Over 2 years in and still tired w/Oscar charts

[Stiltired]

The night of the 7th didn't look terrible via AHI (1.27), though I did have 4 RERA's, which is a record for me.  However, it did leave me feeling like absolute trash all day long.  Well, I tried the lower pressure last night, though I misread what Geer1 had suggested and wound up going with 7-10 instead of 6-12.  The machine was bumping up against the 10cm limit for around 90 minutes and I woke up a number of times, the earliest of which left me feeling like I had taken a dose of adrenaline, which makes it difficult to return to sleep.  

Should I try 6-12 as was suggested, or 11-14?  15-20?      Is the increased EPAP causing my irregular flow patterns?  Why does it look as if the tops of the flow chart are more flat topped with increased pressure?  Shouldn't more pressure be relieving the flow limits?

Somewhat unrelated, but I realized this morning that I misspelled my username.  Geez!  Is it possible to add an extra L?

[Geer1]

Let's try the higher range (11-14)

[Stiltired]

Last night I had set my machine for 11-14.  I didn't sleep particularly well, possibly due to some leak issues, a noticeable and annoying level of nasal congestion or, perhaps, just random awakenings.  The flow limits look good, though I sometimes wonder if that is due to lack of deep sleep or just effective therapy.  I did awaken a few times with memory of dreaming, so there must have been some good sleep in there somewhere.  Seems I should stick with this pressure range for a bit and see how I feel after a few days.  I'm pretty tired today, though I don't think that is grounds for more machine fiddling just yet.  Thoughts?

[Geer1]

That looks better, you can see how flow rate chart looks more uniform. Respiration rate chart still shows some periods of odd respiration but probably not as bad as before (respiration rate not actually that high, just being misrepresented by the flow rate bouncing across zero at times).

I would stick with these settings for a bit and then if you still think more improvement is needed try an even higher pressure. It seems like restriction causes your breathing quality to decline but causes odd breathing rather than obvious flow limitations or apnea. That makes it so the automatic nature of this machine has poor responsiveness (since it reacts to flow limitation, apnea and hypopnea) meaning you have to try and adjust manually to see if it helps further as this increase appeared to.

[Stiltired]

Thanks, Geer1.  

Were I to pursue a Bi-level machine, is the ResMed Vauto what I should look for?  In such case, it could be set with an IPAP of 11-14 and an "EPR" of 4, 5 or 6?   I ask because the higher inhale pressure isn't at all uncomfortable but I do often reset the machine when I wake up as the resistance to exhale isn't a comfortable experience.

[Geer1]

Yes vauto would be the machine of choice and allows you to use higher PS. Can be tough to convince doctor/sleep clinic to use a bilevel for cases like this as they usually only look at ahi. If trying to go the doctor route you would probably have to talk them into a titration study and hope it indicates RERAs.

Part of the issue may be that the pressure is still not high enough. Breathing out against pressure can be uncomfortable but if it is opening airway further it can actually make it easier. For example when trying lower pressure you commented waking up in an alert state which was likely due to restricted breathing at the low pressure.

Edit: Higher pressures can definitely take some getting used to as well. Best to increase pressure slowly while letting body adapt.

[Stiltired]

Now that I have a few nights with the 11-14 pressure, I thought I'd share the most recent two.  I'm not feeling any better, though I understand that can take time to occur, if at all.  

I've noticed that my inspiration time is a great deal longer than my exhale time.  Is that something I should be concerned about?  Would dropping EPR to 2 help in taming the few OA's that are occurring, or is it not worthwhile to chase these down?

[Stiltired]

I wanted to add that with respect to how I feel, today seems worse. My chest feels like breathing wasn't easy last night and I'm feeling more run down than usual. Also, I noticed that my heart rate is about 10 bpm lower at rest than is usual. At any given point during most days, I'll have a HR of around 60-65. This afternoon, I'm seeing low to mid 50's. Actually, when checking my BP, it registered a 47. Is it possible that even though my chart looks better with more pressure, it's causing greater stress to my body when I'm asleep? That sounds really counterintuitive, but I'm just trying to make sense of something that, for the past 2.5 years, hasn't really made much sense.

[Geer1]

The 11-14 does still look the best although not as great as the first night. Your comments about having to reset machine to lower pressure back down aren't really warranted as your pressure isn't noticeably higher during any of the recent shutdowns (maybe 12 cm vs min of 11). When you used lower pressures machine was increasing to 10 regularly and 11/12 is not much higher. Unfortunately not much more you can do with this machine, lower pressure appears to make things worse, EPR is maxed and lowering it will almost certainly make you feel worse, higher pressure probably isn't warranted or likely to be more comfortable. A vauto to try and ease respiration and smooth out your rough breathing is probably the next step.

Your inspiration times are wrongly calculated same as respiration rates due to your odd shaped breathing. Can't draw any conclusions from those statistics other than that they indicate your breathing isn't ideal.

I find it unlikely your awake heart rate is being affected by this breathing or settings. I could perhaps see a correlation with feeling a bit more tired if your odd breath shapes are occurring more often but I wouldn't expect that to affect awake heart function.

[cathyf]

Sorry I didn't see this before, so I'm late to the commenting...

I'm pretty flummoxed by the whole thing. My experience is quite different from yours in one way -- I have distinct episodes of jagged breathing with lots and lots of normal breathing in between. Also, I can usually see indications of movement/position changes that lead into the jaggies and then end them, which makes me highly suspicious that there is some sort of positional/neck angle/etc. thing going on. I have a bunch of examples where I will have a nasty burst of chin-tucking positional apnea, with multiple events in a short time, and pretty deep desats into the lower 80s when they are long (30-60 seconds), and then I move into jaggy breathing.

I'm also kind of confused at the effects of the vauto vs autoset on this. What I've found is that if I set the trigger sensitivity to very high on the vauto (default is medium) then it behaves like an autoset. The mask pressure graph is a mess, and it's a perfect storm of "doesn't know whether it's coming or going" as it ties itself up in knots trying to follow the craziness.

I'm working under the hypothesis that this is a positional thing... What I really need to do is to set up a camera and try to figure out what I look like when this is happening. My husband has the gear (he's a physics professor and they used the cameras for a student research project a couple of years ago) but is insanely busy and we haven't had time to dig it all out and set it up.

I'm actually now working on the hypothesis that I don't have apnea that can be treated by a cpap machine. The insane clusters of chin-tucking neck-angle apnea are immune to pressure, and the jaggies are just weird and screw up the pressure support. I find that if I use a pulse oxymeter I can use it to count the number and length of apneas (by the depths and lengths of the desats.) If I wear a cervical collar I don't have any SpO2 events, while if I don't wear one I have a sprinkling of event clusters but my AHI for the whole night is well under 5.

Anyway, if anything I think that I understand it all LESS than a year ago... (Friday is the one-year anniversary of my first appointment with Dr. Jackass who decided that I don't have apnea but am simply crazy.)