[Treatment] May be Too Late for Me Too

[Tubaman]

Just a question, or two...
Should I be concerned?  The CSR indicators keep popping up lately.  I've (finally!) ordered a cervical collar support but I won't get it for a few more days (maybe by next week).  I've tried to stuff a pillow under my chin but I flail around too much while sleeping for that to be effective (I even knocked my CPAP machine on the floor once).  I've read several entries that address the repeated OA groups which appear to be very similar to what I sometimes see on my charts.  I've included a few more charts from last night which hopefully supply the information you need.

The CSR indication scares me.  My 'Sleep Doctor' recommends I consult a lung doctor.  Since my %SpO2 charts are still pretty much the same as they've been since late 2016 (I run them almost every night and have accumulated over 900 %SpO2 charts), I don't think my lungs have changed.  But then, I'm only a 'lay person' and the doctors tend to brush off my opinions.

If I've forgotten something, please let me know...?
Thank you!

[Sleeprider]

Not a chance, and by the way, your results are looking very good for an Airsense 10 CPAP. When it's renewal time, lets talk about bilevel for you and see if that tidal volume might not improve as well.

It's much more useful to look at the waveform in a much closer zoom to assess CSR vs periodic breathing, but yours is PB, especially since everything is pointing to obstructive apnea here. CSR is a phenomenon of central apnea, usually associated with heart failure. Periodic breathing like yours is any oscillation of flow, usually around obstruction or hypopnea with recovery breathing (a sharp increase in flow) marking the end. CSR is a very even and gradual oscillation with a central apnea at the low-flow point, but other types of events may be present due to respiratory "stacking".  It is also prevalent throughout the night and associated with much higher AHI. Here is an example.

[Tubaman]

Thank you SleepRider!
The information you posted was very informative and makes me feel much better (maybe I won't die from heart failure in the next few weeks after all!).  I am very paranoid when something changes in my results (increase in AHI, CSR, etc.) and easily become alarmed (as you probably noticed).

You mentioned bilevel CPAP machine "When it's renewal time".  What do you mean by "renewal time"?  How do I convince the medical people I need a bilevel CPAP machine (which probably is more expensive)?  They don't listen to me, even though I have accumulated all these records.  They have had me in for sleep tests which never go well because of my messed up sleep schedule (I don't go to bed until 0500 +/- 1 or 2 hours) and I sleep until 1300 +/- 1 or 2 hours.  Ergo, they don't get much, if any, sleep data (their sleep technician usually goes home @ 0800 and I've only been sleeping for 2 or 3 hours, if that).  Their sleeping pills don't help.

I've had my Airsense 10 since June 2016, however, it was subsequently replaced under warranty when the memory chip socket broke (I was removing and re-inserting the memory chip too often, I guess -- at least that's what I was told at the time).  I subsequently added an extension cable so I now insert the cable once into the CPAP machine and then remove / insert the chip into the cable socket.  I check my chip data daily on my computer.  The cable works fine and seems to be enduring much better than the Airsense's chip socket (plus it's much less expensive it it breaks).  Too bad I can't access my Airsense 10 directly with my computer (Bluetooth, for example) instead of removing / inserting the memory chip.

Thank you again!  I might even sleep a little better tonight.
Tubaman (Carl)

[Gideon]

Too bad I can't access my Airsense 10 directly with my computer (Bluetooth, for example) instead of removing / inserting the memory chip.

You can.  Many users us a WIFI enabled SD card to autimagically download their data.

read this thread http://www.apneaboard.com/forums/Thread-...Rest-of-Us

Fred

[Sleeprider]

Carl, your results are excellent on the CPAP with EPR at 3, but your tidal volume is on the low side at 340 mL, minute vent is excellent at 7.88 L/min, but it is taking you an average of 23 breaths per minute to get there. So shallow rapid breathing may be perfectly normal for you, or you might benefit from the deeper breathing that more pressure support could offer. I don't know, and it's mostly a matter of comfort. I took a quick look back in this thread, and nothing has changed since I made post #4 http://www.apneaboard.com/forums/Thread-...#pid169164

It will not be easy to convince your doctor or insurance that it is medically necessary, because it probably isn't. I just thought I'd put it out there and don't want you to worry about it because it appears to be normal for you. It looks like you may be a couple years out from replacement anyway.

[Tubaman]

Mr. SleepRider:
I reviewed my tidal volume values from when I started CPAP up until present.  My lowest was 320 and my highest was 400.  Most of the values were between 340 to 380.  I did not calculate a mean or average but I would estimate my average about 350 to 360.  I suppose that means I have a naturally low tidal volume with corresponding shallow breathing.

I have oxygen assist currently that I've set @ 3.8 L.  I had it higher (over 4 L) but recently turned it back to 3.8 L.  I use my pulse oximeter almost every night which usually gives me a basil %SpO2 level of 93% to 94%, not great for a young person, but (hopefully) OK for me.  Before I convinced my sleep doctor to add oxygen support, I was getting up to 400 minutes below 88% and frequently at least 200 minutes below 88%.  I finally got them to let me use one of their %SpO2 pulse oximeters overnight (at home) to convince them that low AHI levels did not equate to adequate %SpO2 levels.  Incidentally, I mounted my own pulse oximeter on another finger the same night; their meter got over 300 minutes below 88% where my meter got over 200 minutes below 88%.  Ergo, I got oxygen assist immediately.

