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[Treatment] Treating UARS with CPAP and bilevel - Printable Version

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RE: Treating UARS with CPAP and bilevel - sheepless - 02-16-2020

when I see repetitive spikes, usually less than 20 seconds apart (this can vary quite a bit), with relatively flow restricted breaths in between, I associate them with my periodic limb movement. isolated spikes are usually just sighs.


RE: Treating UARS with CPAP and bilevel - slowriter - 02-16-2020

Thanks.

I've been operating under the assumption that if my subjective impressions of sleep are good and the sleep architecture is not fragmented, I'm probably fine.


RE: Treating UARS with CPAP and bilevel - tarah - 02-16-2020

Ha, ok I guess some of us just sigh alot even at night Smile


RE: Treating UARS with CPAP and bilevel - slowriter - 02-16-2020

To be clear, that was my assumption, but wasn't sure, and appreciate the input; that probably does explain it.


RE: Treating UARS with CPAP and bilevel - Geer1 - 02-18-2020

For some reason I can't PM you, I assume because you have that functionality turned off.

I think you need to slow down on your recommendations for high pressure and PS. You have become obsessed with flow limitations believing that they are what was causing your issues but even on APAP with EPR of 3 and Vauto with PS of 3.4/3.6 your flow limitations were a non factor. In fact many of the flow limitations indicated by the machine at those settings weren't even real flow limitations(just irregular breaths) and they almost never were associated with arousals/RERA's. 

I know you believe that it was the higher PS that helped you but I strongly believe that it was not. For some reason the trigger sensitivity made a huge difference for you and I believe it was your main advantage. I'm almost willing to bet you could lower your PS down to 3 or 4 and that your sleep quality would not be affected. Imo your issue was the CA's and perhaps other similar disagreements with how the machine was supplying air to you(easy breath waveform on normal settings just doesn't seem to get along with you).

I think you need to revisit your own SDB and verify what the actual cause of improvement was (as stated I believe trigger sensitivity) before continuing to always recommend increased EPAP/PS on people.

I hope you don't take this the wrong way and get defensive about it, both of our goals here is to help others and the best way you can do that is by confirming what truly made the difference in your sleep. It should be easy to tell by adjusting PS and sensitivity settings.


RE: Treating UARS with CPAP and bilevel - slowriter - 02-18-2020

My view on pressure/PS and UARS is based primarily on two things:
  1. an in-lab sleep study and subsequent discussion with the tech who did it, who found a lot of RERAs (~20/hour) that were only resolved at higher PS. Granted, it was a one night study, but did have the benefit of the full suite of sensors and an experienced technician.
  2. the literature on UARS, including the arguments of Krakow.
So 1 got on a bilevel and ballpark settings from 1, and subsequent adjustments over past couple of months have been minor; really just raising the EPAP a bit to resolve occasional OAs, and tweaking PS to see what's comfortable, and seems to result in better quantity and quality of sleep.

In the end, people have to experiment for themselves to see what works though, where "works" ultimately needs to be based on quality of life.

If I could offer you some advice in response, it would be tone down the hyper-assertive and confident claims about virtually everything, including what you say here about my therapy. You, like me, are fairly new to this, and learning, and there are people here with far more knowledge and experience.


RE: UARS and APAP - Geer1 - 02-18-2020

(11-15-2019, 11:11 AM)bonjour Wrote:
(11-15-2019, 11:03 AM)Sleeprider Wrote: I don't see a problem with the SpO2 levels posted so far.  They are solidly above 92 and appear to have a median near 95%.  In mechanical ventilation, a higher PEEP is associated with better O2 exchange. This is as you noted, an increase in EPAP min.  

There has been a recent trend on these forums to obsess over nuances in these Sleepyhead charts and here we see SpO2 and sleep stage being tracked. The suggestion that flow limitation may be an issue seems pretty far-fetched given the 0.00 in the 95% range and extremely low values in he maximum.  As someone that has evaluated many charts, I would have no higher expectations for results from anyone, including myself.  My best advise is to get out of the weeds with the charts and evaluate results solely on how you feel.  If you change pressure, do it for a week without looking and ask yourself, is this better or not?  There is far too much dependence on the data here, and I think it is way overboard.

