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cpap and apap not effictive
#71
Ezil71,

I want to do a pretty careful analysis of that 3.5 minute snippet of breathing you posted a linke to.

Before doing that I also want repost the snippet of my own breathing from a night that was objectively and subjectively "good". Here's what my breathing looks like when I'm getting high quality sleep.

[Image: FZu5i1xl.png]

The things worth noting about my pretty decent sleep breathing are the fact that it's very regular in both frequency and depth of inhalations and exhalations---i.e. the bumps are all about the same size. It's also worth noting that a RR in the low teens is pretty normal in non-REM sleep.

Now here's what Ezil71's breathing looks like:

[Image: FD4Dl6yl.png]

It's important to note that this comes from a period when it looks like he is most likely asleep.

The largest inhalations in Ezil71's breathing actually look pretty decent: They're nicely round. But there is a lot of raggedness between those "large" inhalations. These "mini-inhalations" are also what's causing the RR to be (relatively) high for sleep breathing. If we count the clear exhalations in this snippet, there are about 36 of them. And the snippet is about 3.5 minutes long. Hence, if we computed the RR based on the clear exhalations, we'd get an RR = 36/3.5 = 10.3, but the RR graph lists the RR rate as bobbing around 19-20.

The reason Ezil's RR is so high is that the machine is counting all that "business" in the wave flow between the end of the obvious exhalation and the beginning of the larger inhalations as "inhalations" even though there's not much evidence of a corresponding exhalation between the "business" and the obvious "inhalation".

Which begs the question: Is this "business" real or an artifact? And I don't know the answer to that. The fact that Flex is set to 3 may mean this "business" is an artifact in the data---in other words, the pressure increase that Flex does during the second half of the exhalation may be affecting the wave flow trace in a way that is not actually connected to Ezil's breathing. Or perhaps Ezil has a longer than normal pause between exhalations and inhalations and the Flex pressure increase comes at a point where it affects the airflow into his lungs in a way that looks like a mini-inhalation. Or perhaps Ezil actually has a weird breathing hitch where he starts an inhalation, stops momentarily, and then continues to inhale. We just don't know.

If the "business" is just an artifact, it will probably go away on its own as your body adjusts to CPAP. But it may also take getting the RLS stuff better controlled as well as any tendency for aerophagia under control.

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#72
(10-22-2016, 09:56 AM)Sleeprider Wrote: Ezil, put a fleece cover on your CPAP hose. I have used one nearly from the beginning, and it makes it soft and warm like part of the bedding, rather than hard plastic medical stuff. You need to give yourself every shot at being comfortable, and this is a big one for me.
I want to second this idea: A fleece cover on the hose does indeed make it feel much more like part of the bedding. I tend to "hug" my hose at night as if it were a large, stuffed toy snake, and the fleece is why it feels like a stuffed toy instead of an medical device invading my space.

I'll add: The P10 headgear is pretty nice in that it is soft and fabric. If the touch of the silicon pillows on your upper lips is irritating, look into pillow cozies from Padacheek. Padacheek is an on-line retailer and she makes pillow cozies designed specifically for the P10.

PS: Yes, I know "snake" creeps some people out, but "stuffed toy snake" doesn't creep me out, and the nickname for my machine is Kaa, after the snake in the Jungle Book.
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#73
(10-21-2016, 04:49 PM)Ezil71 Wrote: I'm not on anything for RLS, but I wake myself up from it at times, mostly flexing and straightening my ankles.
Make sure your primary care doctor as well as your sleep doctor (if you have one) are both aware of the RLS. Be sure to tell them that the RLS does wake you up at times. My guess is that if you can get the RLS under control, it will be easier to get a really good night's sleep with the CPAP.


Quote:As far as sleep positions, I sleep mainly on my left side, largely because I have/had a bad shoulder which I had surgery on a couple years ago.

It still isn't 100% so even when I try to be on my right side, I end up back on my left.
The stomach is usually happiest when you sleep on your LEFT side. So if that's your favorite sleep position, don't fight it.

