easy breath - Therapy Thread

[easy breath]

On the one hand I am getting used to using the CPAP and my numbers look good. Last night AHI at 3.62. I am using 7 for both min and max pressure and EPR level 2. Here is the chart:

   

On the other hand, I am concerned about the patterns I see, of hypoventilation followed by pauses in breathing. On my home sleep sample my SO2 went as low as 67%, during 11% of the time SO2 was below 90%. I do not know how this looks now that I am using the CPAP. I ordered today the ConTec CMS50I Wrist Watch Pulse Oximeter. Is that the best choice?

I had abnormal Polysomnography studies in 2003 (numerous awakening next to superficial apnea) and 2005 (over 150 awakenings with no apnea). I don’t know how my sleep looks today. 

Originally, my health plan rejected my ENTs request for polysomnography, that is why I had the home study. In any case, today I wrote them a letter, again asking for the polysomnography, with a lot of reasons why I need it. I now probably need to see multiple specialist (cardiology, neurology, ENT, neurosurgeon, sleep specialist) all of who will want to see the polysomnography that the health plan refused to allow. We will see if health plan approves it this time. They better!

In any case, I would like to monitor at home my sleep stages and especially to monitor brief awakenings. I was looking into this today, and did not find a solution. I thought about getting an Apple watch, which some say is pretty good, but it does not seem to be able to show brief awakenings, which I have a history of. Does anyone have an idea how to deal with this?

I am so caught up with all this stuff about sleep, for a couple of weeks. It is driving me crazy!

[easy breath]

Correction of last post "of hyperventilation followed by pauses in breathing"

BTW how does one make a correction?

[SarcasticDave94]

If you mean correcting your posts, you have a few minute timer to make edits.

[easy breath]

Me and the Doctors:
I saw ENT and my Cardiologist and they did not have much to say. I saw Pulmonary specialist, he did not know how to talk about CPAP data, and kind of told me to tow the line and have the technician adjust the machine. I doubt that the technician can do better than I’ve done with your help.

It looks like the health plans here in Israel aren’t using ASVs. And even BiPAP only for extreme cases. So, I don’t see much hope of getting  ASV for a reasonable price. I might try eventually to see if I can borrow one, and see if it works better. 

I did manage however, to get a referral for an in-lab sleep sample. So, I will pursue that in due time. Also, I am waiting for an Oximeter to arrive. I also have referral to the sleep doctor. I also have access to a sleep psychologist.

CPAP tuning:
Some nights I can’t fall asleep (because of machine or other reasons). Some nights, I feel that I can’t take the CPAP anymore, and after an hour or so I get up for an hour and eat (not a good idea but hard not to). Also, some night AHI is too high.

So, I collected up data checking which nights I managed to use the CPAP for at least 4 and half hours and with AHI less than 5. The best night was min and max 7, EPR 2. I am going to try using that as a base.

Too much pressure, and CA goes up. Too low pressure, sometimes feels stuffy. 

I think lower EPAP might be working better, so I will try EPR at 3 with min and max at 7. Let see how that works.

[Dormeo]

Well, I'm glad your doctors didn't find anything amiss, but I do wish you had a pulmonologist who knew more about PAP data. I hope the in-lab sleep study will come along soon, ditto the oximeter.

I admire your use of home-grown data to guide your settings. Your plan to use max = min = 7 plus EPR of 3 sounds good to me, and I hope it gives you some decent rest. I'll be interested to see a chart or two after you've tried those settings for a bit.

[easy breath]

Thanks Dormeo for the reply.
 
I have turned to the technician, as my pulmonologist instructed. Not that I have much confidence, but it appears that I need to follow the rules if I want to hope to get my health plan to upgrade from APAP to ASV. 
 
The truth is, that I have improved my AHI using the suggestions given on this forum and my own understanding. On one hand, I am happy that AHI is now often below 5 (compared to 44 in home sleep sample) using the APAP, but on the other hand, I am concerned that the health plan will see that as proof that I do not need an ASV machine!  
 
