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[Pressure] Struggling with pressure optimization, please help
#11
RE: Struggling with pressure optimization, please help
Hello everybody,

I am back here with an update with Boujour's pressure recommendation.

Wow, what a difference in the flow limitation graph!!  I think we are heading in the right direction.  With a little more tweaking, that line should slowly disappear.

All the numbers and the graphs look good, but more importantly is, how do I feel?
I can honestly say that I can feel a difference from how I've been feeling and how I feel today.  Before last night, I use to feel really fatigued and not a lot of energy because even though I was logging 7-8 hours of sleep, it was poor sleep quality.  I had been feeling like I was drunk tired, my mind and concentration wasn't focused, my vision was blurred, I felt light headed a lot of the times, and strangely my hearing was also affected.

I know it's only been one night and things aren't completely perfect, but things seem to be looking up.  A lot of the effects that I was feeling from pressures that were not optimized are starting to subside.  Today, I felt like I had control of my mind and body again.  I'm starting to feel good again.

Thank you so much Bonjour.  
What would you suggest should be the next min pressure kind sir?

And thank you again to everyone who has commented on my thread, I really feel the support.


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#12
RE: Struggling with pressure optimization, please help
Yougotatoyo I will just say your first post showed us your main problem is likely and upper airway restriction that results in severe flow limitations.  While your AHI is acceptable, you are experiencing many arousals as a result of flow limitations which results in respiratory event related arousals (RERA) .  This is illustred in the flat-topped inspiratory curves in this close-up you provided.  The solution is discussed in our wiki for UARS and the use of bilevel. http://www.apneaboard.com/wiki/index.php...ome_(UARS) So I strongly agree with the direction Bonjour is going here. Another possibility is that you are having positional occlusion of your airway that results in these flow limits. A soft cervical collar might eliminate the resistance better than bilevel pressure. The reason for this conclusion is the relatively infrequent clustering of the flow limits is typical of someone that tucks their chin and has apnea. In our case, it only results in partial obstruction.

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#13
RE: Struggling with pressure optimization, please help
OK IMHO VERY good progress.

The next step is min pressure 16, but I want at least 2 more nights with 15 min, a week would be better.  We are getting close to where you had issues with Aerophagia.  I want your body to get used to this pressure.  Per your note you are feeling better and that is awesome.  I think your aerophagia will be better if we take it real slow.  
Once a week bump min up 1 cmw.  so 16 cmw next week.  Do keep track of your perceptions of how you feel and react to the changes.
If you have Aerophagia, drop min pressure during the night by 2 cmw.  That is to restore comfort.  We can slowly work it back up by .4 cmw per week, again to give your body time to adjust to the pressure.

On higher pressures, they are a way to justify a BiLevel.

PR Titration protocol
If Patient cannot tolerate pressure increase or if pressure threshold of 15* cm H2O is reached, switch to BiPAP S protocol
* Based on AASM titration protocol criteria.

ResMed Titration Protocol
Consider using bilevel when:
Patient is not tolerating high pressure settings(1):
- Pulling at mask
- Experiencing arousals or microarousals
- Can’t progress to REM sleep cycle
- Feels bloated or has a sensation of swallowing air
- Saying pressure is too high
- States it’s difficult to exhale despite EPR feature
Events persist at 15 cm H2O(2)
• Women may need to be switched at a lower pressure due
to their increased pressure sensitivity
• Patient has history of ventilatory insufficiency such as
chronic obstructive pulmonary disease (COPD), restrictive
lung disease, or obesity hypoventilation syndrome (OHS)(1)
More than 3 cm H2O is required between IPAP and EPAP.

(1) Gay P, Weaver T,Loube D, Iber C. Evaluation of positive airway pressure treatment for sleep related breathing in disorders in adults. Sleep 2006;29(3):381-401.
(2) Kushida CA, Chediak A, Berry RB, Brown LK, Gozal D, Iber C, Parthasarathy S, Quan SF, Rowley JA. Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. J Clin Sleep Med
2008;4(2):157-171.
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#14
RE: Struggling with pressure optimization, please help
Sleeprider- 

Wow, I clicked your link to UARS and the clinical presentation symptoms basically represents me to a T.
I never really understood why I was having a lot of random flow limitations without apnea and hypopnea flags.  Thank you for educating me on this matter.

