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Sanity check on next steps (still tired)
#41
RE: Sanity check on next steps (still tired)
Rather than talking about numbers right now. How do you feel? And please be critical. Adjustments now need to be about how you feel, not the numbers.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
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#42
RE: Sanity check on next steps (still tired)
(09-08-2020, 11:13 AM)Dormeo Wrote: I doubt whether an ASV is what you need.  It looks like your problem isn't the CAs themselves but the mini-arousals that set them off.  As to what causes them, that's always the million dollar question.  Given your relatively active flow limitation graph, I'd say the FLs might be part of the problem.  The pressure support/EPR that might help with the FLs might also increase your CAs, though.

Did you ever get a copy of your sleep report?  I'd be curious what gave rise to your initial diagnosis of UARS.

Please do also discuss with your doctor other kinds of medical problems that could be causing your daytime sleepiness/fatigue/tiredness.  It'd be good if she/he could screen you for some usual suspects.

I'm waiting for a copy of my sleep report. I had to mail in the request and wait for a copy to be mailed back, so I have no clue how long it will take. The moment I get it, I will be sure to post. Hopefully, it'll come today Smile

I'll read up about flow limitations and see if I can make some adjustments to deal with that. I was thinking about enabling EPR at the lowest value because I find breathing out (when I'm waiting to fall asleep) can be a little tough.

I'll be sure to raise the fatigue with the doctor. I have gone through a lot of testing in the past, which is why I take Modafinil. They just can't seem to figure out what's going on.

(09-08-2020, 11:13 AM)Bonjour Wrote: Rather than talking about numbers right now. How do you feel? And please be critical. Adjustments now need to be about how you feel, not the numbers.

I'm in the process of getting an adjustable bed because I've found that sleeping in a more upright position gives me better numbers. It doesn't make a huge difference in how I feel through the day, but I have no problem sleeping while sitting, so why not? I'm using a bunch of pillows right now, which can cause some back pain if I don't have them set up right.

Falling asleep
When I'm falling asleep, as mentioned above, I sometimes find that I'm fighting the machine to breathe out. Normally repositioning the mask a bit helps. The EPR/support also helped, but I disabled that a while back. 
  • I was thinking of turning it back on at the lowest setting to see if it made falling asleep easier. This doesn't lead to my being up for a lot longer, maybe just a few minutes.
  • I also thought about trying something like the breathe right strips, to help keep my nasal passages open, though I have no idea if that will make a difference.

During the night
I rarely remember waking up at night, so whatever causes me to wake up isn't so bad that I'm conscious. I don't wake up in the night to use the bathroom.

In the morning/after getting up
When I wake up in the morning I feel like I could go back to sleep for the day. It never feels like I've gotten enough sleep. Sometimes I'll have a bit of a headache, though I think that might be more a result of my chin strap being too tight (it's gotten better since I started using mouth tape and stopped using 2 straps).

Occasionally, I will wake up and not feel like going back to sleep immediately, but within half an hour I'm pretty tired. Without Modafinil, by the afternoon I have trouble concentrating because I'm so tired.

I'm not sure what else I can describe... That's really all I can think of, but I'm happy to share more if I think of anything.

I sleep with one chin strap, mouth tape, and a soft cervical collar. None of these seem to bother me, though I normally adjust the collar a bit so it's not too tight on my throat (I'm thinking of putting in a bit of wire to shape it better).


Thanks again!!
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#43
RE: Sanity check on next steps (still tired)
I received a copy of my sleep study! It's 13 pages, so I haven't posted the whole thing here, just 3 pages with overviews. If there's other info that you think would be helpful, I can post more; I just didn't want to post a bunch of unnecessary pictures.

Looks like I had a lot of RERA events. No centrals during the study... Do you think that means that it's the machine causing centrals?


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#44
RE: Sanity check on next steps (still tired)
The level of centrals is not that high, watch it for now, nothing more.
Your sleep study indicate that UARS is a possibility, high RERAs and Low OA.
The way to see if this needs to be chased is by evaluating how you feel, be honest but critical. UARS is an issue with flow limits, and to 'see' it in the charts means reviewing a detailed (2-3 min) view of the flow rate finding non-flagged flow limits and arrousals,
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Soft Cervical Collar
Mask Primer
Dealing with a DME
Organize Charts
Attaching Charts

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#45
RE: Sanity check on next steps (still tired)
(09-12-2020, 07:19 PM)bonjour Wrote: The level of centrals is not that high, watch it for now, nothing more.
Your sleep study indicate that UARS is a possibility, high RERAs and Low OA.  
The way to see if this needs to be chased is by evaluating how you feel, be honest but critical.  UARS is an issue with flow limits, and to 'see' it in the charts means reviewing a detailed (2-3 min) view of the flow rate finding non-flagged flow limits and arrousals,

Thanks Bonjour.

