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Therapy for LPR, OSA, and… UARS?
#11
RE: Therapy for LPR, OSA, and… UARS?
I think our standard time window if it's more or less defined as treatment emergent is 3 months PAP use. Some we'll know before then, especially telling is if there's CA on a diagnostic sleep study. In that scenario, CA are pre-existing and not treatment emergent. Sometimes these 2 types respond similarly to pressure swings or lack of them. We may attempt editing settings to see what happens on OSCAR and how you feel. Noting these result inputs then you need to decide if it had gotten good enough on therapy or if it's not responding. There's a 3rd CA type that's a catch-all, idiopathic.

I'd start this ASAP, make a notebook of symptoms and complaints regarding therapy in general and specific on CA. You'll want to present this to doc if in fact you need to get an ASV.
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#12
RE: Therapy for LPR, OSA, and… UARS?
Wow, noted. The idea of having even 23 centrals in a 5 hr night (last night's improved result) for three months is pretty scary to me. And I have a 60 day window to return the machine if it's wrong. This could prove to be an expensive year. But I need to get healthy, so I'll be patient -- I'm only 2 days in.

I had only a handful of centrals on my WatchPAT. I suppose it's possible that the obstructives were miscategorized, or, perhaps more likely, that the RDIs were central. I did get the raw WatchPAT data, perhaps there is some way I can figure that out.

I've done as you instructed and started a sleep journal for the time being!
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#13
RE: Therapy for LPR, OSA, and… UARS?
FWIW I'm fairly certain we can make a determination of how your CA are being treated or not before that 60 days expiries so you should be able to do something.
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#14
RE: Therapy for LPR, OSA, and… UARS?
Thanks Dave! It truly is such a relief to not be alone in this.
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#15
RE: Therapy for LPR, OSA, and… UARS?
Some fun oximetry observations.

1) I'm sure that this has been pointed out before, but look at the correlation between heart rate spikes, movement sensor spikes, and flow rate disruption between the O2 Ring and the Vauto! There's some latency between the O2 Ring and the Vauto, and who knows which is off-clock, but when zoomed out it really starts to line up.

2) Seeing the role of my heart in this run of 60 second+ CAs from the first night is quite interesting too. Which is to say, aside from the moments of labored breathing and hypopnea -- it's not doing much! I consistently have 30 bpm spikes through the night and this makes me think they aren't due to CA? Though they may be due to related events. Data is so cool. Someday we're gonna be able to pull up OSCAR and look at everything that's happening, and maybe even figure it out.


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#16
RE: Therapy for LPR, OSA, and… UARS?
You're welcome. Keep trying it so you have attempts at the therapy. Don't quit until it becomes unbearable. Probably you'll need to clue doc in soon that you're running into CA trouble. You may need to consider finding out if this doc will support treating CA or if there's CA blindness. If the latter you'll need a new doc.
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#17
RE: Therapy for LPR, OSA, and… UARS?
Quite a rough night last night. I woke up often and laid awake too long for the data to be legible. That being said, I think I made some real progress at tolerating the higher trigger setting! I'll be back with more charts soon.

In the meantime, there are two flow rate interpretation mysteries this beginner is trying to solve. 

1) What makes this 60 second (!!) OA from last night an OA? There doesn't seem to be any flow limitation or much waveform distortion as far as I can tell. Could it be it's a CA that's been mislabeled? 

2) On the other hand, with this cluster of CAs, we see that there is a mask leak with flow limitation, leading to increased tidal volume, followed by a ton of labored breathing before recovery. In terms of airway patency this seems worse than the OA? Or is it just that the mask leak leads to increased pressure which tips the apneic threshold and sends things spiralling out of control.


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#18
RE: Therapy for LPR, OSA, and… UARS?
i have a technical question for the experts. 

i'm still having a lot of trouble with centrals, though i am managing them somewhat with settings. some apneas are resistant to settings, however. i've learned that i nearly always have central apnea during sleep onset. i think this happens even without pap - however, pap makes it much worse. on normal settings, i will have clusters of 5-10 onset apneas, often with two sixty second plus events. however, with trigger on very high, i only have one 15s onset apnea - but that setting causes me intolerable throat pain. 

i suspect these are onset centrals that i've always had that the machine then worsens by sending them into a terrible apneic threshold loop. i say this because i observe that when Tv/Mv is higher before sleep onset, i have more and longer cascading apneas. 

