Pokey49 - Therapy Thread

[Pokey49]

Ok I can list bullet points of why mu AS11 isn’t doing the job for me. 

What would key bullet points be for the BIPAP. I’m
Not clear yet on its advantages

[Pokey49]

Last nights OSCAR doesnt look to good in my estimation due to the reason for the AHI. Attachment #1.  I narrowed my pressure settings to 8-9cm EPR3  as was suggested to see if that would avoid big pressure swings and stop the CAs. My entire AHI of 4.3 last night was all due to CAs. Im starting to get a bit concerned about what is going on. 

Night before last Attachment #2, I used a pressure range of 6-20 and only had 3 CAs all night with AHI 0.65. However breathing was easier last night with the narrow 8-9 pressure range. I did not wake up feeling air starved as in nights past.

Does any of this help make the case for BIPAP?

[jdougc]

Pokey, the good news is that you had more gentle relaxed breathing periods last night, periods of no spikes.

You do get arousals with chaotic breathing after flow limitations and the aggressive pressure increases. They bother me, but I settle much more quickly than you do.
Not sure why a barely noticeable flow limitation caused the pressure increase at 2.44. I had to zoom in to see a tiny flow limitation

Consider trying an even tighter range tonight of 8 cm to 8 cm . No pressure change.
Hopefully you have another night of no obstructive apneas and maybe less CAs.

[Pokey49]

JDoug: how does one explain the nights like the 2nd example I showed where I had a wider pressure setting, 6-20, and had an AHI of only 0.65 and only 3 CAs. But that is not always the case either.  I had other nights with the same setting and higher AHI with more CAs. Im trying to make sense of what's happening and its not make any sense to me.

[jdougc]

Pokey, 
I will defer to more experience people here explaining CAs in your case.

I have seen that you have a lot of spike breathing after flow limitations, which might mean you had an arousal. These large breaths lower your CO2 and your brains says skip a breath to normalize your CO2. This goes on and on for you. 
I suggest a tighter pressure range to minimize the arousals and the subsequent large breaths and CAs. 
I can't explain your sensitivity, but I can offer tips how to possibly minimize the chances of having these arousals.

[jdougc]

Pokey, 
Ii just read a post about CAs. I edited out the info about collars though.
I found it very informative. The writer, Sleeprider a (Wiki Editor), provided settings for my bilevel, 

we treat flow limits with exhale pressure relief (EPR), but the setting only goes to 3, so set EPR full-time at setting 3. This will provide 3-cm of pressure relief during exhale, just like a bilevel. Another way to look at it is, it provides 3-cm of pressure support during inhale to help you overcome the airway resistance.  A final note, your CA events are likely incomplete obstructive apnea. With very high flow limitation we see an open airway as the "victim" attempts to get a breath, but things are so restricted it shows up as an open-airway or clear airway apnea (CA). This is not neurological or even CPAP therapy onset, but an artifact of how the machine detects the type of apnea.

The last part about the CA being an artifact might explain your CAs, since your CAs usually come around the "scored" flow limitations.

[super7pilot]

Pokey, i saw a video about pap basics. And the analogy was one of a teeter totter. With OA’s and H’s on one side and CA’s on the other. Tamp down one side and the other goes up.

That happens to a lot of folks. On Saturday night i had 5 ca’s and 2 h’s. Then on Sunday night I had 1 H and zero CA’s. Same settings and mask (N20 air touch) both nights.

[Pokey49]

JDoug and SuperPilot- I understand that the AHI #s can swing back n forth, despite the pressure settings,  between OSA, Hs and CAs. I'm definitely seeing that happen. I'm not sure about the EPR 3 argument being enough that you shared JDoug. What concerns me more than the actual #s is how miserable I feel when I wake up. I told my wife this morning  I felt like I'm rising from the dead when my AHI is predominantly made up of CAs like it was this morning. I did feel like it was easier to breathe last night on a setting of 8-9 EPR 3, but the #s were not good and Pokey did not feel well.

[jdougc]

Pokey, I am sorry you felt so terrible this morning, but I am not surprised.

The CAs, though numerous, probably were not the culprit.
The Flow limitations are your main issue. 

You have shown a few zoomed in charts with awful breathing tops, flattened or skewed and rarely scored as flow limitations. This machine can't treat them effectively, EPR is at 3 already. 
That is why you would need a bilevel, to feel better. 

You could try raising your minimum but keep a tight range of pressure.
Try 9 cm to 10 cm for a few nights and see if you feel better.

If you don't feel better scroll around your flow rate chart and see some of the breath wave forms and post some anomalies, except the beginning or end of the night

[super7pilot]

Pokey, I think (but could be wrong) your CA situation is more from sleep wake junk from a low tolerance to pap. By that I mean that your being aroused from sleep is what is leading to the unrested feeling and those same sleep disruptions are also setting up the CA's. Not the opposite. It is my understanding (and experience) that a low Co2 type of Clear Airway will not result in a low O2 saturation or a feeling of being unrested.

Now of course a true Central Apnea is quite different and will result in a lowering of one's O2 level.

A low Co2 Clear Airway event on the flow rate is easy to see as there will normally be a large inhale followed by a cessation or reduction of breathing. And can be flagged as a CA or even a Hypopnea. That very thing happened to me last night. I had a deep breath followed by a reduction in breathing. But it never went into a CA and was flagged as a Hypopnea.

A Clear Airway that happens because of Sleep Wake Junk is simply a sloppy hand off from sleep to wakeful breathing (or the inverse) and is easy to see as well.

A true central will show a normal flow rate pattern and BAM you suddenly go to zero breathing.

Then there is the area of variable breathing from a DELAY of the chemical sensor info in your artery to one's brain. Which I take is very similar to how a CSR pattern starts. As I understand it this falls under the banner of "loop gain" And can happen even if one isn't suffering from heart failure. And is just a timing issue.

And here I went most of my life thinking that when we are tired, we just lay down and just go to sleep. Had no idea it was this complicated and frustrating.