2farfromshore Therapy Thread

[jdougc]

Were you on your back?

sleeprider said before. "2far, you need to increase EPR to 3 and resolve the positional apnea." You didn't heed the 2nd part about positional apnea.

https://www.apneaboard.com/wiki/index.php?title=Optimizing_therapy#Positional_Apnea

[2farfromshore]

Not true, and no offense, but you can't know that because you weren't there. I was on my sides last night, and have been for 4 nights running, more than my back. I was always a side sleeper until the nocturnal arrhythmia began. I found that sleeping on my back reduced its occurrence. I suppose its due to added pressure on the heart. The odd thing was it would occur on either side when the expectation is it occurs when lying on the left side.

A couple of things: I was uncomfortable with the EPR on 3 from the go and during the first half of the night. The little bump that transmits through the mask when the pressure is up and you exhale bothered me. 

Also, at the end of the graph where the CSR occurred, I was awake at least half that time because I recall lying on my side and activating the Clinical Settings on the CPAP (takes two hands) so I could see AHI and I got out of bed maybe 10 minutes later.

[jdougc]

You had positional apnea, the clusters of events, starting at 19:15, where you may have tucked your chin to your chest. This cuts off your airway and no additional pressure can open it. It is like a kinked garden hose.
This can happen to side sleepers.
Are you using a soft cervical collar?

What was it about EPR setting of 3 that bother you so much?

Can you explain what this means?  "The little bump that transmits through the mask when the pressure is up and you exhale bothered me. "

Please don't look at the screen as you are waking up, but make a note of how you felt and how your day went.
Look at the numbers later after you have started your day.

[Sleeprider]

We see clusters of events like this with "positional apnea". As the article I linked before suggests, it is not just back-sleeping (supine), but can occur any time you tuck your chin. A common problem in side sleepers is getting into a fetal position with a sharply tucked chin. A trick I sometimes use when sleeping on my side is to keep a corner of my pillow between my lower shoulder and jaw to keep a good head/neck position.

[SarcasticDave94]

Positional Apnea isn't limited to back sleeping. It's something you'll need to watch for and take action on it.

[2SleepBetta]

It sure looks to me like you are unsurprisingly getting good advice from multiple sources. I chose to look mainly at your better flow rate and flow limitation episodes.

What struck me in a quick look at all your graphs were your episodes of the most uniform flow rate, no apnea and lower or mid-range flow limits pretty much throughout. There are other episodes of similarly uniform flow rate where—most often near the end of them—there would be a sharp ramp up of dense higher and higher flow limitations that would become right triangles on the timeline, become triangles which enclosed flow limitations so dense triangle interiors are white. 

Your first posted image and others show flow-limit-rise triangles (not all of them or elsewhere white in the interior). One or more instances show them arising repeatedly within a relatively uniform flow rate episode. Those resets strike me as indicating positional drifting and resettings, or maybe, increasing airway relaxation or congestion or ....?

Those differing episodes, together with some of the few dips in pressure and sometimes a coincident pike in leak gave me, too, a clear impression of positional apnea of some sort.

My apnea and high flow limitations improved tremendously after I lurked and soon applied what I saw and got here. I started with an Airsense 10 Autoset on APAP 4-20 as prescribed by an MD who was a PAPer himself and had me take a home test when I complained of nocturia and had a heart murmur (aortic valve damage from rheumatic fever as a preschool child).

Through time with increases in EPAP and EPR, my getting and using a 3.5 in, and soon, a 4 in. C-collar and a draconian measure to prevent supine sleep my numbers were vastly improved. After that I gained much more, flow limits and numbers wise, when I bought, used, the AirCurve Vauto VPAP and only needed 1 more cm of pressure support to, as I recall the years, get mostly AHI's in the 1.0-2.0 range, much of them lower. But I have never been much troubled by CA. For years, AHI has lingered within the 0.00-2.0-outlier range.

Yeah, lifelong I had times of tiredness, especially with a lot of short sleeps, but even with moderate and severe apnea I thought I got rested most of the time. (Thank you Lord, who will help even fools who turn and stumble along behind you.) But insidious, increasing blood pressure was costing me and my heart and probably not doing my brain or thinking any good.

