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Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
(06-13-2018, 06:20 PM)sleeplover69 Wrote:
(06-13-2018, 02:20 AM)yrnkrn Wrote: I am not sure this is central at 10:05:40. It starts with extreme hypopnea, very low flows going in & out. The catch is the machine is not triggering on this as the flows are so low and then it develop into zero flow that could very well be obstructive apnea. 

Personally I have these issues:

which do resolve with higher EPAP so I suggest you try higher EPAP with same PS.

edit: also, default Timax was annonying while awake/going to sleep, when I took a deep breath the pressure went away in mid-breath. I set Timax to 4s and happy with it.

I took your advice to up TiMax, I have it at 3s but IDK if it's making a difference yet. 

Turns out it was an OSA. OSAs correlate with a certain I:E ratio number (100 in my case) different from a ratio number with CAs. But OSA or not, bilevel is turning out to be central city for me.


Bilevel Night 2 - Split Night 5.6/14/5 and 5/13/5 - Settings: 'High' cycle sens / TiMin 0.4 / TiMax 3s /All else default

Most likely didn't wear the collar for the first half, but did for the second half.

Felt sleepy and went to bed before 3 am, much earlier than usual, but I was rolling in and out of sleep before 4 am so I'm going to leave out sleep data for that portion. 

Night was split deeply after 4h30m of sleep. I don't remember awakening in the first half and there were very brief awakenings in the second. I feel demolished.

[Image: qZweDLc.png]

Aside from the OSAs, 2nd half looks more stable. Since I'm sure I wore the collar for the 2nd half, it complicates things

[Image: qpwxalb.png]

First half

[Image: XADg1hM.png]

And idea of how long the CAs (and OSAs) lasted. Don't know if I should keep going with bilevel at this point

[Image: oEKvQiE.png]

?

[Image: m8eBAb2.png]

More ? I don't see this in the 2nd half

[Image: UUYfbkS.png]

Centrals

[Image: jhsDvUW.png]

How does one get more OAs or hypopneic breathing at higher pressures?

[Image: E4uCZxY.png]

Aside from the OSAs, breaths may be not as deep, but are more stable?

[Image: 87gUzF9.png]

Some wave forms. But what could cause these flat extensions after the expiratory dips? Normal deviations? 
Mouth breathing?

[Image: a8Ct6Jj.png]

More examples of what I mean. And is that rippled one like a mini-CA?

[Image: k3JzxDS.png]

Arousal?

Thoughts and suggestions? What settings to try for tonight?

Thanks for the links.
You ask an excellent question "How does one get more OAs or hypopneic breathing at higher pressures?"

Did you ever get a solid answer?
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RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
Update - Bilevel Nights 6 & 7 + ASV

I had my pressure set to 6/13/4 for the final two nights on the bilevel and actually managed to sleep for over 6 hours on night 7 without awakening or remembering if there were any. I did go back to sleep though for 2 more hours. I felt an improvement and was little more productive that day despite feeling a little exhausted still. Unfortunately I left the SD card out of the machine so I'm missing most of the data for that night. Last day with the bilevel just as it was starting to look promising. 


[Image: Rjeeb5y.png]

Bilevel Day 6. Woke up for reasons unrelated to therapy

[Image: oNuCgqF.png]

Only 9 centrals aren't post-arousal. Longest one being 28 seconds.

[Image: ghobPfL.png]

I still haven't found an answer as to why sometimes the wave forms flatten like this with APAP and bilevel. Little bounces before inspiratory breaths, almost like micro centrals.

[Image: UUuSmJ0.png]

Not sure what's even going on here

[Image: SoLOWUK.png]

Bilevel Day 7 Numbers are all wrong since it's missing data for much of the night. FWIW, the central index for this segment is 7.68.

[Image: R1NUSWd.png]

Of the 21 centrals flagged, 10 were proper centrals, longest one being 30s.

[Image: qE9fAQ1.png]

More bounces before inhalations. Anyone else get these?

Bilevel and centrals - Sadly I don't know if centrals are a problem for me with bilevel. CPAP with EPR 3 already gives me around 3-5 CA index. The question is, given my central numbers, the durations of the centrals, and that half of them seem post-arousal, are centrals a problem for me with bilevel? It's a shame I don't have full data for day 7.




ASV DAY 1! - Settings: EPAP 6, PS 4-9

I am truly blessed and actually somehow managed to get a heavily used S9 VPAP Adapt (model 37006) on loan from one of my parent's friends who has central apnea. However, the first night wasn't too promising with multiple awakenings and a spiky flowrate. Does this machine not compute flow limitations? It seems like my breaths are flow-limited again or at least weak-looking and had around the same tidal volume as APAP. Overall I felt quite exhausted and was really unproductive today.