I should also add something that may be the cause of my UARS.  When I went to the hospital last year, the doctor noticed that I had unusually large tonsils.  Logically, I thought that this was an issue as to why my prescribed pressures weren't sufficient.  I brought this up with my family doctor and asked him if I should get my tonsils removed and he replied that they aren't a problem and I don't need to do that.  

Will my tonsils be an issue if I was to try and use a soft cervical collar?

Should I start considering on getting a VAuto?

Bonjour-

Thank you, I will stick with the game plan and let the pressures settle in for awhile.

What are also your thought with the questions that I have asked sleeprider?
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#15
RE: Struggling with pressure optimization, please help
The collar is to be loose fitting so your tonsils should not be a factor.

To remove or not?  Sorry, no expertize there.  They may or may not be an airway restriction.  I was of the generation where tonsils were removed as a precautionary action.
If you have questions, find an ENT that specializes in the airway.  I could recommend a really good one in the metro Detroit area.

On the subject of a VAuto, We are building evidence to support that decision.
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#16
RE: Struggling with pressure optimization, please help
I will consider looking into getting a collar, it wouldn't hurt to try one out.

I do recall now, when I brought up the topic about my tonsils with my family doctor, I also asked him if I should see an ENT, he said it wasn't necessary because my tonsils weren't bothering me yet.  Maybe I should just go find an ENT anyways and see what they think.

Wow, VAuto is not cheap.

Night 2 @ min15 max 20

Last night's chart looks really good again.
The only thing that jumps out at me from May 31 compared to May 30, is the Insp. Time, Exp. Time, and Tidal Volume.  
The Med times are closer, and the 95% has insp. time longer than exp. time, and tidal volume has decreased a bit.
Is this normal or this situation a one off?
What is up with the 2 flagged OA also?  My pressure was cruising and all of the sudden 2 flags, are those 2 flags possible SWJ?

I also noticed that my friend, Aerophagia, was starting to come visit me.  It was only a little bit and maybe it's due to the big min pressure change from 6 to 15.  My body is probably just trying to adjust to it's new norm.

Other than that, I feel pretty good.  Close to same as yesterday, but still early in the game.  I will let things settle in for a couple days and will come back with an update unless the train comes off the track.

Thanks guys


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#17
RE: Struggling with pressure optimization, please help
Don't increase pressure if you have a twinge of aerophagia.
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#18
RE: Struggling with pressure optimization, please help
Hey guys,

I am back with an update from the last couple of days.

As you can see, AHI is very low, charts are clean, flow limitation has decreased a lot since starting min 15 max 20.
The only thing that is concerning me about the numbers is my insp. time and exp. time. I've noticed that the times are really close and I do recall that there is an I:E Ratio calculation where Insp. time divided by Exp. time, what is a normal or acceptable ratio?

As far as how I'm feeling, it's been alright but I've been feeling a lot of brain freeze lately.  My eye sockets and the space between my brows feels numb and tight.  I'm not sure if this is CPAP related or something external.  Maybe I still need more time to adjust, it's only been a week.

In my last post, I mentioned that I was feeling a little aerophagia.  I believe it was just a one off night, have not felt anything since, so that is a good sign.  Bonjour I know you suggested trying min 16 earlier in my thread, I will slowly increase my min pressure to 15.4 tonight and see how that goes.

Please take a look at my charts and give me you thoughts and if anything really stands out.


Any feedback would always be appreciated
Thanks


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#19
RE: Struggling with pressure optimization, please help
No problem taking it slow.  As you noted your numbers are great.  Keep track of how you are feeling as that will ultimately have a lot to do with your final settings.

I'll let SleepRider comment on your balanced breathing.  I don't believe it is an issue.
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#20
RE: Struggling with pressure optimization, please help
try using titration mode turned on. try min 5, mean 7 max 12
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