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Vauto, PLM, FL & Mixed Apnea
#1
Vauto, PLM, FL & Mixed Apnea
thanks for staying with me mper!  I do sleep through most plm but this is one of many examples where the session ends after a string of plm, so they're clearly waking me, eventually. and while I sleep through a lot of it, plm and maybe the swinging ps is probably disturbing to sleep quality.

here's the end of the same session as previous post in a 10 minute window with RR and TV.  let me know if there's something else you care to see.  

I don't disagree that FL is at the root of the problem; it's just that most of my FLs are caused by plm, and as with chin tucking, I don't think pressure can overcome these non-passive FLs, which leads me to think that I have to stop the plm to stop the FLs.  

even so, while you may think I might be disagreeing with you, you've certainly piqued my interest: I bought a used vauto largely because of your posts, just to see.  if we have to suffer all this, we might as well have some 'fun' indulging our curiosity and experimenting!  my main pre-supposed concern about vauto is that it won't treat my ca, but I still don't feel well rested so nothing ventured nothing gained.


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#2
[split] Vauto, PLM, FL & Mixed Apnea
....I do sleep through most plm but this is one of many examples where the session ends after a string of plm, so they're clearly waking me, eventually. and while I sleep through a lot of it, plm and maybe the swinging ps is probably disturbing to sleep quality....I am afraid, on the contrary, is that your 22:40 wake up would have been caused by RERA (reflected on TV and RR). PLMS usually dont affect that significantly TV, therefore, all this reinforce my previous points.

good luck
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#3
[split] Vauto, PLM, FL & Mixed Apnea
here's my first night on vauto.  I tried to keep settings close to current asv settings.  as expected, ca ran amok.  lower med epap and ipap pressure with vauto.  tidal volume is a bit lower and closer where I wonder if it should be.  flagged flow limitations are quite low, maybe lower than my experience with apap.  it's hard to compare to asv because asv produces a lot of 1.0 flow limitations.  however, I got 0.0 in the vauto med column & do so most of the time with asv.  expiration time is longer with vauto.  baseline leaks are much lower than asv.  overall, because vauto pressure hasn't risen as high with asv, I might be feeling a little less beat up with vauto.   

plm is producing arousals.  some events occur in plm and some occur in a pattern looking more like ca associated periodic breathing. it's interesting: I get fewer events in plm when my min pressure support is under 4 (3.2 - 3.6).

asv addresses my ca and non-plm related periodic breathing; vauto does not.  I imagine that with the help of you all, I can do better on vauto, and I plan to play around with it for at least a week.  

any suggestions for improvement here or should I just go back to asv?


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#4
RE: 18 mths of apap: need help optimizing settings to feel better
(11-06-2019, 05:00 PM)sheepless Wrote: any suggestions for improvement here or should I just go back to asv?


Hi Sheepless,

A few quick thoughts.

On the page above you mentioned Minute Vent.  Your Minute Vent was a little high in both these results and the ASV chart posted on 10/23.  Given you spent a good bit of time in 'heavy breathing' recovering from events I would not be concerned about your Minute Vent being high and (Yea!) for sure not low.  

The ASV and VAuto were pretty close on EPAP min but your Flow Limits on the VAuto looked so much better, event with all those leaks.    Maybe need to raise EPAP Min on the ASV to clear out some of those Flow Limits.  

"ca ran amok"   If you ignore all CA that occur immediately after recovery from a leak or flow limit how many CA are left?   

So many of the arousals and events occurred just as a leak ended.  I through all those out when reviewing a chart.  I would stay with the VAuto until you can run it a night with near zero leaks so you can assess what the VAuto is really doing for you ...  or doing to you.  Ha ha.   


WillSleep

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#5
RE: 18 mths of apap: need help optimizing settings to feel better
thanks for the reply Will. I'm not seeing what you are with respect to leaks. in fact, leaks with the vauto are quite low. med leak at 1.2, 99% at 12 and only 0.006% over red line. no way for you to know this but the only leak over red line happens to be one I did on purpose to indicate wakefulness without shutting machine down. in contrast, med leaks with asv hang around 13 or 14.
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#6
RE: 18 mths of apap: need help optimizing settings to feel better
(11-06-2019, 08:13 PM)sheepless Wrote: thanks for the reply Will.  I'm not seeing what you are with respect to leaks.  in fact, leaks with the vauto are quite low.  