Quote:Same goes for my back. I have never been able to sleep on my back. I've tried wedges, tried to prop pillows around me, and I always, consciously or unconsciously, end up back on my left side.
Go ahead and sleep on your left side. Sleeping your left side is NOT incompatible with sleeping on a wedge by the way.

You may find that sleeping on your left side while using a wedge may help the aerophagia issue.

Quote:As quickly as I fall asleep on my side, trying to fall asleep on my back keeps me awake for hours, until I give up.
OSA tends to be worse when sleeping on your back. So there's no point in even trying to sleep on your back if that's not your natural sleep position.

Quote:If I happen to be on a firmer mattress, I end up on my stomach too, but I'm pretty consistent with my left side.
Stomach sleeping is not particularly good for aerophagia, but if it's more comfortable than sleeping on your left side for one reason or other, the additional comfort outweighs the tendency that stomach sleeping can add to the aerophagia. In general the more comfortable you are when you are asleep, the less problem you are likely to have with aerophagia. That's because the more comfortable you are, the less likely you are to have an excess number of arousals leading to excess swallowing during the night.

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#74
This is based on the data that Ezil71 posted at https://1drv.ms/i/s!AgFs7hWqVGNflXnsOZsPQb6QriN6

(10-22-2016, 09:12 AM)Ezil71 Wrote: I managed to get 7+ hours last night. I can't say that I feel good, but I at least feel slightly less bad than the previous nights.
Some progress, however slight, is good. And "slightly less bad" is actually some progress.

Obviously the AHI is too high. On this night the problem is an excessive number of Hs. It would be useful to post the data again with the following change:

Delete the AHI graph and include the pressure graph.

The AHI graph doesn't contain any data that we can't already see from the event chart. And we need to see how the machine is reacting to the H's on this night.

Quote:I ran at 7-11, aflex 3. I began the night using nasal pillows, but switched back to my full face during the night. My problem with the pillows is that the hose gets in my way which wakes me a bit. Having it run through the strap on my head solves that, but then pulls the pillows up and out enough that it is unconformable and I get leaks. I do have a nasal mask I can try if if really looks like having the full face isn't working as well.
Use the mask you find most comfortable and which mask is it easiest to try to get back to sleep with during the middle of the night.

With the nasal pillows mask, you might find running the hose under the covers and "hugging" it will keep the hose from getting in your way. If you're hugging the hose, you can easily control where the hose goes when you turn over in bed. A fleece cover will make the hose feel "friendlier" rather than like a cold, hard piece of medical equipment.

Quote:I'm not sure what to zoom in on here since there are so many events all night. The first part of the night wasn't horrible feeling, but I did feel like I was tossing and turning a LOT last night, especially after I had gotten up. I tried turning off/on a few times during all that tossing and turning, but I can't say it was really timed around possible RLS events.
So there is known restlessness between 2:10 and 3:00?? That means it's reasonable to discount all the events scored during that time frame. And were you also really restless between 5:50 and 6:30? And were you also restless after 6:30? If so, then it's reasonable to discount all the events scored in those last two CPAP sessions.

My guess is that if you felt like you were tossing and turning all night, then you probably were tossing and turning most of the night. And it's reasonable to say that RLS was at least partially responsible for some, maybe most, of that tossing and turning.

Quote:Aeorophasia is there for sure today, and I was well aware of it during the night, but not at a painful level, just very present and annoying. If I actually was getting real rest, it is at a level I could live with, but certainly isn't good.
It does not surprise me at all that the aerophagia is there today. Remember: The more arousals/wakes you have during the night, the more swallowing you are doing. And the more swallowing you do during the night, the worse the aerophagia gets. And the worse the aerophagia is, the more restless you are. In other words, It you probably were trapped in dealing a bad feedback loop last night:
  • More restlessness (from the RLS or just the tossing and turning) leads to
    More swallowing which leads to
    More aerophagia which leads to
    More arousals/mini-wakes, which leads to
    More restlessness (which may contribute to more RLS) and which leads to
    More swallowing which leads to
    More aerophagia which leads to
    More arousals/mini-wakes, which leads to
    More restlessness (which may contribute to more RLS) and which leads to
    ....

You get the picture. Until you can figure out a way to break the feedback loop on a bad night, the aerophagia is going to be a potential problem.