Seconded!!!  Lolabove

These experienced and knowledgable opinions?

Your data does not show flow limitation. If you look at Sept 1st when you used your lowest PS, PS of 3.4 and zoom in on every "flow limitation" indicated(of which there are few) you will note that they almost all occurred during arousal breathing.

Here are your flow limitation results vs PS for data between Aug 28 and Dec 10. You never once had a flow limited breath over 0.2 and 95% flow limitations is almost exclusively 0.00 (3 nights during this time with 0.01, probably mostly due to arousal breathing). There is no obvious improvement with increasing PS when looking at your data. The titration comments are interesting, maybe PS helps but I don't think it is due to flow limitations.

[attachment=20073]

CA's, time in apnea, your custom user flags, all diminished significantly on October 12th when you changed trigger sensitivity. The results are night and day different in a good way after that change. It is 100% certain that change made a significant improvement. My theory lately is that getting the machine in sync with breathing is just as important as treating flow limitations. With yourself it appeared to be setting trigger to very high, with others it might be different. Your central apneas clearly weren't being caused by CO2 levels because if anything very high trigger sensitivity extends IPAP time which would further lower CO2.

[attachment=20074]

That is all I am going to say. It is up to you to draw your own conclusions or test more.


RE: Treating UARS with CPAP and bilevel - slowriter - 02-19-2020

I'm putting a few research articles I've found helpful, in case people are interested in exploring for themselves:
There's also a video of Krakow, among a few other presenters, on YouTube. Not sure if I'm supposed to directly link, but the title is "When to Prescribe Advanced PAP Therapies for Patients Struggling with CPAP." In it, he goes over the relation between flow limitation, pressure support (and therapy mode) and sleep architecture; so going beyond even RERAs.

My conclusion from all of this is that for UARS treatment you want to minimize FL to the degree that breaths are consistently rounded, and quantity and quality of sleep is high. If one had an EEG, quality would be shown by a "normal" sleep architecture. Daytime symptoms would show improvement.


RE: Treating UARS with CPAP and bilevel - tarah - 02-19-2020

It seems like the marked FL's don't tell a huge part of the story.  If you have chronic flow limitations, like for example, a chronically stuffy nose, PAP cannot respond to that.  That seems to be where adjusting things like PS, until you feel the best, come into play.  If he feels good with the given PS, is waking minimally, and not inducing CA's, why does it matter if the pressure is higher?

The caveat, here, being that I am one person and know my personal story.


RE: Treating UARS with CPAP and bilevel - Geer1 - 02-19-2020

Tarah he might get relief from the higher PS and if so it could be for a multitude of reasons, I just don't believe it is flow limitations.

I am just saying always jumping to vauto and PS of 5-6+ doesnt seem to be the answer. Yourself and others have failed to find satisfactory relief at these settings and in some cases it seems unclear if the people have even found any improvement by it. I believe this is due to other factors that many times a cpap machine will never effectively address. For example how you had to have surgery done, in others anxiety is the problem or periodic limb movement etc. We only get a fraction of the big picture with this data. 

We as a community not just slowriter, are often quick to propose higher PS because it is one of the few things we can adjust and sometimes it works. Usually when it works there seems to be an obvious need for it though (obvious reras, hypopneas etc) at least that is what I have noticed and hence why I don't like to recommend it now if the person just seems to be having off sleep and has the odd flow limitation present. 

My grandfather's median flow limitations are as bad as slowriter's peak flow limitations yet he sleeps ok. His flow limitations are so bad that I believe they limit his ventilation but they don't cause significant arousals and he sleeps like a log even considering what most of us on here would consider bad cpap results. Is there room for improvement, certainly but I will never chase 0 with him because it isn't necessary.