The context, the answer I am trying to give is:  "No, don't go back to the ASV yet, spend the week you mention to see what the VAuto can do for you."   

Before I bailed on the VAuto I personally would want to see no presence on the Leaks Rate and Flow Limits chart and then have a look at the waveform in 2min 30sec snips.  So you, and help from the group if you want it, can go through to steps to tune the VAuto to see "All she's got" in that week you mentioned playing with it. 

Yes the overall Leak rate is low.

The Leaks in that nine minute snip are low as well.  I have not studied your charts over many days and the ripple in the level of Leak Rate, Respiration Rate and airflow wave flow all are two much in sync for me for me personally to learn anything definitive from this specific 8 min 45 sec snip.   There are two many moving parts which raises the "which came first, the chicken or the egg" problem.  

I am just saying it will be easier to tune the VAuto using 2-2:30 snips that have zero leaks, flow limits, anything that distorts the other signals we would want to tune from. 

Night.. Zzzzz

WillSleep

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#7
RE: 18 mths of apap: need help optimizing settings to feel better
………………………………………………………………………..
Hi, Sheeples
Your charts dispositions, with different waveforms on full night and details, bring some difficulties over an already difficult task on working this piece by piece. Anyway, I am  going to take some risks here and add some preliminary interpretations.

What a great V-7.6/4.0 shot !!

Let me organizing my own thoughts on your case:

(a) Earlier, I had mentioned you would be an “undisciplined” nice fellow, sleep hygiene wise;
(b) Earlier, I had suggested your main sleep drawback would be unresolved FL, rather than PLMS (both are important, I see today). It appeared you were able to sleep through some of your PLMS, whereas FL waked you up everytime you started to sleep, kind of suffocating you.
© ASV, while responding to holding breath during PLMS, appeared had deleterious effect on  your sleep;

Then, you have decided to go for this experience with VAUTO. For now, taking into account your historic, current charts, and your information, it looks to me, preliminarily:

a- It was a great Vauto shot on your FL’s, pretty much killing everything, overnight!
b- You keep on going an “undisciplined” nice fellow, sleep hygiene wise;
c- Your PLMS is, indeed, a very important issue, which has become even clearer after this very first step on resolving your FL’s. Yet it appears you keep on sleeping through a great deal of PLMS;
d- CA’s also become clearer while removing FL’s; however they would be all fake events (WillSleep also would have noticed this);
e- All OA and H appear also fake events following PLMS-driven arousals;
f- Your E:I ratio around 1.88 (much better than your previous ASV 1.15…1.21) suggests you are not fighting against the machine, and respiring more normal, with PS:4.0;
g- Your RR: 17.4 looks too high. I WOULD SUGGEST YOU START INCREASING PS: 4.2…4.4…, trying to correct this.
h- You appear not going to delta/REM sleeps, likely due to PLMS interruptions and ending up in poor architecture;
i- Your arousals would be dominantly associated with PLMS, and maybe some still FL’s;
j- It looks CA’s would occur associated with PLMS-driven arousals: where there is no PLMS/arousals there would be no CA’s as well. The same: where there are PLMS without arousal, there is no CA!

k- You have start treating FL, better respiration, I:E ratio.  Next step would be keep care of your PLMS, either trying paralysing them with big shots, or maybe, raising your arousal threshold (eszipiclone, clonazepam, this kind of things….talk to your doctor).

Therefore, more or less in accordance with WillSleep, I think would be a nice to stick with VAUTO for a while as you said,  and keep on gathering data to fine-tuning your EPAPmin, PS (please, EPAPmin+PS = IPAPmax)..... and hope we are doing this well.
Good luck
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#8
RE: 18 mths of apap: need help optimizing settings to feel better
mper and willsleep, you guys are blowing me away.  it's going to take me some time to digest your comments.  I frankly don't understand much of what you're telling me and I'm amazed that anyone can glean so much from the data presented so far.  

a basic question then for mper: you said "...keep on gathering data to fine-tuning your EPAPmin, PS (please, EPAPmin+PS = IPAPmax)...".  

judging by the settings in your profile I assume you're telling me to reduce my max ipap from 22 to, well, right now epap is 8 and ps is 4, so 12 max ipap?  last night's 99%tile max pressure was 14.98.  I'll try anything but want to confirm that's what you are suggesting.  and if so, I'd like to understand the reasoning behind it. someone made this recommendation with respect to my asv a while back.  I didn't understand it then either. 

