Spetzal's therapy thread (Help needed with DreamStation BiPap)

[Sleeprider]

It only took one image to see the problem with session on 12/10, and the poor results do not reflect on the settings.

[spetzal]

As part of my learning curve, i need to understand how youre arriving at the conclusion, which im not disputing.

Let me take this one observation/screenshot at a time, and i will ask you (sleeprider) to comfirm or correct me.

1) looking at this screenshot of a period with no events…..im perceiving a more/less normal expiration flow but the inspiration flow has jagged peaks and also what im referring to as a “hiccup”/smaller peak about halfway between expiration trough and inspiration peak.  These peaks indicate the presence of positional/chin tucking….otherwise the inspiration flow would be more like a gentle rolling hill.

   

[Sleeprider]

Your inspiratory flow during this period where there is no apparent chin-tucking, has characteristic mild flow limitation which is described in this wiki article http://www.apneaboard.com/wiki/index.php...limitation You are achieving normal tidal volume in a normal inspiratory period, but there is some slowing of the inspiratory flow. This is not something we need to correct, but inspiratory flow might be further rounded by higher pressure support of a longer duration of IPAP pressure. We cannot tell from your chart what the mask pressure is doing, and whether the plateau or decline in peak flow is related to a drop in IPAP pressure or restriction in the airway.

Where flow limitation is more severe, we normally resolve flow limitation by using additional pressure support, however you have expressed concerns about using higher pressure or pressure support. Your inspiratory flow curve often shows a good strong initial flow increase to a sharp peak followed by a decrease in flow with no secondary or tertiary flow peaks. This suggests as you approach peak flow rate, your inspiratory effort rapidly diminishes and inspiratory flow declines until you expiration begins.  During chin-tucking, we would see much greater flow limitation as inspiratory flow is squashed by the obstruction. You can see an example of this looking at your 12/10/22 chart closeup at 20:10:30.

Some studies have attempted to classify flow limitation https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4688581/ and your flow is described as a Type 4 Flow Limitation where there is a peak during the initial phase followed by a plateau.  This suggests initial effective phasic upper airway dilation with a slowing of inspiratory flow. This is a borderline FL and may not interfere with normal respiratory volume or effort.



Table 1
Classes of inspiratory flow shapes.

Class Description Interpretation Flow limitation
1 Sinusoidal Normal inspiration No
2 Two peaks during inspiration Upper airway reopening after initial collapse Yes
3 Three or more (tiny) peaks Soft-tissue vibration during inspiration Yes
4 Peak during the initial phase followed by a plateau Initial opening indicates effective phasic upper airway dilation Yes/No
5 Peak at midinspiration with plateau on both sides Significance uncertain; intensive phasic muscle activity at midinspiration (?) Yes
6 Peak during late phase preceded by a plateau Marked tracheal traction support during lung inflation Yes
7 Plateau throughout inspiration Collapse of noncompliant upper airway Yes

[spetzal]

Sleeprider, that was an excellent and highly informative response!  Im at th gym right now getting less fat, and will respond more in a bit.

Goimg forward, i now understand that showing 02 and HR graphs on my screenshots are no longer necessary I think.  I did read the OSCAR guide about the 5 most typically relevant graphs to show in screenshots.  Due to my laptop’s physical screen size and resolution constraints, i can only show 4 graphs in a single screenshot.  From this point on, which 4 would you prioritize?  I can always swap out in a subsequence screenshot if needed.

[spetzal]

Sleeprider, while awaiting your response, I am posting a screenshot of 12/10 during a time with no events, and providing a different set of gaphs which I think might address some of the unknowns referenced in your post #43

Disregard the increased AHI ansd time period, as I went back to sleep later and uploaded the data.

[Sleeprider]

Graphs content is fine but replace respiration rate with leaks. Consider adding a dotted line at zero on the flow-rate. (right-click near y-axis for menu)

[spetzal]

Leak rate is graphed directly above resp rate

[Sleeprider]

Events, Flow, Pressure, Leaks.

[spetzal]

removed calendar, sorted graphs as you indicated, and added "zero" dotted line to flow rate and "max"/"min"" dotted lines to pressure

[spetzal]

With the recent acquirement of a heated tube, I decided to try the sleep study recommendation again of CPAP 13 w/CFlex 3 (but using soft collar)

Attached is screenshot of the night; ignore everything after 2 AM as I took the collar off and was just resting mostly awake

Observations:
1) had the collar on too tight; caused significant neck pain and headache; was subconciously aware much of the night/restless
2) I perceive that it was actually provoking some degree of OA
3) all this impacted the results to an unknown degree
4) With the heated tubing, that previously perceived "excessive pressure" causing severe sinus/ear pain is now not only tolerated but quite pleasant....had to do a little fiddling, as apparently its only such at a specific tube heating setting and humidity setting combo.  The Dreamstation doesnt allow tubing to be set at a particular temp, but rather 1 of 5 preset (exact degree unknown to me) temperatures.


Screenshot 1: night overview
Screenshot 2: time with no events

During no events, I THINK what Im seeing is an improved (not great, but improved) flow rate.  The plateau and peak on inspiration is less jagged/pronounced, and the expiration isnt quite so sharp in its drop.  The general flow is more rounded/rolling hills, compared to the night of 12/11 discussed in posts# 42 and 43.  Im also tolerating the CFlex this time around, but i do dislike how it seems to "anticipate" my inhale/exhale, as opposed to "respond" to it. (I read somewhere that ResMed EPR does the opposite?)  I perceive a somewhat insufficient support on exhale and Im not sure my inhale is sufficient.  Im understand what CFlex is, but I have no practical experience with it, or understand its full impact.

My preference is to avoid a sleep collar if feasible, and the sleep study from 4 months ago was done without one. 
I intend to try CPAP 13 again tonight, without a collar this time, and observe results.

Sleeprider (or whoever), do you have any observations/opinions?  especially on possibly changing (or eliminating) the CFlex setting?