I was and probably most newbies are skeptical about all this "positional" stuff members bring up in their responses to posts. Early struggling with masks and all, it took not only the measures mentioned earlier, but also my use of an accelerometer to prove to myself that I have to avoid sleep within about 20 degrees either left or right of supine. My sleep test 15 months ago stressed avoidance of supine sleep, without that MD, or my earlier pulmonologist (a prof at the University of San Francisco Medica School), ever mentioning use of soft C-collars—but I told them of the benefits. 

If needed and interested in my two draconian, DYI, supine block ideas, search my member name with "vest" and "pipe". Currently, while cutting coffee use, I'm using the pipe block again to eliminate "supine" noise so I can see changes from caffeine intake. With the block and coffee cut: immediate good results, I even got five consecutive 0.00's after never seeing more than a pair of them before and, moreover, I've had two dreams in about a week, as I rarely remember having any in recent years. Supposedly, more physiologically restorative sleep came from REM (it being associated with dreaming). I cannot say I feel much different except with less coffee I begin to feel more ready to hit the hay, quit the monitor screen. 

Knowing how we feel, better or worse, after sleep prophylactic changes, is the most important, it troubles me not much remembering now big jumps in better sleep after I started and continued using PAP. It helps health and I just have to do it. 'Could be a bit like some women who do not totally remember pain of childbirth . . . . or from declines of some with advanced age.

[2SleepBetta]

Not seeing activity here, long ago when I began this post today, I thought it possible advisors might have moved on thinking your follow through on recommendations was insufficient. So I’m blathering on, having had difficult first months of PAPing myself. 

Seasoned members’ helps for challenging  responsive cases have continued indefinitely for, maybe, more than a year.  ‘ Could be your helpers are here already or have been working, paying for my Social Security and Medicare.

Also, I came and saw no new post with fresh graphs from you.
,
Comments after a second look at your graphs and, particularly, your disappointment with EPR 3 in post no.30. If it were me I’d have been pleased with reduced flow limitations.

If graph no. 30 were mine in a thread context like yours, I’d bump pressure up at least 0.5 and keep EPR 3. 

CA might go up too alarmingly. If so cut the  pressure increase back to 0.2 and feel your way higher with hope to find CAs were either  treatment emergent or just false as Sleeprider indicated.

C-Collar: stand like a new Marine-to-be at t-shirt collar inspection. Measure distance jaw bone to top of the two knobs in your collar bone. Get a collar height as high as tolerable in sleep, inch it up over time if you must. 

Neck lengths may differ. My knobs to jaw is near 3.5”, (hard to measure for oneself, maybe understated). C-collar chin-dip height 4” and jaw height 2.5” off the dip center line 4”. That collar performs much better than 3.5” one  it replaced. Worn now in Marine posture, there are a very slight vertical force jaw to jaw contact and inserting below the chin my index finger to mid-knuckle comfort seems close to that of my first moments lying in bed; I can easily slip all four fingers between collar and neck, clear up to largest knuckles stopping against my chin.

Our physiques and some history are almost identical in metrics you shared, extending even to arrhythmia, PVCs, sleep bradycardia (HR 40) and one long ago episode each of tachycardia in resistance and, later, cardio exercise. Serially I had LAD artery stents, a TAVR (bovine valve) and a pacemaker implant over the course of 9 months, all done 9 years ago by this August.

[Crimson Nape]

The last time the OP was on the board was June 15th.
- Red

[2farfromshore]

I appreciate the thoughtful replies, Jon, thank you. I don't view or log-in every day and also don't click the link in every email alert to replies. I get up very early in the AM and go to bed early, so that's a big part of it, especially when I'm busy. And I've been very busy lately. 

I'll try EPR 3 again and see. 

The AHI total has been at/below 5 for a week now, but the morning headache has returned pretty much every morning. I didn't have them when the AHI was higher. C02 or something going on possibly. The headache passes within an hour or so after my morning (wait for it) ..... coffee :p