Aggravating things on this particular night is the fact the machine scored a boatload of H's. And hence my guess is that you were probably running at max pressure much of the night. And that too can feed the aerophagia. And if those H's are just "tossing and turning" glitches in wake/semi-wake breathing, then the increase in pressure was probably not actually doing anything positive in terms of your sleep.

I will add this: In my own battle with really painful aerophagia, the most critical thing I had to do to get my aerophagia under control was to end as much of the restlessness and tossing and turning as I could. In my case, that meant learning how to get to sleep quickly enough to prevent the tossing, turning, and the start of the aerophagia. But this past year, it also meant dealing with the fact that I still have a large number of spontaneous (unexplained) arousals/awakenings on bad nights. The gabapentin has helped that a lot.


Quote:Here is the overview from last night, let me know which areas to zoom in more on.

https://1drv.ms/i/s!AgFs7hWqVGNflXnsOZsPQb6QriN6

Thanks again for all the help.
I'd like to see the whole night with the pressure graph replacing the AHI graph.

Then I'd like to see the following zoomed in snippets:

1) a series of screen shots of the very beginning of the night. I'd like them to be about 10 minutes long or so so that the individual breaths are visible. That would mean I'd like to see:
  • 23:30-23:40 (Get the very beginning of the night!)
  • 23:40-23:50
  • 23:50-0:00
  • 0:00-0:10

2) a 5-minute snippet centered around 0:20. There are no events here and my guess is that this represents a period when you may have actually been asleep. I'd like to see more about what your "best" sleep breathing seems to look like.

3) a series of screen shots that show what happens at the beginning of the 2 hour, 58 minute session that starts around 2:50. Again, I want them to be about 10 minutes long so I can see the individual breaths.That would mean I'd like to see:
  • 2:50-3:00 (get the very beginning of the session!)
  • 3:00-3:10
  • 3:10-3:20
  • 3:20-3:30
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#75
I do think I have a pause between breaths. I will try flex off tonight with the same range as last night and see what I get.

Hadn't known about a hose cover, looks like a great idea.
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#76
Ezil,

I finally got a chance to read the whole thread.

One of the things posted much, much earlier is interesting:

(10-16-2016, 04:33 PM)Ezil71 Wrote: I would add that the time I had my titration I had taken some trazadone to make sure I actually slept (since I barely did during my first study). I've noticed that when I take it my pressure can be lower relative to the ahi I see without it, but I hate taking it because it always makes me feel bad/tired the next day no matter what my ahi was.
First I want to stress I understand why you don't like taking the trazadone. I had to be switched from Ambien to Belsomra because the Ambien hangover was really bad even when I was taking a mere 5mg at the beginning of the night.

But having said that, I want to add this: When you don't take the trazadone, you may have more of a problem with getting stuck bouncing between Stage 1 sleep and Wake. Stage 1 sleep is not stable, and bouncing back and forth between Stage 1 and Wake is often described as "tossing and turning". Given the data you've posted, it seems that you may have a problem getting stuck bouncing between Stage 1 and Wake rather than making it all the way to Stage 2 sleep, which is stable. When you get stuck going back and forth between Stage 1 and Wake, your APAP machine tends to score a lot of events, many of which are Hs, and that can lead to pressure increases. Between the tossing and turning, the mini-arousals from Stage 1 to Wake, and the pressure increases, you wind up swallowing air.

Now some things about the trazadone: Trazadone has been shown to reduce Stage 1 sleep, and that's considered a 'good' thing in the studies that have been done; it's also been shown to increase Stage 3 (deep, non-REM sleep) and has no serious effect on the amount of REM sleep.

Hence on the nights when you have taken the trazadone, it's possible that you had an easier time transitioning from Stage 1 sleep to Stage 2 sleep. That would reduce the number of the events that get scored during sleep transition, which would lead to lower pressure levels during the times you are normally pretty restless. At the same time, if you are less restless overall, you stand a better chance of actually getting into REM sleep. And if the pressure is not high enough to prevent the REM-related events, then the REM clusters could have as many (real) events as you get on a night with a lot of restlessness and sleep transition events, but little or no REM-sleep.