3rd night with vpap.  I saw 2 folks in another thread increased their trigger setting to reduce ca.  I moved mine from med to high last night and ahi dropped from >5 to 1.04; cai dropped from about 3 to 0.4.  how does that happen in a machine that doesn't treat ca?  how does higher trigger setting avoid ca?  

my vauto flow rate charts still show some plm but unlike my asv charts they now also show quite a lot more of the waning/waxing non-plm-related periodic breathing that looks more like the ca csr pattern, sometimes with ca, sometimes with apparent ca less than 10 seconds long.  

had a few more leaks over the red line (2% of the time).  maybe because I raised epap from 7.6 to 8.  but I take that as a good indication in a way: to my knowledge my mask doesn't leak and my sense is that my lip leaks increase with deeper sleep.  the flip side is that the leaks or the dry mouth or both wake me sometimes.

after a lifetiime of untreated apnea and 3 years of inadequate treatment, I'm not sure I know what being rested feels like.  I'm a little reticent to say this because historically, apparent improvements haven't lasted very long, but if pressed this moment to declare how I feel, it just might be pretty darn good today.  a step up from anything in memory, with the possible exception of the first few days after starting ripinirol for plm and getting in a few 8 hour sleep sessions for a change (before seeing an uptick of plm and fragmentation since then).

I guess I'll start pushing min ps up a notch at a time; see what happens.  I need to read up on the settings unique to this machine, only departing from default settings so far by raising trigger.  

there are suggestions of possible improvement with vauto but I'm concerned that I might need asv for ca and non-plm periodic breathing. suggestions for how to optimize the vauto are appreciated.  I'm happy to post data if you let me know what you want to see.  some want the usual graphs at closer scale, some ask for different graphs, some at a closer scale, some at 10 minute scale.  it seems I haven't thread that needle very well.  
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#9
RE: 18 mths of apap: need help optimizing settings to feel better
(11-08-2019, 02:53 PM)sheepless Wrote: I'm not sure I know what being rested feels like.  I'm a little reticent to say this because historically, apparent improvements haven't lasted very long, but if pressed this moment to declare how I feel, it just might be pretty darn good today. 

I guess I'll start pushing min ps up a notch at a time; see what happens.  I need to read up on the settings unique to this machine, only departing from default settings so far by raising trigger.  

Congrats!

Good long sleep, low pressure change chaos, AHI of 1 and a strong Minute Vent.  Looks like a great night!

I am not sure I would make any changes yet.  I might give these settings a few nights run to see if the results stick and also to see from consistency if there are and which types of events I might want to do micro tuning to improve.  

The night looks awesome.   Are those CAs even anything to be concerned about? (e.g. Were the CAs long in duration and they far enough away from any pressure changes, leaks, flow limits, snores, changes in position, other arousals, increased prior Tidal Volume or other non-CSA change in respiration rate to be worth any concern?)

From this zoom level the lone Hypopnea at around 6:50am is the only one that looks far enough away from Leaks to be free from 'confounders'.  Unless you see solid evidence the Hypopnea are bringing injury to your sleep (arousals, increased heart rate or lower SpO2) then just a few Hypopnea a night is not worth raising pressure because the higher pressure can also extract a cost (higher heart rate and at some point an increase in pressure adds to nightly, ongoing micro-injuries to your pulmonary system like ongoing high blood pressure damages your cardiovascular system).    
 

What I would do to see which is a better machine for you ASV vs VAuto.
  • Compare the chaos/variability in your Respiratory Rate on the VAuto from this night and the next few nights to few a pretty average and and a few good nights on the ASV.  This might signal what nightly pulmonary, cardiovascular and arousal workload overhead cost each machine is burdening your body with in order to achieve an AHI of 1.0.    
  • Compare the machines using other metric charts in OSCAR as well.   
 