[Image: GY2l9IU.png]

Millipede-looking flow rate

[Image: KuYCUYt.png]

Got these bands of very suppressed wave forms, one lasting 2 minutes and another 6 minutes. pt. 1 of 2

[Image: H3UKZed.png]

Pt. 2

[Image: A8jfzBo.png]

Typical weak and flat-looking wave forms throughout the night. Example 1 out of 3. 

[Image: tQz4P8p.png]

2 out of 3

[Image: EBsfy3t.png]

Last one.

It was only one night but it was a rough one with a lot more arousals than bilevel, especially that last day with bilevel. Why are my inspiratory breaths so flow restricted despite the corresponding increases in pressure? I'm thinking of trying EPAP 6, PS 5-9 tonight to see if that makes a difference. 

From what I've gathered, this model 37006 and the AirCurve 10 ASV have the same algorithm so I'd likely get the same kind of results and therapy with the latter, correct? Would I do even worse with the PR Dreamstation Bipap ASV? Really wonder how long it'll take before I can determine if ASV is right for me. Will the flow rate look better the longer I use it?
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RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
You may be expecting too much from the human body... real flow patterns are never perfect, even for people without SDB. I'd consider the flows with the ASV (PS=9, 7, 5 in the graphs you presented) as near perfect, and the Bi-Level are very good - with the exception being around 11:02:45 where a higher PS was probably needed. 
The ASV function as the bi-level by setting PSmin=PSmax.
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RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
Hi sleeplover69,

People sometimes find it takes a few weeks to get used to ASV.

You didn’t mention air swallowing or heartburn.  Did you have problems in those areas when using the ASV machine?

ResMed ASV machines won’t let the Max PS be set lower than five higher than the Min PS setting. So if you would like to try Min PS of 5, then the Max PS will need to be set to 10 or higher. A higher Min PS would tend to increase the average amount of ventilation you’ll be getting, but may worsen air swallowing, which in turn may worsen heartburn.

ResMed ASV modes will mark all apneas, whether OA or CA, as UA (unclassified apneas). With ASV, the apneas will be type OA if the Flow remains very low even though the machine (in response) has automatically adjusted PS to be very high.

I suspect higher EPAP would help avoid the periods of low Flow.

Earlier you had asked what might explain sometimes getting a higher number of obstructive apneas and hypopneas after EPAP had been raised (a little).  When that happens, I think the explanation is likely that changes in sleep position allowed the increase in obstructive events.  Sleep position changes can more than counteract a higher EPAP setting.

If I remember, I think when you were using an APAP machine sometimes the machine would need to raise EPAP to 10 or higher in order to avoid obstructive events.

However, if you find that higher EPAP causes painful air swallowing or heartburn, you may need to compromise by not raising EPAP high enough to avoid all obstructive effects.

Hang in there.
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. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
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RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
The S9 in ASV mode does not record flow limitations, you need the later 36037 model with the auto ASV mode to see flow limitation and snore information.


I would want to use the ASV for a week as the larger pressure swings can be disruptive to your sleep and takes some getting used to, I now sleep like a baby but it takes a few nights to get in sync with the ASV and there is no saying the ASV may cause more disruptive sleep it can be hard to get used to.


You may find you need more pressure support than the current value of 9 maybe raise it to 15 to eliminate the milipead flow graphs, of increase epap.
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RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
Based on your success with bilevel at EPAP 6-10 and PS 4, I think the only problem with your ASV settings is that the PS max is too low at 9.0. You want the machine to cause a breath when a central or hypopnea occurs, and that may require up to PS 12. In auto bilevel, your pressure was relatively constant, staying near EPAP min. That works in your favor for ASV because the EPAP of 6.0 should be pretty good. You are using PS min of 4.0, which gives you bilevel pressures that are similar to Vauto.

It's interesting on ASV that the machine really isn't stepping in very much. Your median pressure support is 4.4 (IPAP 10.4), and even the 95% PS is only 6.4 (IPAP 12.36). It could even be argued that you could drop EPAP to 5.0 to lower overall pressure a bit, and see if any obstruction enters the mix. Probably the best advise is by Vsheline that "some people take a while to get used to ASV". I agree, this is almost always the case. I also agree with Jaswilliams regarding a higher PS max. So I think we're all on the same page...give it more time for you to adapt, and consider a higher PS max.
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RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
Update - First week with ASV

Sorry for the delay, folks. After so many bad nights in a row, my spirits are dashed and I've been too enervated to post in over a week. I really appreciate and followed all suggestions to increase different pressure settings, but in an erratic and desperately impatient way. I'm fighting the machine to breathe in sync with it so it's been taking me much longer each night to fall and stay asleep. It's like learning how to use CPAP all over again but harder.

With higher pressures during first sleep onset, I'd wake back up immediately burping with some aerophagia. Also, the dusty odor coming from the blower is kind of concerning, too. I just hope I won't get sick from that as I don't know if it's a good idea to try to take it apart to clean it. I don't know if the smell probably adds to the sleep disturbances. I apologize if this update is way over-long.

