96 days in, the Hen will finally see Dr. Questions?

[TheManseHen]

And as a thought that just occurred to me looking at your flatline under snores...

When one is well treated with a low low AHI, do snores totally disappear for everyone?

Is absence of snores a significant sign of perfect pressures/treatment response?

Must be nice.

Hen

[TheManseHen]

Here is my most recent overview, and an example of an avg good day and an avg less than good but not worst, day.
So far, as best I can figure, the sleepyhead on Mac doesn't allow me to do the little drag thing it did on Windows to make the viewing area thicker or thinner. This is the best I can figure right now. Hope I have the one's I intended to post here as I can't seem to see a preview.

[attachment=1381]

[attachment=1382]

The one below, as you can see there were some mask off areas. I never ever knowingly sleep with mask off, not for a nap, not for anything. I have gone through a period in the last three or so weeks, where I sometimes take the mask off in my sleep and don't know why.

[attachment=1383]

And a particular bad night with close-up of what it's calling central apneas.

[attachment=1384]
Any thoughts?

The Hen c-pap was an easier adjustment
for me than going to Mac. I'll get there, hopefully.

[Sleeprider]

Cropping an image is an easy way to isolate information. That wave form is simply a crop of a much larger screen capture.

Snoring for me varies. It can go away completely for weeks, then reappear, generally below 1 to 1.5/hour. I prioritize OA followed by H. With the BiPAP I have been able to completely eliminate those, for the most part. I tend to try different things, and my current "experiment" is to lower EPAP pressure to reduce CA and increase pressure support to prevent OA and H. The trick is to work on one thing at a time and allow time for results to show a meaningful average.

[TheManseHen]

Maybe in light of what you are saying, my next step should be to lower EPR, but I'll probably make that one of the doctor questions as I'm so close to appt now.

[Sleeprider]

Thanks for the new graphs. Those are great. The clusters of CA and periodic breathing in the last graph are indeed characteristic of the waxing and waning pattern seen in Cheyne Stokes. In patients with congestive heart failure, that pattern can go on for the whole night, and they need to be treated with adaptive servo ventilators with timed backup. For you, this is fortunately a pretty rare occurrence, but the presence of centrals in your AHI is keeping you near an AHI of 5.0 on good nights. On bad nights CPAP does not seem to be very effective.

It appears your pressure is treating OA fairly well, but not great, but your CA index is moderately high. CPAP does not work with centrals very well. I would take these charts to your doctor and ask whether bilevel therapy might be worth considering. Bilevel would allow you to increase inhalation pressure to keep the airway open, and provide relief to 4 cm during exhale. The pressure shift is noticeable and can help you improve your respiratory volume, which may be comfortable, or might make you feel like you're being forced to breath until you get used to it. You have been using EPR at 3, and we're talking about an EPR of 5 or more with bilevel. That maintains your airway at 10 to 12 cm during inhalation, while backing off to 5 to 7 cm or less during exhale.

I don't want to get ahead of the game, but you have both OA and CA above accepted (5 AHI) levels routinely, and the bilevel discussion seems warranted at this point. It would be good to know how you respond to less EPR so we could evaluate what the effect of more EPR might actually be. I think less EPR might help with OA and H, but could aggravate CA, but some people respond well to less pressure swing, so no way to know without trying.

[TheManseHen]

Thanks SleepRider,
I think I'd read somewhere that they don't typically prescribe Bi-level's for centrals unless the centrals exceed, it was either 5.0 or 10.0 They are definitely keeping my AHI high when they are present.

My biggest fear is that the Dr will give up on me. That is probably not likely, but it can happen. Given that he's a specialist and not a GP I think it is even less likely to be so. I know I'm giving it ALL I have.

Since you have a Bi-level, can you tell me, are they any harder to adapt to typically, than c-pap? Do you have to use different masks etc?

Thanks for the help!
The Manse Hen

[justMongo]

Bilevels are most often prescribed for patients who are non-compliant on CPAP; or need high IPAP pressures; or need more EPR (PS) because of obstructive lung issues. The ASV is the gold standard for CA.

In my amateur opinion a lesser EPR might help. Dropping pressure on exhale may permit too much CO2 to be expelled effecting central ventilation drive.

I'm on a bilevel auto; and with "easy-breathe" tuned on, the transition from IPAP to/from EPAP is smoothe.
My PS is 5; and I throw a short central perhaps one in a week with a time duration less than 15 seconds.

[Sleeprider]

I agree with JustMongo. Sometimes EPR can cause centrals, although it is pretty rare. Bilevel is just a more comfortable version of CPAP with greater exhale pressure relief. It lets you hit higher inhalation pressures while maintaining a low exhale pressure. To me, that sounds like a solution to issues you have raised with regard to sensitivity at higher pressures.

You progressed from very fragmented sleep and therapy to where you now tolerate a full night without breaks. You have indicated you feel better and have addressed nocturia issues. Nevertheless your apnea incidence is barely acceptable to moderately severe under your current treatment. I think you need to at least discuss bilevel with a doctor and get his opinion. It may well be he will not see it as beneficial, but you started this asking us what you might discuss. I think that finding a path to consistently enjoy unfragmented sleep at LESS THAN 5 AHI is a valid discussion.

Bilevel uses the same mask.

[rhandel]

Hen,

A good night's sleep is really wonderful.

I joined you all in January on CPAP, (I had a friend's old one for trial before so I kinda knew what to expect). I am still learning. I admire you determination.

I have been totally unable to get my AHI to reliably stay below 5 more than 4-5 nights out of the week. I am also trying little changes to my range on the Auto PAP but not without confirmation of my Dr. I do put a call into the Dr. on occasions to ask to have the machine prescription changed. That seems to work well. I use the following rational:

Doc, I cannot breathe and get to sleep. How about increasing the LOW end of the range from 4 to 6? Dr. calls me back and has changed script. DME calls me to do the adjustment. My answer is, it's already adjusted. Case closed. LMAO

I let the Doc know that I knew how to do medically related changes and that I am an avid reader. I was up front with her and she has been really responsive.

It's a two way street. She lets me know what to expect and I tell her my experiences. I can contact her via private messaging service through the hospital she is attached to. Great stuff.

My next thing is to see if a different mask and some more tweaking will improve my results. But she is fairly certain I am fighting more CAs than she would like and that my treatment is on track otherwise.

For example, my AHI was 6.3 last night but I had a great night's sleep. I try and check how tired I am during the day and how I feel when I get up BEFORE I seek confirmation of the AHI number on the machine. Numbers and graphs and all aside, if you feel better that is the key.

The empirical method goes like this:
1) Improve with small changes one at a time.
2) Wait a week to evaluate.
3) Evaluate.
4) If improved go to step 1
5) If worse, reverse the small change
6) go to 1 with a DIFFERENT change.

Just some rambling thoughts.

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Sleep Rider / et. al.,

Thanks for your thoughts. I learn so much reading your analysis.

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RAH