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Vauto, PLM, FL & Mixed Apnea
#11
RE: 18 mths of apap: need help optimizing settings to feel better
I notice that I have more events in plm with vauto than with asv. many of these are ca and h (possibly central as well). that makes me wonder: I've assumed that rapidly rising ps against my respiratory response to plm is incapable of resolving these non-passive flow limited breaths between jerks; while that may still be true, now I'm wondering if asv ps was in fact successful in swatting down ca following the jerks, leaving the flow limited breaths instead.
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#12
RE: 18 mths of apap: need help optimizing settings to feel better
Well, sheepless

My conclusions on your case thus far:

_ Properly managing EPAPmin and PS, as have I suggested above, would ultimately work out your minor remaining FL-associated arousals. This could be easily reached, by tailoring your parameters. Once there, next step, would be work out your PLMS, by using the best drugs, lesss harm ones (these would causing what remains on CA, OA, and H);
_Your CA’s, as well OA/H, would be secondary fake events due to arousal/sleep transitions, caused by PLMS.

I would suggest you reading this, from which I have highlight this parts, which would have to do with your case currently.

https://www.ncbi.nlm.nih.gov/pmc/article...00705/#B16

" Importantly, by augmenting tidal volume, BPAP reduces CO2 and thus the intrinsic ventilatory drive.11 If CO2 is sufficiently lowered, apnea will be produced if BPAP fails to deliver tidal volume effectively…….. In addition, BPAP may promote CSA in the presence of a variable upper airway resistance (e.g., during inadequate expiratory PAP), which should, in principle, act to destabilize the ventilatory control system. Likewise, state instability (e.g., as occurs with a low respiratory arousal threshold) may also promote CSA since a change in sleep state can be accompanied by large changes in ventilatory drive.16.  State transition apneas may further be promoted with arousal-induced reductions in PaCO2 levels.17 . ...(3) Could adjustment of the arousal threshold (e.g. using sedative/hypnotic agents23) improve the state transition apneas which may develop over time? " I personally, do believe on this possiblity......

good luck


:……..just to refresh and update you on my UARS-PLMS case, I have brought my PLMS to a well acceptable level using a row of supplements (boost ferritin to 150, Mg 500, K100, all kind of B vitamins), and Valerian 1060mg, both of package demands persistence (a  least 1 month) to produce results. I also use Melatonin 3mg (I think it works to slow down a bit the my arousal threshold). PLMS and Unflagged RERA still wake me up some 1.5 times/hr, which is acceptable, as long as I go back to sleep quickly. All these, most of the time, return me a score > 4.0 (in my scale of how  you feel index of 1 to 5.0).
_
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#13
RE: 18 mths of apap: need help optimizing settings to feel better
I reduced vauto ps/ipap max to the sum of epap 8 + ps 4.4 or 12.4.  at upper limit of 22, ipap was reaching close to 16.  this chart is unusual because pressure never wavered from epap 8, ipap 12.4 (the max setting).   rr is still relatively high.  tv & mv went up.  

ipap maxed out but I don't know why epap never rose against the oa.  last 4 nights 99% epap was between 10.5 - 10.98.

timing settings are default except trigger at high (which reduced ca 2 nights ago).

looks to me like I need to raise my max ipap but I'm uncertain whether that should be via epap or ps.  I would think epap for oa but I think I'm hearing the suggestion to raise ps.
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#14
RE: 18 mths of apap: need help optimizing settings to feel better
(11-10-2019, 04:02 PM)sheepless Wrote: I reduced vauto ps/ipap max to the sum of epap 8 + ps 4.4 or 12.4.  at upper limit of 22, ipap was reaching close to 16.  this chart is unusual because pressure never wavered from epap 8, ipap 12.4 (the max setting).   rr is still relatively high.  tv & mv went up.  

ipap maxed out but I don't know why epap never rose against the oa.  last 4 nights 99% epap was between 10.5 - 10.98.

timing settings are default except trigger at high (which reduced ca 2 nights ago).

looks to me like I need to raise my max ipap but I'm uncertain whether that should be via epap or ps.  I would think epap for oa but I think I'm hearing the suggestion to raise ps.

Apart from any conversation about legs a traditional from me would be:

You have turned your VAuto into a CPAP by locking down the IPAP Max so tightly.  Based on what you posted here and that screenshot I would:
  • Set EPAP Min to 7.0 
  • Set IPAP Max to 14.0 - 16.O
  • I would not raise PS as you are already seeing CAs.     

