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Lots of flow limitations? Newbie wanting tips on sleeping better with PAP.
#1
Lots of flow limitations? Newbie wanting tips on sleeping better with PAP.
Hi there,

I've been using a Dreamstation for a few weeks now, and have finally situated things so that I'm able to sleep with it on for most (or all) of the night. However, I'm waking more often than I'd like and my husband says I'm tossing and turning a lot. Looking at my data in OSCAR, I'm seeing what I think are lots of flow limitations in my flow rate graph, but my machine isn't tagging these as such. This image from the OSCAR wiki classifies different types of flow limitations:
[Image: Flowlimitations_Classes.png]
I seem to have a lot of waves that look like #2, #4, and #7. Am I seeing this right?

As I scroll through each night, my typical sleep breathing looks something like this (lots of "batman" ears and flat tops):
   

I also see what appear (to my very untrained eye) to be flow limitations causing arousals? Like this:
   

And final example, apneas that I think were preceded by FLs:
   

I suspect that I may have UARS, but my in-lab sleep study isn't for another 5 weeks. I'm doing a PAP trial with this borrowed machine, trying to get some rest and feel a bit better while I wait for my study. Any suggestions? Should I change my pressure, or try to keep it at a constant pressure?

Thanks!
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#2
RE: Lots of flow limitations? Newbie wanting tips on sleeping better with PAP.
I agree with your assessment. The Philips Respironics Dreamstation machines do not offer either EPR or pressure support, therefore it does not treat nor really measure flow limitations, instead it measures reductions in flow/time that it really does not respond to with pressure increases.  You want a Resmed Airsense 10 or 11 Autoset CPAP which has EPR. Exhale Pressure Relief (EPR) acts exactly like a bilevel machine with a pressure support (PS is IPAP-EPAP) identical to bilevel, but limited to 3-cm.  The Philips CPAPs use FLEX which is a temporary reduction in pressure during exhale that is flow-based and limited wo 2-cm.  That was way too technical, but the point is, if you are coming up on an opportunity to select a CPAP, hold out for the Resmed Autoset.

EPR works the same as pressure support and increases pressure during inspiration to make it easier to get a full normal breath with less effort. It then reduces pressure during exhale and stays low until you start inspiration.  The Philips Dreamstation makes the pressure transitions a bit less abrupt using Flex, but increases pressure during expiration so that by the time you inhale, you are already at set pressure.  In other words no pressure support. This is what a Resmed Airsense 10 looks like with EPR set at 2. You can see the delivered mask pressure (you can't with Dreamstation) comes in behind inspiration to support a normal peak. Compare your pressure line to this mask pressure and imagine how much better this is for someone with upper airway resistance.

[Image: attachment.php?aid=27301]
Sleeprider
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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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#3
RE: Lots of flow limitations? Newbie wanting tips on sleeping better with PAP.
I SO appreciate this response. I'm oddly happy to hear that I may finally have found the reason (UARS) for my decades-long fatigue, unrefreshing sleep, insomnia, and brain fog! And I'm not surprised by your recommendation for a ResMed machine--I have seen this in other threads, and ResMed was also recommended to me by OpalRose. A few follow-up questions, if you don't mind:

1. I assume there's nothing I can do to improve therapy at this point, since this is the only machine I have access to right now?
2. Does it seem worthwhile to continue therapy with this machine, or should I not bother until after I'm able to obtain a different machine? On one hand, I'd like to keep it up so that I don't lose the progress I've made regarding my tolerance of the mask/therapy...but if continuing inadequate treatment could be setting me back in any way, please let me know!
3. If I continue with treatment, how long before my sleep study should I stop using the machine? I was told I should pause use before the study. 

Thanks so much!
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#4
RE: Lots of flow limitations? Newbie wanting tips on sleeping better with PAP.
1. What is your current flex setting? You might get some relief by using Cflex at a setting of 1 or 2. I think C-Flex is better than AFlex in your case because it acts mainly on the expiration.
2. I assume your AHI is lower now than your diagnostic baseline. Your apnea is reasonably well treated based on the one-night of data we see here, but there is clearly flow restriction. All of your charts provided are at your minimum pressure setting, and your respiration might be improved with moderately higher minimum pressure and the use of Flex.
3. I'm not aware of any guidance to discontinue treatment ahead of a sleep test. If you have records from a previous test, those may be sufficient for getting a new machine.
Sleeprider
Apnea Board Moderator
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____________________________________________
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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: Lots of flow limitations? Newbie wanting tips on sleeping better with PAP.
1. My current A-FLEX setting is 3. I tried it on 2 very briefly, but found it to be hard to breathe. I just looked up the difference between A-FLEX and C-FLEX (I had no idea), and it sounds like C-FLEX might be more uncomfortable, but I'll give it a shot! It does seem as though it'd be more effective. TY!
2. Worth noting--I don't have a diagnosis yet. I've never had a sleep study before. But I'll raise the pressure a bit as well and see what happens. Thank you again for confirming the flow restriction!

