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THE ROAD TO SUCCESS...almost there, help fine tuning please!
#1
THE ROAD TO SUCCESS...almost there, help fine tuning please!
Following on from my earlier post http://www.apneaboard.com/forums/Thread-...ly-stopped, I think I am now finally heading in the right direction.

So, now I am looking for help to decide where to next.

My goal is to 
a) have AHI of less than 2 or even less than 1.
b) minimise leaks: (pretty much taken care of)
c) avoid recurrence of the side effects in my previous post: (avoid EPR of 2 or less and avoid undertreatment with too low pressures.)
d) achieve restful restorative sleep: still need to get there.

My "numbers" are generally very good but I still feel there is some way to go. 

I am still waking up during the night for no reason that I can see: not related to leaks/events.

I am still concerned about my flow limitations. I suspect these are my limiting factor, certainly associated with sudden spikes in FL or when my pressures Max out.

I am not feeling as refreshed as I used to when I started PAP therapy. Perhaps I am sleeping deeper and therapy needs changing. Certainly in the last few weeks I have been nodding off during the day, or in the evening while watching DVDs.

When I choose to not use the Nonin Oximeter I tend to sleep deeper (less disruption with the Oximeter lead getting tangled).

So I have now moved back to FFM and have settled on F30i Small Wide or Dreamwear Large.

I have largely chosen the For Her setting because this responds sooner, if a little gentler, and holds the pressures for longer. It lowers the 95% FLs somewhat, but there are still high max FLs and I am keen to tackle both of these.

I have gotten used to MinPress 9.4, initially this gave me aerophagia, but am adapting to this, and anyway I would rather have that than my other symptoms.

Still need to find that perfect pillow.....

My thoughts going forward are:

1. Back to APAP/Autoset, but with different settings, or try Soft Mode.

2. Dare I even try CPAP, say 10 with EPR3. I hesitate to do this because of this limits max pressure which caused my grief in the first place, prevents machine responding to FLs, maxes out the pressure and leads to HA and RERA.

3. Increase Min Pressure even more?

4. Find a way to increase PS?

Any ideas and input would be appreciated.

Here are my charts from the last few nights, generally representative of the last month.

Dec 24
   

Dec 25
   

Dec 26 (initial daytime sessions removed: I was trialling an F&P Simplus while awake)
   
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#2
RE: THE ROAD TO SUCCESS...almost there, help fine tuning please!
And here is my recent overview: 

   

the vertical red line is when I was hospitalised with chest pain etc. Came out of hospital, dumped the P30i and after that changed to FFM with higher pressures and EPR 3.

I note the gradual increase in FL, RERAs and AHIs.

I am wondering if this is as good as it gets with my Airsense 10?

Can I improve the FLs with this machine? I think I know the answer but would appreciate 2nd or 3rd opinions.

Thanks!

Chris
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#3
RE: THE ROAD TO SUCCESS...almost there, help fine tuning please!
I think it may be helpful to zoom in on the respiratory flow rate chart at a 2-3 minute zoom level. I'm curious why it looks unbalanced and "hairy" at times, and punctuated with large spikes in flow. I would typically suspect flow limitation and perhaps leg movement, especially since you have had some issues with leg pain recently. I think we should focus on those two possible issues as suspects in arousal.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
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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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#4
RE: THE ROAD TO SUCCESS...almost there, help fine tuning please!
I'm sure someone with more expertise than I will come along but I don't see any changes to take.  Your EPR is at 3, it is as high as you can go and that is what seems to help with the flow limitations.  And the flow limitations are the most pronounced event that you have.  Have you tried other settings like regular instead of for her setting?

The only other thing is a VAUTO which gives you more PS.  It will go up to 25ps which is like EPR in the bpap.  That is a lot of money for one without a good reason to think it would work.  sorry that is all I got - like I said, I hope someone will be able to make a more and better informed answer for you.
Apnea (80-100%) 10 seconds, Hypopnea (50-80%) 10 seconds, Flow Limits (0-50%) not timed  Cervical Collar - Dealing w DME - Chart Organizing
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#5
RE: THE ROAD TO SUCCESS...almost there, help fine tuning please!
Thanks SleepRider:

I have zoomed into 3 of the areas of concern of the 25th December for comments.

this is on For Her, 9.4 - 13.0 EPR 3 with F30i.

