Please Let it Be the Apnea

[Sleeprider]

Without the sleep report and recommendations, we won't know what your therapist was looking at, or how you ended up at such very high pressure with no apparent reason. We know you are uncomfortable and so we're assuming your pressure needs are on the high-side, but we are basically starting over. Nothing about those old settings was working for you, and I can guarantee you will not only feel better, you will sleep and eventually recover from their error.

Bonjour is correct. IPAP minus EPAP equals PS at any pressure. Titration normally identifies a minimum EPAP pressure where obstructive apnea is brought into efficacy, and pressure support is used to control hypopnea and RERA. That's where we're going.

The 16 cm pressure is interesting, because if your study intended to give you PS 7 with a maximum pressure of 16, then we just nailed EPAP at 9.0. We'll figure it out.

[Woke]

Thank you folks for the clarification on pressure support, this has been a lot of learning.
 
I did much better last night; I am noticeably less tired.  The unrelated obstacles were less of an issue than of late, but I would not feel this good regardless of that before the CPAP.  I spent much more time continuously in bed with it on than previous, and though I still cannot vouch for how much time I actually was asleep—I had some dream-like stuff going on at one point!  I have attached the screenshots.
 
It looks like I do have a copy of the actual machine/supply order to the original DME.  Unfortunately, this doesn’t do much explaining.    I left a message with the sleep lab hoping to get direct copies of both studies, so that I have that titration information.
 
I had some weird issue with tubing initially that delayed things last night: air was loudly rushing from somewhere that sounded like the connection between hose and machine, but I could not identify the location readily by feel.  After several attempts to examine and re-connect, I tried with a new hose and the same thing at first, but then success upon reconnecting it.  Both are the ClimateLineAir (37296), I cleaned and am letting dry the original so I can try it again tonight.  I would prefer to conserve supplies given this new DME has the worst ratings I think I have ever seen for a real business on Google/BBB, largely about supplies either never delivered or delivered late by weeks, months, or more.  If only my original company was in-network now…

[Dormeo]

I'm so glad things are getting better for you! Don't be discouraged if there isn't a straight line of continued improvement -- just keep your eye on the general trend. (Though a straight line of continued improvement sure would be nice!)

[Sleeprider]

I'm glad to see the improved comfort and hopefully it will continue. In this latest chart we see several CA events and it looks like you have some periodic breathing going on. It's surprising because you were using 7 cm of pressure support before, and here you are with 5 cm and having pressure support related issues. I'd like you to make the following settings:
Reduce pressure support to 4.0
Change "trigger sensitivity" to high.

Everything else the same.

It's possible the air leak was a loose humidifier tub that seated when you were attaching the new hose. Hard to say. The nedian leak rate has gone down quite a bit with the new settings from 9.6 to 1.2 L/min compared to your last charts.

[Woke]

Sorry about the delay, I seem to have confused OSCAR by having an existing record for the night of the 27th, so it does not display the actual night of the 27th.  It was a great night and I had the machine on longer than ever, and if ResMed’s myAir is correct had very few leaks, etc.  Last night was decent.
I did get a copy of the sleep studies, although after all the trouble they only gave me the reports and not the diagnostic data.  I gave up as I needed to get back, perhaps this is all that matters anyway.  Regarding the pressure selection:
“Overall, throughout the night his apnea/hypopnea index fell from 118 down to 25 with a minimum oxygen saturation of 86%.  However, at bilevel of 23/16, the apnea-hypopnea index was 6.5 with a minimum oxygen saturation of 91%...”
It sounds like the logic was there during the test, making the case for a starting point anyway.
I have posted last nights screenshot.
 
I saw the recent discussion of UARS earlier—something I had never heard of—and how something was missed because it was not significant enough to flag.  That got me curious on what various things look like up close and trying to interpret what I see.  To that end, I took some screenshots.



Figure 1

For instance, in the above one with flags: I see the OA incident at 04:41:20, that makes sense, and I guess I see how it arrives at the hypopnea conclusion at about 04:42:50, but what is going on at 04:40:20 and 04:43:40?  Maybe these are just normal variations, I am just curious.  I can find little weird patches here and there throughout the night with no flags by zooming in, are these just expected little variations that happen naturally?  Apnea/hypopnea events that did not get picked up, presumably owing to being under the qualifying ten-second window?



Figure 2



Figure 3



Figure 4


And a longer-duration pattern:


Figure 5

[Sleeprider]

Your chart above shows median flow limitation at 0.00 and maximum at only 0.15. This is exceptional, and inconsistent with a chronic UARS response at PS 4.0. It's possible you just had an off-night at the sleep lab, but the fact is, you are less than 1 event per 2 hours at a much lower EPAP and pressure support than what was titrated. The most valuable part of a titration report is the chart where the sequence and time of pressure trials is done, and the apnea, hypopnea, oxygen and other data are recorded in a table. That table would show how they arrived at such high EPAP and pressure support. Suffice to say, they got it wrong.

In your detailed charts, the events at 04:40:20-40 appear to me to be a couple flow limited inspirations at 04:30:35 followed by normal breathing and an arousal. That lag time is about right for the limited breaths to cause a CO2 response. This looks like a shift in body position with irregular breathing, and the following apnea is not followed by recovery breathing, so it may have all been part of a toss or turn in your sleep. Note the single spike in leak at the same time suggesting movement. There is 30 seconds of flow limited breathing ahead of the flagged hypopnea and some more at 04:32:45. These are not severe flow limits but they do show up in the full night chart as some of the highest of the night. Most of the rounded and irregular wave-forms you found look like arousal or awakening that you probably were not even aware of.

I told you, we'd make you sleep. Now let's see if you can stay asleep for 7-hours or so.

[Sleeprider]

Regarding the OSCAR problem for the 27th. Highlight the data you have for the 27th that is not displaying or go to the calendar day for the 27th. Now use the Data menu, Advanced, and select Purge the Current Day. Once you do this, OSCAR will properly re-import the data for the 27th when you import data again.

[Woke]

Sleeprider –
 
Thank you for following things and helping me adjust my settings (and view my missing data).  From these numbers, CPAP therapy is a viable treatment option for the obstructive breathing while asleep, and it has given me some energy to explore any new options I can find to deal with the insomnia and any other barriers in order to stretch that duration out.  This whole sleep process will no doubt take some time, but I am spending less of that time feeling half-dead.

It is too bad that sleep doctors don’t all have little “ApneaBoard.com” business cards they hand out to all newly diagnosed patients.  Or DMEs, for that matter.  This board has made a big difference in my success and perception, and I am grateful to all involved.

With luck, this thread can mostly rest peacefully, and I the same!

[SarcasticDave94]

Congrats on your success. I hope it'll continue this way for you.

[Sleeprider]

Results like this are a lot of fun for me. Your frustration and sense that PAP therapy would be futile were palpable. You were tired, uncomfortable and bloated from aerophagia. Thanks for trusting me to guide you and making this happen. I wish you the best of luck in tackling the remainder of the insomnia issues. I think your success with the Vauto will give you a path to solve insomnia and greatly improve your life.