To all the good people on this forum [sleep issues and machine adj questions]

[A KLERK]

https://www.dropbox.com/l/AABSVmvUlK9lS3...VVWvMlQdpQ

[sleepyzzz]

i'm 6 foot 209 lbs. and i see what you are saying , according to the charts i should be around 600. 
i'm also setting the trigger very high for the PS 7 compared to the PS 3 and 4

Ask you doctor, but I would guess you need enough PS to give a good tidal volume and minute vent. I have a variable machine, sometimes I need a higher PS, up to PS18 (sleepyhead internal chart data, maxes out at just under 25 pressure, so you need to look at mask pressure to see the 30cm)
The trigger is the adjustment on the amount of air flow it takes to cycle the machine to inspiration. It shouldn't matter a lot what PS you would use. You don't want it too sensitive that it self triggers, not too coarse that it feels like you have to suck to get it to trigger. I would make sure the Ti and trigger are back in the suitable settings and go from there. I don't think your machine has rise time and cycle settings?
The resmed titration guide gives some good info, 
https://www.resmed.com/us/dam/documents/...er_eng.pdf

ajack, A.Klerk is gathering the SD card data. Please feel free to upload your SD card to this Dropbox. https://www.dropbox.com/l/AABSVmvUlK9lS3...VVWvMlQdpQ  The advanced machines are in need of some work as evidenced by the machine information below the AHI in your graph.

Thank you all for the replies, i been studying some more and trying to analyze my data from all the nights of restless sleep.
Heare the findings i got, with attached screenshots to correct me. Also to advice what titration i should do.

Findings:
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1- i have a REM predominant apnea, that matches the flow limit intervals of 90mns- 2 hrs. IT matches my sleep study(first page) saying my REM apnea is 42/hr while my NREm+REM is 17/hr.
2- my apnea is worse supine, so i try to sleep on my side.
3- I was thinking i was waking up with RERAs each time i dream, but probably, the OSA is too high for my pressure to handle, so the airflow limit is not 100%, but maybe less than 50% and that is why i get RERAs and have a fragmented sleep of 2-3 hours that become shorter and more intense after 5 am.
4- i tried following the advice of setting a narrow range with constant pressure, it did not resolve RERM apnea. ( see graphs 1 - 8).
5- i tried letting the machine handle it and i am still unsuccessful to find the right settings ( see graphs 9-11). Based on these, i would like to ask you :
    Should i increase EPAP or PS ? it seems that my 95% EPAP is from 5.7 to 6.7 but i do not know is that because the machine is trying to increase IPAP and because the PS is constant      it is raising the EPAP instead ? you can see in my graphs (5 - 9) in increased the PS, while mainting EPAP constant, and it did not resolve REM apnea or RERAs.

Questions:
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1- Based on my data, do i increase EPAP ( like to 6), leave PS at 4 ( or less) and leave IPAP to max 15 ?
2- Do i increase both EPAP and PS ? and leave the machine on auto for max IPAP ?
3- I have read the higher PS could cause RERAs( not just CAs) that is why it is advised to lower EPR in APAP to 1, but in the titration proptocol for bilevel, it was said to start with PS of 

Notes:
--------
1- I started using neck collar ( in the last graph) do not see /feel a difference.
2- i can not tolerate high pressure, i get aerophagia ( higher than 12-13 IPAP).
3- I went to yet another  sleep doctor and he will do a DISE ( drug induced sleep endoscopy) to see what is really happening when i sleep. i have found an interesting doctor note on interpreting the results of DISE in choosing the type of therapy and would like your opinion, i will share my DISE results later when i get them:

Dr. Michael Schedler : "First assess history of patient. If he/she complaints about SPBA (supine position based apnea) i.e. cannot ly on back and breath normally, feeling a choking sensation, when lying supine, sometimes impossibility to find sleep in supine position.

Then, please perform somnoscopy in Propofol induced sleep with and without NCPAP and look if you note an aSGO (adult supraglottic obstruction, abstract: schedler, supraglottic obstruction) regarding base of tongue and/or epiglottis. In case of aSGO avoid APAP, since the ventilationpressure will steadily increase with rising upper airway resistance. Settle then for a lower range Bilevel therapy, which can be titrated in Propofol sleep, sneaking a thin endoscope under the mask, while setting the pressure level so that no obstruction (e.g. bending down epiglottis by airflow) is induced. Or refer to airway surgeon, who can address the problem surgically. I have personally performed about 520 laser epiglottis partial resections (EPR), close to 300 HPPs (Hyoidpharyngoplasty) and 3 Supraglottoplasties; simultaneous Laser EPR/HPP procedure".


4- The doctor told me to try an oral device if i am not getting the sleep quality from the machine, but i read here that many people had adverse effects from oral device because it messes up with your bite, so i want to give the Bilevel another chance, that is why i am posting here to get your opinion how can i get rid of the REM apneas.

Thank you.