Do note I am using a SCC full time.

CloseUp1 at around 05:45.
   

CloseUp2 at around 05:49
   

CloseUp3 at around 23:30.
   

for interest my limb movement index for the diagnostic study and the titration were low, < 3, does that help?
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#6
RE: THE ROAD TO SUCCESS...almost there, help fine tuning please!
Hi Stacey

Yes, since I am on the F30i I have tried both the Autoset/APAP only, Autoset For Her. 

Here are some closeups of some trouble spots from the 26th when I was on APAP, (not the For Her)

HA1
   

HA and OSA
   

RERA1
   



Next thing I will do is try the Soft Mode for a few nights and see how this goes.

(Becker44a has found this to be useful 
http://www.apneaboard.com/forums/Thread-...rapy-Modes
and I last used this with the P30i which I have now discontinued.)

thanks for the reply.
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#7
RE: THE ROAD TO SUCCESS...almost there, help fine tuning please!
All of the events in your charts above show a rapidly increasing obstructive flow limitation leading to either OA or H events, and any of these can result in arousal as well. I had not expected to see a positional pattern, but it is certainly there, and these clusters of obstruction are most likely the result of chin-tucking from your sleep position. Another problem is that with the For-Her mode, your machine is not responding appropriately to the obstruction when pressure is at 12 or higher. I recommend you move to Autoset Standard, and increase max pressure to 15.

Take a look at the positional apnea wiki http://www.apneaboard.com/wiki/index.php...onal_Apnea You are repeatedly experiencing a chin-tuck or similar positional problem, and it clears after an arousal and repeats. We have found this pattern can be disrupted using a soft cervical collar http://www.apneaboard.com/wiki/index.php...cal_Collar Think about your sleep position, pillows and other factors that might be contributing to this pattern.
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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#8
RE: THE ROAD TO SUCCESS...almost there, help fine tuning please!
In some cases, your arousals/disturbances/blockages are concurrent with leaks.  The leaks aren't large, but who's to say you aren't sensitive to them when they DO OCCUR?  they look like they are innocuous, and that they would not bother the majority of us, certainly not well into our history of PAP usage.

If you look at your leak charts, you have few of them, but you do have the odd one.  Why do you also experience a disturbance in your sleep of some kind, whether holding your breath, taking a deep breath, or actually stopping to breathe?  If you aren't actually closing off or pinching and narrowing your airway, and causing arousals or hypopneas, maybe the way you relax fully is to deform or to deflect your mask, and that brings on a leak large enough to arouse you.

I'm must swinging in the dark here, hoping I hit something...anything that won't break me hand.  Too-funny
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#9
RE: THE ROAD TO SUCCESS...almost there, help fine tuning please!
@ Sleeprider, many thanks for the reply, very helpful, indeed.

1. on the issue of neck collars, yes I have been using this for months now. Indispensable. ATM I am just using the cheap and nasty ones from the local pharmacy but may need to import some better ones from the USA.

Also, I am looking to find the best combination of pillow and SCC.
A flat pillow keeps the neck more extended, which keeps the airway open and leads to more CA,  but my Medium size collar allows some jaw escape from the FFM. When I bunch up the pillow on its side, the SCC snugs up against my chin, and the jaw escape no longer happens. But I can feel my soft palate closing off a bit.

So now I have a slight thicker pillow, still soft. Why soft? because I have a thin neck and the SCC overlaps at the back and bunches up against the base of the skull, really uncomfortable. Still want tackle that with the wife's sewing kit.

2. Yes! The For Her mode. I did read something about the 12 cm H20 limit but never registered the practical application of this! I had this on my list to ask the sleep tech, too many other questions, but I think you have hit the nail on the head there. I will go back and look what happened in the past few months with the For Her mode when the pressures go to 12 or so. I will abandon the For Her mode for now.

I am trialling the Autoset Soft Mode for now, to see what that does for my FL, and my pressures.

Will keep you posted.

@mesenteria.