i found this very interesting article about apneic threshold centrals (see figure 2 in it) 

https://physoc.onlinelibrary.wiley.com/d...004.028985

"Thus, hyperventilation per se protects against apnoea and ventilatory instability by requiring a larger additional transitory hyperventilation to reach the apnoeic threshold, whereas reduced drive and hypoventilation make one highly susceptible to apnoea, requiring only very small further transient ventilatory overshoots."

hyperventilation before sleep seems like a bad idea of course, but it suggested to me that quicker, shallower breathing before sleep could help my central events. in fact, it has -- by breathing less deeply before sleep, i've had one or two nights with NO onset centrals, though i'm still waking up so often and going back to sleep that some onsets are better than others.

this got me thinking that getting the VAuto to pace me so that i breathe at something close to what my median inspiratory max is during actual sleep breathing might in fact be a way to target therapy at eliminating onset centrals. so, for instance, just to look at one example of a bad onset cluster, the sleep that follows it has, without exception, inspiratory times between 1.32 and 1.50 s. if i set the inspiratory max at 1.52, i would be limited by that before sleep onset and thus my minute vent would theoretically be restricted to a point that it would be less likely to induce apneic threshold onset centrals.

is this crazy? is this safe? should i try it?


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#19
RE: Therapy for LPR, OSA, and… UARS?
There's quite a few parameters to tinker with on a VAuto.  That being said, if I were you, I wouldn't unless you understand what each parameter does.  I didn't find the clinician's manual all that obvious.  I still rely on members here to help me interpret the parameters.  Some parameters behaved opposite to what I expected.

For myself only, I changed TRIG to Very High.  This setting practically eliminated my CA's.  Many members recommended it to me.  I couldn't tolerate the Very High setting at first.  What helped me was to change CYCLE from Medium to Low.  In my case, I felt that the machine was cutting off inspiration, especially after an arousal.  I would wake up like I was slightly short of breath.  Can't say that the above settings will help you, but they helped me a lot.

Keep a log.  You can use OSCAR notes for this, or just a little notebook.  Write down all your settings and changes and note what happens.  If you have a particular distressing night remember that it could just be a bad night and NOT due to your setting.  At least for me, my apnea scores seem to be random.  So one good night, or one bad night really mean nothing.  Eventually you will find what settings work for you.  It's not a fast process, or at least it hasn't been for me.  Don't change more than one parameter setting at a time.  Otherwise you will not be able to figure out what setting did what.  Wait a week or ten days.  On average, did the change make it better?  Worse?  Believe me, it is real tempting to change a lot at once.  We all want to be better FAST.  Of course, you need to use common sense.  If last night was far and away the worst night in your life, it might be prudent to back off that last change you made.  But remember - it could have been a coincidence!  If you try it again and it's still horrible, congratulations, you have discovered what your body doesn't like.  If, however, it was the best sleep you ever had, it still could have been a coincidence. Sad That's why we repeat the experiment the next night, and the following night...

If you have specific questions on what a certain setting does, please ask us.  Read up on TRIG, CYC, Ti_min, & Ti_max.  For the most part you should be on the defaults.  Only change if required.  

FWIW, my first night on the VAuto (October 2020) I had CAI=6.29.  Now for the last two months, my average CAI=0.24.  So it is possible - if you don't have a CA problem - to adjust your VAuto to not induce CA's.  If you do have a real central apnea condition, the VAuto is not the correct machine to treat CA's, you need an ASV.
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#20
RE: Therapy for LPR, OSA, and… UARS?
Thanks for your thoughts happydreams. I read through your thread and learned a lot - the sections with Crimson Nape and TiControl were particularly illuminating. Very inspiring to hear that you stuck with it and are now getting such better results. 

I'm going to add changing CYCLE to Low to make TRIG High more tolerable to the potential toolkit. I do think my issue with TRIG High / Very High may be different from yours - it felt like I was being overventilated, and left my throat muscles very tight for all of the following day - even impacting my voice. In fact, when I first started on the default settings, one of my earliest subjective observations about the VAuto was that the breaths went on for too long. I weigh 135 pounds so it might just be down to the size of my lungs compared to whatever the default settings are calibrated for.

Great input about OSCAR notes. I didn't realize those were there. I've been keeping a log at Dave's suggestion, so will now make adding the entries to OSCAR part of the daily routine. 

I didn't get any concrete feedback about my idea to limit Ti_Max, so after testing it for comfort in the afternoon, last night I went ahead and did it. By the numbers, it worked. No onset centrals at all despite three separate sleep onsets. I had two long awakenings, so it was still kind of a miserable night, but that's been lately. I'm gonna try again tonight and then post the charts.
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