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Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
#51
RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
Arousal with recovery breaths followed by CAs is perfectly normal, the CO2 is flushed out of the lungs and you have no need to breath for a bit. 
In such situation, the question is the reason for arousal - if it's not respiratory related no air pressure machine is going to fix it.
If you're going to spend money, a competitive titarion (obviously not with your current stuff) could give you pretty good answers as to why you wake up and what should be done about it.
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#52
RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
Hi sleeplover69,

I’ve been reading your thread. Hang in there.

I agree with Sleeprider that only an ASV would be able to treat both your obstructive events (including UARS) and your central events.  It would also be able to increase your median Tidal Volume (which I think is too low for a 73” tall man).

You may be able to find a general practitioner doctor who would be willing to prescribe for you an ASV machine (because I think GPs tend to be more open minded), but even then you might have to buy it out of pocket, with no help from health insurance.

A regular bilevel machine would be able to provide higher EPR (Pressure Support) to treat your UARS and low Tidal Volume, but probably at the cost of terribly increasing the severity of your Central Apneas. Regular (non-ASV) bilevel machines are notorious for making CAs worse.  Only a machine with a “backup respiration rate” such as an ASV machine can treat both Obstructive events and Central events.

The Philips-Respironics ASV is more adjustable and (UNLIKE ResMed) also can approximate an Auto CPAP or an Auto Bilevel machine.  I think the Max Pressure Support setting can be set as small as desired on Philips-Respironics ASV machines, unlike ResMed ASV machines which require the Max PS be set at least 5 higher than the Min PS setting.  ResMed ASV machines offer only two or three therapy modes: (1) a super-dumb CPAP mode without EPR and (shamelessly!) without CA detection, (2) an ASV mode with fixed EPAP, and (3) an ASV mode with auto-adjusting EPAP on ResMed Model 36037 and later.  All ASV machines have fast (breath by breath) auto-adjusting PS. 

However, compared to Philips-Respironics, I think the ResMed inhalation waveform is smoother.  Some have no difficulty adjusting to P-R machines, but a few are not able to get used to the somewhat on-off choppiness of P-R bilevel machines.

If you are getting a used machine on your own dime, I think it would be helpful to be able to use same power supply unit, humidifier, heater hose and filters as the S9 Autoset unit you already have.

Take care,
—Vaughn
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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#53
RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
Last night was worse with multiple brief awakenings. I'm slacking with the sleep hygiene, too, I'm sorry. I had a stimulant-induced headache, though. I should set a timer to remind myself to shut off the computer at night. I'm pretty damn exhausted.

Thank you so much for your help and support, vsheline. I appreciate the breakdown between the different brands of ASV. So I've gathered that Resmed is more foolproof, like Apple vs PC. EPR 3 improved the median tidal volume slightly, but yeah, it is quite low. I do see a slight decrease in 95% resp rate. The PS issue with Resmed is worrying and you can't use it like an auto-bilevel.
 
Given last night's numbers, CAs don't seem to be much of a problem for this therapy session. Out of 14 CAs, only 5 of them were not pre-empted by recovery breaths and these 5 lasted only around 12 seconds. The rest all seemed to follow recovery breaths, with the longest lasting 23 seconds, but they lasted on average around 15 seconds.There was a tiny bit of burping.

[Image: PKjipM9.png]

[Image: OfyvuhD.png]


Same old arousals with or without CAs

[Image: Yi8Xrvp.png]

Without

[Image: G8Fj84d.png]

If my tidal volume is low, my respiratory rate is likely too high. I seem to get these bonus breaths out of nowhere each night. Normal, right?

yrnkrn, do you mean if I'm able to get a new titration study at a different clinic, I should use their machines, not mine?

I'm going to see what the supplier can do about my situation on Monday in terms of trying out different machines.
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#54
RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
Is there anyway you can try a bilevel without committing to purchase? I can see now that the CA events are not likely typical central events, bur arise out of sleep disturbance. I think you need to try bilevel at 9/5 and 10/5 (IPAP/EPAP) to see if it can resolve your flow limitation and keep you sleeping without these disturbances. Those two settings are PS 4 and PS 5, and should make a big difference for you provided it does not trigger CA.
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#55
RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
[quote pid='262232' dateline='1528654987']
yrnkrn, do you mean if I'm able to get a new titration study at a different clinic, I should use their machines, not mine?