I don't discount this at all. when I used the P30i the mouth leaks drove me crazy and certainly led to disrupted sleep even with a complex arrangement of partial mouth taping. So far, I cannot cope with full mouth taping.

so yes maybe the leaks are still disturbing my sleep, I am getting used the little leaks from the FFM. Leak rates of 6 - 8L/min don't worry me anymore, perhaps as I get used to them I will be aroused by them even less. 

Swinging in the dark is always fun and can lead to surprises, I do like the lateral thinking. Just look after those hands!
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#10
RE: THE ROAD TO SUCCESS...almost there, help fine tuning please!
I am following up on this, desperately looking for more advice at this stage.

I feel  as if I got as far as I can with the Autoset For Her.

I will need PAP therapy for the rest of my life so I figured a backup machine would be a good idea.
No point in getting another For Her so I bit the bullet and am trialling the Vauto from one of the board's recommended suppliers. 

I started off with the Vauto on similar settings to those with the For Her, initial CAs were up but they are coming down.

Happy with my AHI, no longer chasing numbers.
There is still something missing in terms of therapy: I need to get rid of the side effects of therapy.

So: How do I feel? Not good: my sleep could be much better. Where to now?

My main sleep problems are:

1. Still waking up 1 to 3 or 4 times at night for reasons I cannot explain: no noises, events etc.
2. My leg veins still feel distended when I wake in the mornings, even sometimes during the night, this tends to last into the day: I never had this before PAP therapy. Reduced venous return. Sleep tech has no idea why.
3. Some mornings I need an hour or two for my breathing to "catch up" after mask off, some days I remain tachypneic during the day, RR around 20 at rest. Most days I recover from this during the day.
4. On masking up and settling in to sleep I like to take some slow deep breaths, but the machine seems to fight this.
5. Occasional headaches in the morning on waking up.
6. Despite the low MinEPAP when the mask comes off there is a noticeable sense of "Ah relief that feels better, glad to get the mask off"
7. Still having the left precordial fullness.

I have no ideas at this stage whether I am under treating or over treating, but I am sure the PAP therapy is messing with my vascular hemodynamics.

My Sleep Tech threw a minor wobbly when I showed them the new machine: (made in Singapore so Modem won't work here in Oz, no worries I will sort that out later if I stick with the Vauto). "Good on you for taking control" was the comment, "but would not have recommended the BiLevel for your condition."

I have good sleep hygiene, no stimulants after 3 PM,  evening meal at 6:30 PM then nothing more to eat. Meds and glass of water 8 to 8:30 PM, in bed by 10 to 10:30 PM.

SCC size medium every night, F30i SW or W, minimal leaks.

These are my settings for the last 6 days.
Min EPAP 6.0
Max IPAP 12.0
PS 3.2
Ti Min 0.3
Ti Max I have at 2.6
Trigger Sensitivity High: (machine came set as Medium but after advice in other posts I increased this to High and this seems to help reduce the occasional CA.)
Cycle Sensitivity still on default Medium.

Average Machine readout results:
Ti Max 2.6
MV Median 6.4
Vt Median 520
IE Median 2.13
IPAP Median 9.4 (95% = 10.7)
EPAP Median 6.2 (95% = 7.4)
Generally refreshed but could do better. 

Did I do the right thing? 

How can I improve the side effects I still have from the PAP therapy?

With respect to the congested leg veins. These incompetent perforators only started since I commenced APAP therapy. Despite all cardiac workup as normal, to me this means there is reduced venous return to the heart at night. Could the I:E ratio effect this? Do I need longer Insp time or longer Exp time? Are my pressures all messed up?

I am at a loss wrt what to change next?

I am leaning toward lowering Min EPAP to 5.0 - 5.6, lowering PS back to 2.4 - 2.6 at the risk of more FLs.
Change Cycle sensitivity or Trigger sensitivity?

Charts from the last few nights attached: I would really appreciate some expert input here, if someone could cast their eyes over these and share some thoughts as to where to go from here?

See also Spreadsheet.

PS:
The only thing I am happy with is the way the FLs have come down but disappointed with lack of feeling better. Are these reduced Low Limitations real or just the way the Vauto calculates them? I had hoped that by reducing my FLs my sleep would get better. Does the Vauto use the same formula for calculating  these as the For Her?

14 Jan 2021
   

19 Jan 2021
   

Thanks in advance.


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