You posted the following night's data much earlier in this thread.

[Image: screenshot-20161019-083620.png?psid=1]

At the time you posted this, you described the way you felt as: "Pretty tired today, but at least I'm not as full of air." But you didn't describe the night as "restless with a lot of tossing and turning."

Now I have no idea if this was a night where you took the trazadone or not. But this data is qualitatively different than what you've posted later in the thread where you DO say you tossed and turned for much of the night. The data for this night looks pretty clean until you hit the cluster of events at roughly 0:42-0:53. The timing of that cluster is right for a nasty REM-related cluster: It's just about 90 minutes after you went to bed AND the first REM cycle is usually short--no more than 5-10 minutes long. And the worst of that cluster happens in a 7-minute period. You wake up 30 minutes after that cluster. (Why? The data provides no clue.) And another cluster of events starts up around 2:10. That could be a second nasty REM cycle (it occurs roughly 80 minutes after the end of the first postulated REM cluster.) Or it could be early morning restlessness kicking in.

The data in this night is similar: https://1drv.ms/i/s!AgFs7hWqVGNflWQWqfKcW73bEnIC Short, brief, but nasty clusters of events that may be REM related.

The more recent data where you are specifically saying you were restless all night long have significant clusters of events at places where REM doesn't usually occur---i.e. right after you return to bed after a wake or right after you try to fall asleep after an obvious real wake because you turned the machine OFF and back ON.

As much as you hate taking the trazadone, you might want to take it for 2 or 3 days in a row to see if the restlessness (tossing and turning) and the aerophagia is less when you take the trazadone and the max pressure is still set to 10 or so. If the trazadone helps with the restlessness but you can't tolerate it, then it may be time to explore an alternate prescription sleeping pill.

Alternatively, with the RLS, it may be enough to treat the RLS and that might be enough to end the restlessness.

At any rate, the point is: There appear to be two distinct, but interrelated problems that are combining to make it difficult to optimize your CPAP therapy:

1) Restlessness and tossing and turning that lead to a lot of sleep transition problems and aerophagia.

2) Possible REM-related clusters getting through when you do manage to get some real sleep instead of getting trapped in Stage 1-Wake restlessness. If the machine increases the pressure too much in response, however, that can lead to aerophagia and restlessness problems later in the night.

Personally, I think you've got to get the restlessness and tossing and turning under control first. In order for CPAP to help, you actually need to be getting some sleep. Once you are doing less tossing and turning during the night, it will be easier to tease out whether any residual REM-related clusters are a big problem or a small problem.


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#77
The tossing and turning in the last few days has been unusual, at least in degree. I would say that it can happen on a semi regular, but random basis, but the examples here, especially last night and the night before, are as bad as it gets and not the norm.

None of the charts here are with any trazadone, but I am open to experimenting with it again to see what the impact is. I'll probably wait a few more days before adding that.

Here are the charts you were asking about, I really appreciate your looking at them and providing insight. Thank you!

Last night with the pressure included in place of ahi:

https://1drv.ms/i/s!AgFs7hWqVGNflXvYZytUTfwZ5kLy

This was such a bad/unusual night I wouldn't draw too much from it



1) a series of screen shots of the very beginning of the night. I'd like them to be about 10 minutes long or so so that the individual breaths are visible. That would mean I'd like to see:

https://1drv.ms/i/s!AgFs7hWqVGNflXzLN6l9r5KUxlqi

23:30-23:40 (Get the very beginning of the night!)



https://1drv.ms/i/s!AgFs7hWqVGNflX059wGxaaAIlaIB

23:40-23:50

https://1drv.ms/i/s!AgFs7hWqVGNflX6sX71W95iq5pjH

23:50-0:00

https://1drv.ms/i/s!AgFs7hWqVGNflX6sX71W95iq5pjH

0:00-0:10

https://1drv.ms/i/s!AgFs7hWqVGNflX-8HOhvTG--gg9f

2) a 5-minute snippet centered around 0:20. There are no events here and my guess is that this represents a period when you may have actually been asleep. I'd like to see more about what your "best" sleep breathing seems to look like.