Having said that I believe that sometimes once people have reached a level of AHI in the 2-4 range tuning for other factors in priority over reducing AHI more might yield better sleep and lower cardio stress through the night.  So I would have a bias to see you and Mper play out for a while his/your shared concepts.

WillSleep

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#15
RE: 18 mths of apap: need help optimizing settings to feel better
I don't disagree, WillSleep. at the moment I'm trying out mper's suggestion to cap ipap at epap + min ps. I assume there may be a happy medium between asv ps unsuccessfully swinging high (22 cmw-ish) against flow limitations in plm and pinning the pressure at 12.4. once we figure out how to get the most from vauto, I plan to use your suggestions with respect to how to decide between vauto and asv. thanks for the ideas!
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#16
RE: 18 mths of apap: need help optimizing settings to feel better
mper, while I don't trust consciously counting breaths, all I have is 3 years machine data which probably skews high, so, counting with hand on stomach for 1 minute, 3 times, average = 15 bpm. / 2 = 7.5. x 0.89 = 13.35.

what program are you plotting points on? a spreadsheet? I can take a close look and recreate the ones you did for me with additional data points.

fwiw, I felt great yesterday and awful today (after increasing ps in chart in post #207).
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#17
RE: 18 mths of apap: need help optimizing settings to feel better
Hi, sheepless, Will

that's fine.... let us suppose your normal RR around 7.0....implies your RR would slow down by decreasing from 8.0....

I plan to go to more details later on.

for now, I suggest for next night:
EPAPmin: 7.6, PS: 4.4...we would need to quickly to adjust these parameters to tame remaining FL.....weird points, if they occur, are invaluabe to do this!
IPAPmax: EPAPmin+PS : 12.0

good luck
good luck
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#18
RE: 18 mths of apap: need help optimizing settings to feel better
Hi, sheepless

Just to put some historic, and illustrate how hard is changing paradigms.
You started this thread on Sept 5th,2018; 425 days ago. On Aug, 30th, this year, I posted this here:

Hi Sheepless,
After going through this thread, trying to understand your case, I have these first impressions and questions:
(a)_What a quest and suffering from your part all these years; I empathize!
(b)_ Unfortunately, I don’t why, I could not get any picture from the time you used VAUTO rather than ASV, so I have not understood why you have been on ASV, exactly?
©_ It looks to me you have got lost into details of the waveforms;
(d)_It looks to me you have a very important and untreated UARS, as well as PLM’s. It was not possible yet to get the relationship between these two in your case;
So, I was wondering if I could help after so many more experienced people already have gone through your case. Anyway, I am curious. Could you please:
1_ replot your last full night picture, with wave forms and scales like this, from top downward
Don’t need event chart
Pressure
Flow limitation (compressed)
Flow Rate (-120 to 120)
Tidal Volume (max 1000, adding the median reference line)
Leak
Then plot some 10min-windows, please. Initial idea is to fly by your forest, before examining the trees.
Good luck

Your case called my attention because, hidden behind some arousal-associated fake CA’s, OA H, could be actually a typical case of unresolved UARS-PLMS. This diagnostic kept confirming day after day, since ASV times do most recent VAUTO times.
At one point in time, it became clear for me that ASV had become deleterious for you, basically because it was increasing-pressure responding to anomalous, false FL during PLMS-driven arousals.

Then, very fortunately, you decided to move to BPAP, which in my opinion would be the correct machine for you.

Now, I know it is hard to accept new paradigms in general. I think I know this very well, since my old days as a nature’s sciences’ researcher professional. I am resilient, though, at least up to the point I feel I am not bothering anybody.

Learning from 210-day therapy, and experiencing (registering everything) a great deal with BPAP, EPAPmin (4.0 to 7.8), PS (3.0 to 7.0), and so on, some 90 days ago, I realized I could manage this semi-quantitatively, empirically, and predictively. The median RR (includes drops associated with false CA’s themselves) would be the anchor, very sensitive to EPAPmin and PS.

CA’s increase with PS? Yes, they do, however only above the point tighten with your normal RR. And, also, is more difficult to surpass the CA’s triggering threshold while increasing EPAPmin at the same time.