Graphs:
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Graph 1: (EPAP 4, PS 1, IPAP 5), sleep quality : poor


Graph 2: (EPAP 4, PS 3, IPAP 7), sleep quality : poor - medium


Graph 3 : (EPAP 4, PS 4, IPAP 8) : sleep quality : poor - medium


Graph 4: (EPAP 4.4, PS 4.2, maxIPAP 8.6) , sleep quality : poor - medium


Graph 5: ( EPAP 4, PS 5, IPAP max 9), sleep quality : poor - medium


GRAPH 6: (EPAP 4, PS 6, IPAP 10) sleep quality : poor - medium


GRAPH 7: (EPAP 4, PS 7, IPAP 11): , sleep quality : poor - medium


GRAPH 8: (EPAP 6, PS 6, IPAP 12) , sleep quality : poor - medium


GRAPH 9: (EPAP 4.6, PS 7.2, IPAP 15 ) , sleep quality : medium .     Note using high or v high trigger would eliminate all these CAs :


GRAPH 10(EPAP 5, PS 4, IPAP 15) , sleep quailty : medium


GRAPH 11 (EPAP 4, PS 4, IPAP 15) , sleep quality : poor to medium

[sleepyzzz]

?? anyone

[Gideon]

The difference between 7 and 7.2 is remarkable, so much so that I question the results (AHI 4.69) with all the CA recorded as suspecting another cause than the increase of .2 in PS.

Otherwise, your numbers are good across all the tests and I do not see any significant amount of apnea.

[Sleeprider]

I think this is just a case of data overload. You have a lot of variables and charts here, and very little objective difference between the results. Leaks seem to be a bigger contributor to variations than pressure. If anything, you proved that your PS threshold is 7.2 to increase CA. If I did the same experiment I'd probably have an AHI of 10 or more. You have very good results (where have I heard that?) and tolerate a wide variety of settings. It's really up to you to choose what works best. We can help interpret the individual graphs, but I go back to my first sentence...data overload.

[sleepyzzz]

The difference between 7 and 7.2 is remarkable, so much so that I question the results (AHI 4.69) with all the CA recorded as suspecting another cause than the increase of .2 in PS.

Otherwise, your numbers are good across all the tests and I do not see any significant amount of apnea.

I think this is just a case of data overload. You have a lot of variables and charts here, and very little objective difference between the results.  Leaks seem to be a bigger contributor to variations than pressure. If anything, you proved that your PS threshold is 7.2 to increase CA. If I did the same experiment I'd probably have an AHI of 10 or more.  You have very good results (where have I heard that?) and tolerate a wide variety of settings.  It's really up to you to choose what works best.  We can help interpret the individual graphs, but I go back to my first sentence...data overload.

Thanks for your replies. I was trying because i was not sleeping well, and the fragmented sleep was killing my day even though you see low AHI. I am sorry i posted so many graphs but wanted to give you as much data as seemed reasonable.

The good news it seems leaving IPAP max open and increasing the EPAP as in attached below, is helping me staying asleep longer.

My question is i already tried EPAP 6.8, PS 4 as you see, should i keep increasing EPAP till i eliminate flow limits/snores or PS ? what do you suggest my dial numbers be ?

[ajack]

Well if you want to try BPAP to get decent air flow, without an op or a mouth piece. You will need to increase the PS, difference between epap and ipap. I'd keep the min epap on 6.8 for now and increase the PS 1cm at a time and see the results. You currently have a median tidal volume of 400 and the chart you looked at is 600 for your height. I would have a goal of 500 for a start. Your 95% was 600 and max was 1,080. So 500 is well within your limits. I would still put it past your doctor what you are doing. If you find you get aerophagia still and it doesn't settle down. It does for a lot of people. It's back to the doctor.

This titration guide gives a good overview.
https://www.resmed.com/us/dam/documents/...er_eng.pdf

[Sleeprider]

I think in theory, what ajack suggests is right. He is targeting tidal volume, but with a respiratory rate of 16 bpm and minute vent of 6.9, I'm not too concerned. I also don't agree it is necessary or desirable to eliminate all PS and snores from the charts. If anything, you are titrating for comfort. I think a more gradual increase in PS, while tracking how you feel might be the best approach. It's the same idea as outlined by ajack, but a slower and more observant approach based on how you feel rather than a tidal volume objective.

[sleepyzzz]

Well if you want to try BPAP to get decent air flow, without an op or a mouth piece. You will need to increase the PS, difference between epap and ipap. I'd keep the min epap on 6.8 for now and increase the PS 1cm at a time and see the results. You currently have a median tidal volume of 400 and the chart you looked at is 600 for your height. I would have a goal of 500 for a start. Your 95% was 600 and max was 1,080. So 500 is well within your limits. I would still put it past your doctor what you are doing. If you find you get aerophagia still and it doesn't settle down. It does for a lot of people. It's back to the doctor.

This titration guide gives a good overview.
https://www.resmed.com/us/dam/documents/...er_eng.pdf

I think in theory, what ajack suggests is right. He is targeting tidal volume, but with a respiratory rate of 16 bpm and minute vent of 6.9, I'm not too concerned. I also don't agree it is necessary or desirable to eliminate all PS and snores from the charts. If anything, you are titrating for comfort.   I think a more gradual increase in PS, while tracking how you feel might be the best approach.  It's the same idea as outlined by ajack, but a slower and more observant approach based on how you feel rather than a tidal volume objective.

thank you both. I was thinking to go to EPAP of 7.6 maybe before stopping and trying to increase PS. But you are advising to not increase EPAP no more and try to increase PS in small fractions and see how i feel, right ?


N.B: this is last night with same numbers unchanged. i did wake up around 4 times that i remember, but like i said lot less than with epap of 4 and IPAP of 8.