A thought occurred to me:  If I had a higher tidal volume, I might not need so much supplemental oxygen.  That might be a good argument to use with my sleep doctor.  It probably would not work but it might be worth a try.  Whenever I've tried deeper breathing while monitoring my %SpO2 levels with my pulse oximeter, I usually get higher %SpO2 levels.  Unfortunately, I cannot make myself breath deeper while sleeping but if I could, maybe the supplemental oxygen support could be eliminated.  Knowing my sleep doctor, I don't have much confidence in this ever happening.

My wife is suggesting I check in with a different medical clinic -> sleep center.  I have lots of data (of my own) that I could bring with me, plus some from my current sleep center.  The trouble is, the professionals (in general) won't accept data generated by lay people so I might just be going from the 'frying pan into the fire', so to speak.  Accomplishing nothing but aggravation for everybody.

Oh well, off my soap box.  Sorry to have bothered you with my moaning and groaning.  I did order a Wi-Fi enabled SD chip (comes from Japan).  Should have by early February.  My cervical collar should arrive by Friday.

Thank you for all the help you have given me!  I get virtually nothing useful from my medical people, even when I ask.  I guess they cannot be bothered with the mundane concerns of their patients.
Carl

[Sleeprider]

There is a clear therapeutic application for bilevel positive pressure machines to increase the tidal volume and better manage respiration in patients. In many cases, practitioners actually will use the VPAP ST or BiPAP ST (spontaneous/timed), but in your case the backup rate does not appear to be required. More pressure support would without question boost tidal volume. This is often used for COPD and any restrictive pulmonary or upper respiratory disorder. I don't know your health situation, so that might ring a bell. Your Resmed Airsense 10 Autoset provides up to 3-cm of pressure support (EPR), and substantially more is available with bilevel.

You are currently using a pressure range of 9.3 to 20 cm with EPR at 3. In bilevel terms that is a range of 9.2/6.2 to 20.0/17.0. Your median pressure on the chart above was 9.8/6.8 and the 95% pressure was 11.7/8.7. So pressures are generally pretty low. So what would happen if you could use a pressure support of 6.0 cm? You might start at a pressure of 12/6 and allow a pressure range using auto bilevel up to say 18/12. That would probably boost tidal volume into the upper 400s to lower 500s range. Whether that would translate to better oxygenation, I don't know, but it would certainly reduce your CO2 which may or may not be a priority. This is normally determined by a simple blood test that measures your bicaronate (HCO3) level, or am arterial test that can measure arterial oxygen and carbon dioxide. These tests are very comonly done for individuals with COPD or those using supplemental oxygen to evaluate the need for improved ventilation and effectiveness of your oxygen therapy. These are matters for your doctor, but understand there is a therapy that can change those results.

If you want to zoom into a typical 2-minute segment of your flow rate chart, we will be able to see the alctual respiratory flow wave and tell you if there is any evidence of restriction that is limiting volume.

[Gideon]

If I may make a suggestion, look for a sleep doctor who is a Pulmonologist. That is a specialty doctor that specializes in breathing issues such as I suspect that you have. They do exist

Approach to try with your doctor. My home instruments indicate that I MAY have a problem my nighttime Oxygen sats. I have two questions, can you verify these readings are accurate with your instrumentation AND is so what would you suggest we do about it?

[Tubaman]

I included last night's chart (kind of active, comparatively), a "typical" (whatever that is) 2 minute segment where all was quiet and a 2 minute segment with a couple of OA events.  I hope that is what you requested.  If not, please let me know.

I awoke just before 1300 (bathroom) and I don't think I went back to sleep after I returned.  I tried to take deep breaths during that period (rising tidal volume as a result?).

I did see a Pulmonologist a couple of years ago.  He had me do some lung capacity tests and he also did some x-ray (or other types) of scans.  He said my lungs were OK, maybe slightly small.  He did mention my lungs looked like they had a 'snow storm' occurring in them (lots of tiny specks throughout).  He said that was not cancer but he never did explain what it was/is.  I was experiencing the same tidal volume values at that time as I'm getting now.  I've always wondered if playing tuba in German style dance bands all those years (I played quite hard -- blew hard) and actually played one or two beer festivals that lasted 11 hours (that's a lot of wind for a long time) may have done something.  I can no longer play because I no longer have adequate lung strength to blow into my tuba.

Thank you!
Carl

[Sleeprider]

Very curious. Somehow at 11:00 you managed to exhale around the mask. I don't know how, but you have slightly flow-limited inhale and no exhale, or a possible expiratory snore. The flow is not equal to inspiration which is impossible unless you are breathing around the mask, so that is what I suspect. With nasal therapy we consider this oral exhale and nasal inhale. You are using a FFM, so go figure:



At 07:45 your respiration starts off normal, and degrades gradually into apena which is a signature for central apnea, not obstruction! There is no suggestion here of flow limitation, just a lack of effort to breath. The first OA looks flow restricted. I believe that one, but not the second.



Just out of curiosity, what are your sleep hours? This shows 6:00 AM through 2:00 PM.