im getting really confused now, what do you mean by pressure support? If i LOWER my EPAP from 3 to 2, it means my EPAP will be HIGHER meaning a greater exhalation pressure without modifying my IPAP, that increased exhalation pressure will keep my airway splinted better thus causing less flow limitations will it not? Or am i missing something here, i thought my last comment explained how i understood it pretty well. 

Yes a higher EPAP is what you want. But what I'm not getting is why do you want to lower your IPAP? 

Pressure support = EPR = IPAP - EPAP. Pressure support is what provide the additional ventilation I was writing about before so you want to keep it as high as possible while raising your EPAP. If you had a bilevel, to solve remaining flow limitations, I would keep EPAP the same and increase the IPAP and therefore the pressure support. The difference between the IPAP and the EPAP is the important value not the IPAP by itself. But since you can't do that, your only option is to keep the pressure support to the same value and raise the EPAP.

Hope it makes sense  Smile
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#46
RE: OSCAR data review - Low AHI Still tired
Ok so pressure support is the difference between IPAP and EPAP and a greater value here would have benefit to my flow limitations? i appreciate this is a bit of a technical question but can anyone explain why the sudden drops and peaks in pressure are beneficial to flow limitations? My logic was if its EPAP that needs increasing i could have lowered my EPR and still seen the same benefit without blasting an even higher air pressure into my face at night but now i see the actual pressure difference is beneficial so ignore that, i have no issue with increasing my IPAP but then the difference will still be 3 as thats the max EPR setting, so if were raising overall pressure just to raise EPAP that could have been done through an EPR setting reduction.
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#47
RE: OSCAR data review - Low AHI Still tired
[quote pid='310951' dateline='1568211159']

 ....." just reduce the EPR? which will raise my EPAP without further increasing my IPAP".
[/quote]
_thanks alexp for support.
_cwbolton: a bit further. Yes, indeed, i think you appear on an untreated UARS (taking into account that UARS is just the Dr. Guilleminaut's original name for  a kind  of plateaued-type restrict flow rate, which always leads to arousal). Sometimes UARS is taked of synonimus of FL or RERA. 
For me, what matters is whether or not any kind of flow restriction, whatever the name you want, lead me to arousal/awakening/wakeups. And, such flow restrictions can be easily spotted with Oscar, either flagged or not.
How to start treating? based on what i have been learning with  more experienced people in this Forum.At least in my case, and many others  here: (1) firstly is trying EPR: 3.0, and increase EPAPmin as (It did not work for me, and i am afraid, for anybody in this forum, as far as I remember; I would ask for more inputs here, though!!!). (2) go for the BPAP and start your proper adjustments and fine tuning, concerning EPAPmin and PS (minimum 4.0); It may take a long while to get the optimum if these two parameters. 
There is a protocol by Fred and Sleeprider you may want to investigate.
GL
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#48
RE: OSCAR data review - Low AHI Still tired
(09-11-2019, 10:01 AM)cwbolton Wrote: Ok so pressure support is the difference between IPAP and EPAP and a greater value here would have benefit to my flow limitations? i appreciate this is a bit of a technical question but can anyone explain why the sudden drops and peaks in pressure are beneficial to flow limitations? My logic was if its EPAP that needs increasing i could have lowered my EPR and still seen the same benefit without blasting an even higher air pressure into my face at night but now i see the actual pressure difference is beneficial so ignore that, i have no issue with increasing my IPAP but then the difference will still be 3 as thats the max EPR setting, so if were raising overall pressure just to raise EPAP that could have been done through an EPR setting reduction.

The difference is important because by raising and lowering the pressure, the machine acts like a ventilator or a lung if you prefer. It's breathing for you. Your lungs work the same way. If you keep the pressure always the same, the only thing the machine does is splittering your airway but the air will not move unless you breath. 

Air moves from high pressure to lower pressure places. Just think about what happens when you open a can of soda or defatle a tire. So by switching from a high to a low pressure, you are forcing the air to enter than exit your body again and again.
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#49
RE: OSCAR data review - Low AHI Still tired
And now it all makes perfect sense, i completely understand so with an EPR of 3 my body still isnt getting the oxygen it needs naturally so my body is having to work harder to breathe in my sleep meaning i experience arousals as this happens, right? But with a greater pressure support air moves in and out of my lungs more freely/easier requiring less effort in my sleep leading to less or no flow limitations.
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#50
RE: OSCAR data review - Low AHI Still tired
(09-11-2019, 10:19 AM)cwbolton Wrote: And now it all makes perfect sense, i completely understand so with an EPR of 3 my body still isnt getting the oxygen it needs naturally so my body is having to work harder to breathe in my sleep meaning i experience arousals as this happens, right? But with a greater pressure support air moves in and out of my lungs more freely/easier requiring less effort in my sleep leading to less or no flow limitations.

Yes exactly. You can see it in your flow rate chart. When you are experiencing flow limitations, the top of the inhalation will be flat. In order to keep the same amount of air coming in (the tidal volume chart), your inhalation starts getting a bit longer and the pause between exhalation and inhalation is much shorter. In my case, my inhalation was about 0.5 s longer. The tidal volume remains about the same unless the flow limitation is too important. After some time, sometimes you'll see a couple of jagged breaths. That's an arousal or RERA if you prefer and the idea is that if you get ride of the flow limitations, you'll get ride of the RERAs as well.

Note that's there are some papers pretending that small but constant flow limitations through the night without arousals still have bad effects on the body and on our level of fatigue. So RERAs may not be the only problems but we don't know yet.
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