Now, in practical terms, in what point you are in all of this, aiming at the best you could get with the BPAP and parameters ? Well, hoping you believe in me, you would be within maximum 30 days to get at that point, in part because you could count on my 210-days experiencing on that approach. And, also, of course, thanks to so many invaluable inputs from so many other experienced fellows here.

Concerning how you feel (HYF). Well, I wish we could go even faster than 1 month, overnight maybe, but I am afraid it would not be possible. That because, we have not yet given the very first step, that is, get your tailored EPAPmin and PS (I would predict this within maximum 15 days). After this, we will see how smooth is going to be your curves, concerning your tens of tens of micro arousals (1.5 to 3.0 secs), arousals (3.0 to 15 secs), and awakenings (>15.0 secs).

Then, you, your doctor, would see what be the best approach to tackle your PLMS, so that you could start experiencing going to some delta/REM sleeps, and, in consequence, experiencing better HYF.

Meanwhile, maybe it would be interesting bear in mind you have got significant achievements, in particular the diagnostic of what seems to be your main drawbacks, UARS-PLMS, and maybe the tailored machine to handle those, the BPAP, rather than the ASV.

Good luck
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#19
RE: 18 mths of apap: need help optimizing settings to feel better
mper and anyone else that cares to comment:

for tonight I changed settings to your suggestions: dropped epap from 8 to 7.6, ps 4.4, ipap 12.0.  I changed trigger back to med from high (high substantially reduced ahi and cai, but now med as you suggest) and ti min from .03 to .08 as you suggest.  

screenshots from last night are attached.  these are intended to be a broad overview.  let me know if you want a different scale or different graphs. 

I remain interested in / concerned by the fact that pressure hasn't wavered off settings for the last 2 nights.  IDK why epap doesn't rise against obstructives and it's apparent the machine wants to go higher than ipap max.    

meanwhile, I'm not clear whether (and why) we're using rr/2 or rr*0.89 and exactly how it's used.  I guess I can figure out how to do a scatterplot in a spreadsheet or on paper but I'm still not sure what it tells us. 

re paradigm shift: yes, that's what this feels like.  altering one's assumptions and approach make me want to understand how and why, which probably sounds skeptical, but I'm open to finding out where this leads.  goodness knows, I'm still dragging.

re 'undisciplined nice fellow': great term! very tactful. it made me laugh.  I think the only thing anyone can know about my sleep hygiene is that I continue to nap during the day, so I assume that's what you're referring to.  all I can say is that the day I don't need to nap is the day I will stop.  it's an indication of how inadequate my treatment continues to be.  I yearn for the day I'm rested enough to not feel the need.  I believe my naps do more to compensate for poor quality fragmented nighttime sleep than detract from what might be better sleep without the naps.  someday when nighttime sleep is good, naps might have a negative impact, but I'm not there yet.  I have no trouble falling quickly asleep almost anytime of the day or night.


Attached Files Thumbnail(s)
   
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#20
RE: 18 mths of apap: need help optimizing settings to feel better
Hi, sheepless
_ that was a interesting night! However, your settings were: EPAPmin 8...PS: 5.0...IPAPmax: 13, which accidentally brought invaluable information toward your fine-tuned parameters. It looks, as expected due to your very low RR while awake, you are going to tolerate higher PS without detrimental CA's, at least > 5.0, we already can see.
_ it looks we are moving in right direction. I have the impression your waveforms are becoming more smooth, which mean less awakenings, maybe. You know, we UARS-PLMS, target lower arousal/awakenings, not AHI.
_from your sooooooo compressed charts, it looks your arousals/awakenings are becoming, luckily, more RERA's-driven, maybe diminishing PLMS-driven ones. This would very good news, if it confirms. That because, we have room to fine-tuning your parameters toward this goal.
_to go further and suggest changes; I would need better understanding your patterns, starting discriminate between your RERA's-driven and PLMS-driven awakenings, etc: For that, I would need you blow up your charts for me, and only these ones, please, if possible, top-downward:

: no need for event chart, as long events are superimposed on the others
:no need for pressure, as we already know they are flat all the way
: RR pinned right on top, scale 13---22
: FR..-120 to 120
:FL (can be very compressed)
: TV, scale 250 to 800
: leak
Confusednoring

Full night and 10min-windows at same curves, same order, scales, please. Otherwise this piece by piece analysis could be misleading.

all the best.
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