[/quote]

Cpap/bilevel titration in a competent sleep lab you will get quite reliable answers you can't get from the cpap/bilevel flow data only. Such as if you're waking up due to respiratory effort (RERA) or due to PLMS or unrelated, if you have real CA etc.

If you don't know any reliable sleep lab or just don't like the experience (most people don't...) it makes sense to trial bilevel as Sleeprider suggested and see if it works for you.
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#56
RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
I should have looked at my CAs more thoroughly. For the night before last night, there were a total of 22 CAs and only 10 of them were unprompted by a sleep disturbance, though they were a bit longer with one lasting up to 23 seconds. Looking back at my last few days with 8-12cm + EPR 3, there aren't enough CAs happening on their own to think that I would require an ASV as far as centrals are concerned. I think you guys are right to think that I should try a bilevel first to see how it goes. Only problem as always is access to one before committing out of pocket.

I'm returning the For Her to the supplier tomorrow and I'll ask to try a bilevel. Not confident they'll have one to try though.
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#57
RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
I don't know why I got sidetracked on ASV, but I think a bilevel will smooth out your airflow and most likely prove to be a very good solution. You're using EPR at 3 and doing acceptably, better than before you had the pressure support. I think somewhere between 4 and 5 PS using a bilevel we're going to nail this flow limit and you will finally get some good sleep. Let's start thinking positive here. So Imetimes I look at so many different people's therapy, I lose track o the history. I did go back to check early results in this thread, and this pattern has been around a while and not gotten worse.
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#58
RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
(06-10-2018, 04:18 PM)Sleeprider Wrote: I don't know why I got sidetracked on ASV, but I think a bilevel will smooth out your airflow and most likely prove to be a very good solution.  You're using EPR at 3 and doing acceptably, better than before you had the pressure support.  I think somewhere between 4 and 5 PS using a bilevel we're going to nail this flow limit and you will finally get some good sleep.  Let's start thinking positive here.  So Imetimes I look at so many different people's therapy, I lose track o the history.  I did go back to check early results in this thread, and this pattern has been around a while and not gotten worse.

Well, it's also me being too tired and sloppy with not taking the time to find patterns surrounding the centrals. Then again, CAs may start creeping up for me with a bilevel as I've learned they're notorious for that. I hope I can try one to find out if that's the case. You and other folks here sacrifice hundreds of hours of your own free time to be literally volunteer life savers. Who can fault you for that. You people are heroes. The kindness and selflessness I've seen here is overwhelming. Thank you.

From what I've seen, UARS, if I have it, can be a real beast to tame, but I try to be optimistic and can't wait to try a bilevel or an ASV still if I can. I was able to get much more exercise in today despite even less sleep, so hopefully that counts for something. I did start to get dizzy again though when I exert myself. I better go see a doctor about it.
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#59
RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
Last night was much worse even with shutting down the computer and sitting in the dark two hours before going to bed much earlier. I had multiple awakenings throughout the whole night and a prolonged awakening at 4-5 hours. Hopefully it was partly to do with sleeping much later the previous days.

OTOH, I finally managed to get a hold of an AirCurve 10 VAuto to try out, but only for a week.

Whats a good starting point for pressure settings and are there other settings to tweak as well? I'm thinking of trying 5/10/5 EPAP/IPAP/PS, but my supplier wrote down suggested settings of 8/16/4 EPAP/IPAP/PS so I'm confused by those numbers. I am outside right now so I'll have to go home tonight to double check if I'm remembering correctly.
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#60
RE: Please help! 4+ years fragmented sleep and insomnia – Extremely Desperate
Your proposed settings of 10/5 at PS 5 is essentially fixed pressure (EPAPmax/IPAPmin at PS). Your doctor is suggesting 16/8 at PS 4. I think I would split the difference and try 14/5 at PS 5, assuming a Resmed Vauto. I would not hesitate to move to adjust settings as indicated by the results. You tend not to be affected by obstructive events, so a lower PS makes more sense. The idea of using pressure support to overcome flow limitations points to the higher PS. If it's too much, it's very easy to back off. I would be very surprised to see the pressure increase a lotj, but this covers the range of what has worked for you so far.
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