To clarify: I have risk factors and symptoms of UARS, but have never had my sleep tested before. I was having terrible trouble the last few months with sleeping, to the point that I was missing work. So a co-worker is letting me borrow the DS1 she's no longer using. I decided to try it out to see if I could get any relief and/or troubleshoot my sleep issues while I wait for my sleep study which is still 5 weeks away (March 31).
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#6
RE: Lots of flow limitations? Newbie wanting tips on sleeping better with PAP.
Hi Sleeprider,

I've been working on increasing my pressure and adjusting FLEX. I was wrong, I've actually been using C-FLEX this whole time, and it has been on 3. I tried it on 1 with a min pressure of 10...and that was a bad night. LOTS of aerophagia. Anyway, I'm not sure there's much I can do until I can get a new machine, but I'll continue trying to much more gradually increase pressure and see what happens.

Two more questions, if you don't mind:
1. You suggested I decrease FLEX to 1 or 2. Can you explain how this affects flow limitations? I find that the lower I go with FLEX, the more aerophagia I get. Eventually (once I'm OK with higher pressure) I'll try it at 2, but I think that's as low as I can go without a ton of gas pain. 
2. Could you (or anyone reading this) assess my awake breathing? Screenshots below. These shots are from a few seconds-minutes after I initially turn my machine on, so I'm definitely fully conscious. I'm wondering if I might just have upper airway issues generally, not necessarily sleep-related. I never seem to get a rounded top to my inspirations, even when I'm awake. I think the tops of the waves are supposed to be rounded, but mine are jagged and/or flat. I have no idea if this is typical, or an indication of some kind of breathing issue, or a sign that the delivered pressure is problematic. Thoughts?
   
   
   
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#7
RE: Lots of flow limitations? Newbie wanting tips on sleeping better with PAP.
I too have a steady stream of higher flow limits and brain fog that lasts till mid afternoon.   Picking up on this thread, I think I am hearing that one would treat flow limits by ...

RM 10 in APAP with 7-12 and EPR 3 with nasal pillows and mouth tape

- increase min pressure to support soft tissue ?    My flow rate graph looks like type 5 in the first post.

- maybe bring min and max closer together ... say going to 8-12 min/max ?

Just trying to get the gist of how to treat flow limits.   I have too much brain fog to figure this out myself.

Also wondering if CPAP mode would be better.   Tighter hold on soft tissue support?    Or moving Max and Min pressures close together and run in APAP mode with EPR.


Oh ... my AHI is typically between .2 and 1.0 and I still feel foggy and such.  

Much thanks!  -Don
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#8
RE: Lots of flow limitations? Newbie wanting tips on sleeping better with PAP.
I have repeatedly said that the Philips machines are inferior for treatment of flow limitation as compared to Resmed. That said, the images you posted don't mean a lot unless I know the settings and conditions you are trying to illustrate. I want to especially caution you against showing the flow chart in the moments after starting therapy when you are still awake as this is pretty meaningless to your sleep respiration.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
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Optimizing Therapy
Organize your OSCAR Charts
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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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#9
RE: Lots of flow limitations? Newbie wanting tips on sleeping better with PAP.
I understand, and I plan to buy a resmed after my sleep study (assuming it's positive). I take your response to mean that there's no improvement I can make in the meantime. I feel terrible. If that's going to continue the next few months while I wait for diagnosis/new machine, I'm debating whether it's worth continuing with this DS1 or just go without until I can get the resmed. 

Regarding FLEX, I was wondering why you suggested I keep it lower. I did some more research and I think I understand (higher FLEX can potentially artificially shorten inspiration because the PR machine tries to predict breathing vs react to it). Lower flex settings should allow you to breathe more fully if you're sensitive to the predictive thing. 

And I was asking specifically about my awake breathing via those images. Perhaps that's beyond the reach of this forum, though. Or irrelevant, given that the machine is for sleep. I was just wondering if it's normal to have non-rounded breaths all the time (both awake and asleep).
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#10
RE: Lots of flow limitations? Newbie wanting tips on sleeping better with PAP.
Flex does not follow your spontaneous breathing. I pretty much showed in post #2 how Resmed follows inspiration with a pressure increase, and expiration with a pressure decrease. Philips does not. It predicts when the next breath is coming and has already increased pressure before the breath is taken. This means the increase in pressure in not there to support peak inspiration, in fact it might be dropping in anticipation of expiration. At setting 3, the machine transitions sooner and this causes increased sync problems. The Philips does not follow your respiration, it leads it. The Resmed always follows and supports. That's the best explanation I have. Find any cohort of individuals on this forum that have used both, and 90% plus will have experienced a 50 to 90% reduction in AHI with Resmed. There are a minority that will say the Philips was better, and I won't argue it's different, and probably better for some.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


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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