[Image: 8lNNZjz.png]

6 EPAP / 4-9 PS - One of the first nights with the ASV. Look, there's a smiley face, so it should be promising. I still had three brief awakenings near the end of therapy though. While it was better than most days and I was hoping it'll start to get much better from here on out. Maybe I made a mistake adjusting my settings for the next couple of nights?

[Image: 3JS4HRX.png]

I get these large clusters of widened wave forms every night with very deep expiratory dips that may lead to rattiness which for the most part is being corrected by the ASV and is reminiscent of this:

[Image: PQQnHAZ.png]

(Digressing) This is with CPAP at 9-13cm + EPR 3. I imagine this widening of the waveform with deeper exhales is common? I understand I’m struggling to inhale here, but why? Am I mouth breathing? Exhale pressure intolerance or something? Anyway, back to ASV.

[Image: OO80nN7.png]

5 EPAP/6-11 PS – Does this night look more stable? I did wake up pretty early into therapy and woke up 2-3 times this night.

[Image: Wv7Scf3.png]
[Image: 2Rj0qWC.png]

Hypopnea followed by 4 minutes of shallow breathing not picked up by the machine.

[Image: Vxb2AxI.png]

6/4-12 – In contrast to the first night I posted. Lots of narrowed breathing. Was definitely not a good night.

[Image: H4q0bb5.png]
[Image: nuBlYwc.png]

Events.

[Image: HvmAUoK.png]

Then this weirdness happens where the resp. rate shot up like never before. Lasted a good half an hour.

[Image: FW4jEW6.png]

Uh, enhance. What is this? I’ve never seen this before. Only with ASV on this night.
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RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
First week with ASV, cont’d

Sorry about the length.

[Image: 5m75oRR.png]

5/5-12 – Another fragmented night. I actually felt sick and dizzy today on top of the serious exhaustion. Got a headache the night before.

[Image: yjbwpN5.png]
[Image: i5fAyFJ.png]
[Image: KejfFw9.png]
[Image: UwynYNN.png]

Event cluster.

I’m pretty lucky and grateful for this experience with the ASV, however I’d describe this first week with the ASV as being quite painfully fatigued and very unproductive overall as I’ve remarked in my SH notes. I had one relatively good night that seemed promising that was contrasted by a bad night with the same pressure settings and also a string of terrible nights.

With the bilevel I managed to sleep for 6h30m before waking as I thought I was starting to dial the machine in. Fluke or not, it’s tempting to throw in the towel with the ASV and just get a bilevel from Supplier #2 to see if I can replicate that night again every night. However my problem is I’m still unsure if bilevel would cause enough centrals to be a problem as EPR at 3 already shoots my centrals up. I just don’t have enough data with the appropriate pressure settings. Of course the only way to know if I have complex apnea to get a sleep study done, right? But there’s no chance I’d be able to get a study done with a bilevel.

[Image: tsp2TjJ.png]

Second last night with the bilevel at EPAP/IPAP/PS 6/13/4.

[Image: XzDSfkP.png]

IDK how meaningful this is, but the highlighted centrals are ones that don’t directly follow from a arousal-like breaths.

I sort of just want to get a new machine, but I’m not sure what kind of machine to get or what to do right now. My brain is really fried right now. I guess I’ll try another week with the ASV.

One more thing, does it make any sense to do CBT-I right now meanwhile as I try to make ASV work?
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RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
Your new results are worse than ASV Day 1.

[Image: KcitmyR.jpg]

10:49:00-10:49:40
10:50:30-10:50:50
9:51:30-9:52:20

the ASV is maxing out at 12, but fail to cause deep breaths and then you wake up.
These look very obstructive. Even higher PSmax needed here? your machine can do up to 20.

ASV vs Bi-Level - actually the ASV changes PS very nicely, thus avoiding high PS when you don't need it. May eventually work better for you than Bi-Level.
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RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
I value your continued input, yrnkrn. Thank you. I went back to CPAP for a day since I've been wary about the odor coming from the ASV.
I wonder if I also need to increase my IPAP min since my breaths still look kind of flat and shallow compared to bilevel despite being at similar pressures for some reason:

[Image: qrpnG2n.png]

Two awakenings, very short and extremely DSPD night.

[Image: AckyS0Z.png]
[Image: Z4kllSc.png]
[Image: o95rYIJ.png]

I might have had one almost decent night with the ASV despite several brief awakenings but I've managed to sleep almost through an entire night with the bilevel on one occasion which I have incomplete data for stupidly, but alas the centrals. Maybe I'll just take a chance and drop the money on an ASV and hope for the best despite having insufficient evidence thus far that ASV would be right for me.
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