3) a series of screen shots that show what happens at the beginning of the 2 hour, 58 minute session that starts around 2:50. Again, I want them to be about 10 minutes long so I can see the individual breaths.That would mean I'd like to see:

https://1drv.ms/i/s!AgFs7hWqVGNflgCg7cqvB-DLfr57

2:50-3:00 (get the very beginning of the session!)

https://1drv.ms/i/s!AgFs7hWqVGNflgEmm4B5fPg5Pvmw

3:00-3:10

https://1drv.ms/i/s!AgFs7hWqVGNflgIgm3LiXzaJc0mO

3:10-3:20

https://1drv.ms/i/s!AgFs7hWqVGNflgPcLwqByamoqQPg

3:20-3:30
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#78
Robysue, the October 18 night was an experiment with some radically lower pressure 6/6 that I suggested to see if the OA was still present. It really wasn't too bad, but the hypopnea and comments by Ezil71 had us abandon it without a fair shot. The purpose was initially to see if we could relieve the aerophagia with lower pressure, and to see if a consistent CPAP pressure could be useful. We did this in auto mode to correlate any flow limitation, and I think we overlooked that channel in the data.

Just a quick question. With what you've seen so far, do you concur with my conclusions that bilevel would be advantageous, and he should pursue this aggressively with his doctor?
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#79
(10-22-2016, 05:31 PM)Sleeprider Wrote: Just a quick question. With what you've seen so far, do you concur with my conclusions that bilevel would be advantageous, and he should pursue this aggressively with his doctor?
Yes, I think a real bilevel would be useful here, and not just a Resmed AirSense with EPR.

A real bilevel would keep the pressure at EPAP through the entire exhalation (unlike Flex) and it would also allow for a greater than 3cm difference between IPAP and EPAP, which could help eliminate the clusters of Hs at continued to pop up when Ezil used CPAP at 6.

With a PR DreamStation BiPAP Auto, Ezil would also have the ability to run in an auto mode that would increase the EPAP only when snoring or OAs were present. And it would keep the EPAP down all the way to the beginning of the next inhalation. On a Resmed machine, the EPAP would be increased in response to all types of events.

To make that last point clearer, let me talk just a bit about my own experiences and why I'm glad I have the PR BiPAP.

My stomach can handle EPAPs up to about 6cm for short periods of time without any real problems; based on multiple trial runs with dial winging, I know that an EPAP of 7 for even a short period of time guarantees I have aerophagia problems. My stomach also prefers to have the IPAP at 7cm for as much of the night as possible, but there are times when I need an IPAP = 9cm to properly address my flow limitations, RERAs, and hypopneas. If my IPAP goes over 9cm at all, that also will trigger the aerophagia. And there are rare times when I do need an EPAP = 6 to deal with OAs.

With the Dreamstation, I can set min EPAP = 4, max IPAP = 9, min PS = 3, max PS = 5, and this allows the IPAP to go up to 9 (if needed) without increasing my EPAP from 4cm when there are no OAs or snoring. But it also but it also prevents my EPAP from going above 6 based on more than average snoring during the night. (Snoring is what usually drives my EPAP increases rather than clusters of OAs.)

Most nights my 90% EPAP is either 5.0 or 5.5, but my 90% IPAP runs at 9.0 almost every night. If I were to use a Resmed AirCurve V10 Auto, I'd have to choose what to use for the fixed PS. If I set PS = 3, then my EPAP would hit 6cm a lot more frequently than it does now; if set PS = 4, then my IPAP would not be able to go up to 9cm when it needs to do that.



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#80
I agree. I have both the Aircurve 10 auto and PRS1 760. I mainly went to bilevel to deal with RERA, and the PRS1 I bought out of pocket worked great at 18/9 PS 2-6. I now have fixed PS on the Aircurve, and have had to keep it at 3 since I get some CA clusters at the higher PS. That and the Aircurve does not record RERA events. Both seem to work well so since the Aircurve came form insurance, I'm using it until I'm sure it is irrevocable.

Sorry for the slight thread hijack, but appreciate you confirming what I as suggesting earler in the thread, and I still think this is the most important effort Esil71 can make for long term therapy efficacy.
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