Hope to see these great results continue!
 
WillSleep

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#10
RE: 18 mths of apap: need help optimizing settings to feel better
(11-08-2019, 02:53 PM)sheepless Wrote: mper and willsleep, you guys are blowing me away.  it's going to take me some time to digest your comments.  I frankly don't understand much of what you're telling me and I'm amazed that anyone can glean so much from the data presented so far. ...later on, I could go in more details maybe... 

a basic question then for mper: you said "...keep on gathering data to fine-tuning your EPAPmin, PS (please, EPAPmin+PS = IPAPmax)...".  

judging by the settings in your profile I assume you're telling me to reduce my max ipap from 22 to, well, right now epap is 8 and ps is 4, so 12 max ipap?....yes, that is.  last night's 99%tile max pressure was 14.98.  I'll try anything but want to confirm that's what you are suggesting.  and if so, I'd like to understand the reasoning behind it.....this because, we UARS/PLMS people arousal/awake too much, generating false events of OA and FL (like yours); the machine autobump,punch you all the time, unecessarily, disturbing your sleep further and provoking leak. It does not pay off. For me, was a great relief. As your are going to see, as soon as get adjusted PS and EPAPmin, you are not going to need this open range IPAPmax.  someone made this recommendation with respect to my asv a while back.  I didn't understand it then either. 

3rd night with vpap.  I saw 2 folks in another thread increased their trigger setting to reduce ca.  I moved mine from med to high last night and ahi dropped from >5 to 1.04; cai dropped from about 3 to 0.4.  how does that happen in a machine that doesn't treat ca?  how does higher trigger setting avoid ca?  ...well, this is an interesting question. However, I am still wondering if your have any problem at all with true CA'', other than artefacts following microarousal/arousal/awakenings due to PLMS.

my vauto flow rate charts still show some plm but unlike my asv charts they now also show quite a lot more of the waning/waxing non-plm-related periodic breathing that looks more like the ca csr pattern....for me,  just for brain storming, it looks more like periodic arousals (increase FR due to PLMS, during which FR/heart beat increase, decrease oxigen, and CA like follows, resuming oxigen, sometimes with ca, sometimes with apparent ca less than 10 seconds long. .....I wonder if your

had a few more leaks over the red line (2% of the time).  maybe because I raised epap from 7.6 to 8.  but I take that as a good indication in a way: to my knowledge my mask doesn't leak and my sense is that my lip leaks increase with deeper sleep.  the flip side is that the leaks or the dry mouth or both wake me sometimes.

after a lifetiime of untreated apnea and 3 years of inadequate treatment, I'm not sure I know what being rested feels like.  I'm a little reticent to say this because historically, apparent improvements haven't lasted very long, but if pressed this moment to declare how I feel, it just might be pretty darn good today.  a step up from anything in memory, with the possible exception of the first few days after starting ripinirol for plm and getting in a few 8 hour sleep sessions for a change (before seeing an uptick of plm and fragmentation since then).

I guess I'll start pushing min ps up a notch at a time; see what happens.  I need to read up on the settings unique to this machine, only departing from default settings so far by raising trigger.  

there are suggestions of possible improvement with vauto but I'm concerned that I might need asv for ca and non-plm periodic breathing. suggestions for how to optimize the vauto are appreciated.  I'm happy to post data if you let me know what you want to see.  some want the usual graphs at closer scale, some ask for different graphs, some at a closer scale, some at 10 minute scale.  it seems I haven't thread that needle very well.  
Later on I could go on more details on all of this above. For while I would suggest (see also attached graphs):
_ stay for while on EPAPmin: 7.6, while start increasing PS to 4.2 (IPAP max: 11.8)....4.4...Let us try to slow down your median RR, first. Remaining FL could be eventually be worked out by PS increase only, maybe. Your OA H are insignificant (agree with Will).
_once you work out FL, it would remain PLMS only. Your CA's, well, do they exist?
_Vauto parameters: Ti min: 0.8, Ti max:2.0, trigger and cycle med.
_see attached for an analysis on your RR and other parameters.

good luck


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