[Treatment] Still fatigued, history, are these CAs real?

[Sleeprider]

I think we need to back up a bit here. CA events were never out of control and EERS is not improving anything that I can see in results or comments. Back on the first page of this thread, Fred suggested the Vauto. I’m becoming convywe may be back to that.

[Gideon]

looking at the before and 12inch flows I'm seeing somewhat less in the flows, so I'm interested to see what happens at 18inches with EERS.
Flow limits were a part of the original picture, thus I'd like to see what PS=4 and possibly Trigger sensitivity can impact wo EERS.
Looking at stopping the undulating flow rate (EERS) and the flow limits (EPR, PS) to stop the disruptions Guy was feeling. Always saw both being integrated.

Doesn't mean I don't want a new baseline with the VAuto.

[GuyScharf]

Match your AutoSet and PS=4
Night 2 try Trigger Sensitivity on high or very high, it does help many with centrals and this way you can see the difference.

With or without EERS?

[Gideon]

initially wo, pick best VAuto setup and if needed, then try EERS. If some combination of Trigger Sensitivity and PS resolve your issues, there is no need for the EERS

[sawinglogz]

I used a range of 10 - 11.2 last night.  AHI was 0.57, which is at the low end of the range of values I typically see.  Not sure if I feel much different; it will take a few days to know if there is a difference.  I am sure that I don't feel worse.  Fitbit says I got a bit more deep sleep than usual.

As I skim through the flow graph, I see a lot of waxing and waning.  Attached is one example that includes both a CA and an H.

I wonder if I should try a fixed pressure?

The thing that I found most alarming with your oscillatory flow was the SpO2 levels that tracked the flow. The swing between 91% and 96% that tracks your flow suggests you're on the edge of your respiratory requirements.

If you eventually try EERS again, it's most often (clinically) used with constant pressure. The theory is that pressure changes (such as ASV) disrupt sleep, but constant pressure doesn't. As to contraindications, I only know there's a contraindication for ASV with certain cardiac conditions (low ejection fraction, I think).

For others with more experience, could this be mild CSR? I've never seen such cyclical breathing with EERS-treated (complex) apnea.

Another thing to try (after everything else) might be acetazolamide. There's now a lot of literature on its use for central apnea. It doesn't work for everyone (and could be contraindicated), but it's one more possibility in the arsenal.

[Gideon]

I was hopping to see a little more improvement with EERS so am looking forward to seeing the 18-inch results, Guy has documented 0, 6, and 12 inch EERS. I was looking at a blend of EERS with EPR/PS to flatten all the mini "CSR" which is what caught my eye and suggested EERS. IMHO this is CO2 influenced breathing short of actual CSR.

Fixed pressure, I can see this coming in, but I'd like to see it after the 18 inch EERS so that EERS is the main change we are watching. Also we have a VAuto coming in.

[GuyScharf]

Attached is 18" EERS data.  I used 18" for three days; the Excel spreadsheet shows 3-day averages for 12" and 18".  I haven't been getting to sleep easily the last few nights, which has reduced the hours sleeping.  I've stopped wearing the oximeter for a while -- I don't like having anything on my wrists.

I increased pressure slightly on the third day of 18" and found that more comfortable.

It does seem to me that the breathing pattern is somewhat better with 18" EERS.  Also, it is looking to me like the oscillatory flow usually follows a flow limitation, often just a slight one. Of course, I have lots of flow limitations and have not tried to do any statistical correlation (which I would not know how to compute anyway).  Overall, as EERS length increases, tidal volume and minute vent increase.  Pulse and SpO2 are not affected.

Attached are graphs from last night and Excel summary.  Note there are 3-day average columns for each EERS length in the table. While spreadsheet shows better statistics for 12", my impression is that the flow diagrams are better at 18".

VAuto is supposed to arrive today; we'll see if USPS does what it said it would (I'm not counting on it).  I am otherwise ready to go with the VAuto, have a new Flashair card ready for it, etc.  I will be very interested in seeing if increasing PS will reduce flow limitations and any breathing issues that follow flow limitations.

Regarding fixed vs auto pressure, I used fixed pressure on a few days and have been keeping pressure range low.  Based on previous experience, the machine would happily raise the pressure to 12 to 13 cmH2O, but with no material effect on AHI statistics.  I do suspect there will be fixed pressure in my future.

                   

[Sleeprider]

As the volume of EERS increases, it is not surprising to hear you need more pressure. Event rates are low and the sonic oscillations are mostly tamed. I think Vauto pressure support should complete the optimization of therapy. I’ll be interested to hear from bonjour.

[Gideon]

Note the orange circles.  They all have a somewhat slower breathing rate, and for the most part have Flow Limits.  I'm concerned about the Flow Limits they will come out easily, but why the slowing of the breath?  This pattern is also evident in the "Ford" chart.  Essentially it precedes ALL of the waxing waning episodes as if it is the cause.  

Thoughts?

This is IMHO the best results looking at the charts so far.  Of note I believe all of the EERS are with EPR=3.  Want to see what PS=4 does with the VAuto, then possibly add in the Trigger sensitivity increase.  One thing at a time though.  I do understand the need to increase pressure as EERS "grows"

   

[GuyScharf]

The VAuto is a bust -- contaminated with cigarette smoke so I have returned it. Given my relatively low AHI, I don't know whether I could get Medicare approval for a VAuto. Any thoughts on that?

Despite the graphs being better with 18" EERS, I feel more comfortable with 12". I'll look again and reducing pressure to see if I can find an adequate solution.