The technician did not view my data from the cloud, rather he asked me to read measurements from the CPAP screen. He actually said that I am doing a good job adjusting, but instructed me to set pressure for 6-9. So, I will try that because he said so.
 
On the NY Heart Association scale of "Heart Failure" I have been rated as level 3 ("Symptomatic heart failure"). So, Cheyne-Stokes respiration makes sense. Also, I see from the Oscar charts the pattern of Cheyne-Stokes respiration. Furthermore, the charts seem to show no problem of obstruction. So ASV is the type of machine that is designed especially for my  case. The technicain, of the other hand, was not interested in all this.
 
Of course, it is important to see SaO2 during the night. I ordered an oximeter watch from China but it is now stuck in local customs because it needs to be approval by the local department of health. I hope that works out soon.

[Dormeo]

Did you manage to get in a few nights at min = max = 7 and EPR of 3? If so, how did that go? While there's no real harm in the settings the technician has recommended, I will note that when your pressure is at 6, you can't get EPR of 3, since a pressure of 4 is the lowest the machine can go.

I'm glad an oximeter is on the way and hope it arrives soon.

[easy breath]

No, I did not have with EPR at 3, rather at 2.

Sat. night and Sun. night I had min=max=7.2 both with EPR at 2, with kind of strange results.

Sat. night the sleep time was really bad, AHI 8.01 with CA at 5.58, OA was 1.94 but look at the data, I think these OAs were also from central or CSR, do you think so too?  I am missing data data from about 4:30 AM till 9:00, I think I got up to go to the bomb shelter and did not put mask back on when I got back to bed! I don’t know what to make of the Leak Rate on this night. Here are the charts:
         

Sunday night was real good. I failed to return the data card to the CPAP, so do not have charts, but AHI was 2.10, CA was 0.8, UA was 0.8, H was 0.5.

>>I will note that when your pressure is at 6, you can't get EPR of 3, since a pressure of 4 is the lowest the machine can go.

I know, but at 4 it should be easy to exhale. 
I am not sure, however, about the significcantsof the difference in pressure. I think maybe I exhale more completely with larger EPR. I am not sure if this is benificial for CSR or makes it worse. Exhaling more completely would lower CO2, but it would be delayed for the body to register. If that happened on a steady basis, perhaps the overventulation phase would not happen in the first place, or maybe the lower CO2 could encourage an apnea. ???

[Dormeo]

People do sometimes react to EPR, or higher EPR, with an increase in CAs, though often the problem isn't really the CAs themselves but the arousals that come before them. Higher EPR can often do a better job of reducing flow limitations and hypopneas, so there's a bit of a trade-off there.

I think those OAs are true obstructive events. The machine sends out little pulses of pressure to see whether the airway is obstructed or not and flags an OA or CA accordingly.

What we can see is that your deeper recovery breathing after the OAs is sometimes followed by a CA, which makes sense.

We can also see that you had some clusters of CAs near the start of sleep sessions. That may reflect sleep-transition conditions, where there's a little glitch as the neurochemical systems that control daytime breathing hand off to the different systems that control asleep breathing.

I'm so sorry your life includes trips to a bomb shelter. May you be safe.

[easy breath]

Thanks for the response.

>>I think those OAs are true obstructive events. The machine sends out little pulses of pressure to see whether the airway is obstructed or not and flags an OA or CA accordingly.

You are saying that because you could not see tidal volume on the clip that I sent. This time, I am sending another screen-catch of the same events but this time with the tidal volume showing. Tidal volumes jumps from 312 to 779 before the first "OA"!  Also note that by flow rate chart the breathing cresendo up and then down before it stops at the first apnea. Furthermore, note that flow limits are at zero during most of the clip. These are the reasons that I think it is really a central-apnea. The CPAP must have caught a tiny bit of obstruction, but I do not think that obstruction caused these apneas.

For reasons like these, I have come to doubt the Dx of OSA and I am thinking perhaps that I have ONLY central apnea. That is why I am pushing for a proper sleep sample done at the Lab, not at home.