Regarding how I feel - tired. There's still lots of room for improvement. For example, last night I had an AHI of 3. I woke up this morning and wanted to head back to bed after 10 or 15 minutes. I took my medication, which helped, but by 1 I needed a coffee because I was falling asleep. By 8pm, I was napping. Today was a bit worse than usual, but that sums up my level of tiredness fairly well. Tired in the morning and by afternoon I need a coffee or else I'll get dozy.

Since Dormeo mentioned flow limits, I looked into this in my charts a little more. I did notice there are some times where they increase, but there aren't always events when they spike.

Could you please let me know what to look for to identify arousals (is there something in my charts?)? If it's better for me to read the wiki and search the forum, please let me know and I'll do just that.

I'll post some examples of flow limits tomorrow morning.

Thanks again for this. I'm trying not to get excited, but any time there's a new potential cause for my level of tiredness, I can't help but be a little hopeful.
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#46
RE: Sanity check on next steps (still tired)
The key is the Flow Rate. Normal breathing is smooth and consistent. This needs to be viewed so you can easily see the individual breaths. You are looking for that consistent breathing then inconsistent breathing.
Normal and abnormal breathing http://www.apneaboard.com/wiki/index.php...Limitation
RERAs http://www.apneaboard.com/wiki/index.php...8c57f0.png
Wake breathing vs sleep breathing http://www.apneaboard.com/wiki/index.php...b10ed3.png
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Soft Cervical Collar
Mask Primer
Dealing with a DME
Organize Charts
Attaching Charts

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#47
RE: Sanity check on next steps (still tired)
(09-12-2020, 10:34 PM)bonjour Wrote: The key is the Flow Rate.  Normal breathing is smooth and consistent.  This needs to be viewed so you can easily see the individual breaths.  You are looking for that consistent breathing then inconsistent breathing.
Normal and abnormal breathing  http://www.apneaboard.com/wiki/index.php...Limitation
RERAs http://www.apneaboard.com/wiki/index.php...8c57f0.png
Wake breathing vs sleep breathing http://www.apneaboard.com/wiki/index.php...b10ed3.png

This is great info. You are amazing.

I'll read this over and post what I find.

Thanks again!
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#48
RE: Sanity check on next steps (still tired)
Thank you again for this. I've gone through a few nights looking for flow limitations that are similar to the posts you referred me to above.

In the few nights I checked, the flow limitations don't appear to be as consistent as those shown here. They're more spikes that drop off. They seem to be relatively small, though the graph goes up to 40, which I'll have to change. Maybe I'm just very sensitive to changes in flow limit?

For the RERA events, I don't really see recovery breaths after the events. Not sure if that is indicative of anything.

For the wake vs sleep breathing - there's lots of spots where flow limits appear to be linked to wakeful breathing (all sorts of chaos on in the breathing, rather than the smoother more consistent sleep breathing).

I've posted a few examples. Please let me know if there's anything else I should send to clarify. I'll also poke around the forum for flow limit threads.

Thanks again!


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#49
RE: Sanity check on next steps (still tired)
Reading the forum is a good resource Smile

Before I made some changes to my setup, my flow limit was better, but AHI higher. I disabled ramp, increased the minimum pressure by 1, and turned off ramp. After doing so my AHI was reduced, but there were more flow limits. recently, I set EPR to 1; it seems like EPR off and EPR set to 1 has an insignificant impact on flow limit.

So, if I increase EPR, my AHI goes up, but my flow limit is better... Is this another matter of balancing between the two? In which case I'll set EPR to 2 and see how it goes? Or is increased flow limit linked to the higher minimum pressure?

I've attached a pre- and post-change OSCAR report.

Thanks again!


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#50
RE: Sanity check on next steps (still tired)
TSomm, I agree it's hard to see why a RERA was flagged. The other zoomed-in views show flow limitation, both where there are flags and where they aren't. The signs are at the top of the inspiration flow rate trace, where you see a dent, a peak, or a flattened trace. Not all FLs are on the radar of the ResMed algorithm.

You are right to ignore the FL instances where the breathing is clearly awake breathing. It tends to be pretty ragged-looking.

About the two charts. It's hard to infer a lot from just two nights; trends over multiple nights will give you a clearer picture. But if all I had to go on were these charts, I would say maybe you did better heading off obstructive apneas with the higher EPAP that you achieved by raising your minimum and turning off EPR. Compare the median of 8.4 to the median of 5.1.

Your CAI (central index, or average CAs per hour) was higher with EPR on, though it was almost 2 even with EPR off. This may well reflect choppy sleep, with CAs occurring when you are awake or half awake. (We pause our breathing much more when we're awake than when we're asleep.)

You reduced your FLs and your hypopneas with the EPR of 3. Those are the kinds of improvement that EPR can produce.

I'd like an expert to make recommendations about your pressure settings. I'm not sure whether you'll do better sticking with one of these settings for a few days or trying some tweaks now -- maybe a higher minimum and a reduction of EPR to 2? I don't feel competent to say.
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