[Treatment] Treating UARS with CPAP and bilevel

[slowriter]

I think you are sensitive to pressure changes, and that you don't benefit a great deal from pressures above 7.0/4.0.

I wonder if we could go back to this, sleeprider?

Why the above two conclusions, and what does the subsequent data I've posted suggest to you?

[Noripterus]

I would appreciate an answer as well.

[slowriter]

I think you are sensitive to pressure changes, and that you don't benefit a great deal from pressures above 7.0/4.0.

I wonder if we could go back to this, sleeprider?

Why the above two conclusions, and what does the subsequent data I've posted suggest to you?

Or ... I got a great deal on an almost-new Aircurve 10 VAuto, arriving Wednesday; where should I start?

[slowriter]

To pick up where I left off with CPAP, I decided to try:

EPAP 7
IPAP 12

I woke up again as usual, with the usual surrounding SWJ, but machine-reported flow limitations are totally gone, and waveforms look really good to me.

During my time awake, I lowered IPAP to 11, to see if any difference, but looks to me results are worse at that setting. 

Right?

I still have a titration study next week, but not sure how much they'll prioritize eliminating RERAs, which I still suspect is my problem. And for professional reasons (just back from extended vacation, and very hard to do my job with these symptoms), I'm anxious to get this pointed in right direction ASAP.

The detail at bottom happened right around when I woke up. That's a RERA; right?

[alexp]

To pick up where I left off with CPAP, I decided to try:

EPAP 7
IPAP 12

I woke up again as usual, with the usual surrounding SWJ, but machine-reported flow limitations are totally gone, and waveforms look really good to me.

During my time awake, I lowered IPAP to 11, to see if any difference, but looks to me results are worse at that setting. 

Right?

I still have a titration study next week, but not sure how much they'll prioritize eliminating RERAs, which I still suspect is my problem. And for professional reasons (just back from extended vacation, and very hard to do my job with these symptoms), I'm anxious to get this pointed in right direction ASAP.

The detail at bottom happened right around when I woke up. That's a RERA; right?

Good if your flow limitations are gone. The question is how do you feel? Do you feel it's making a difference? The bottom picture could be a RERA or maybe it's your body having trouble getting used to the pressure support. Hard to tell. I saw a lot of this stuff at first after switching to a bilevel. You will probably see some breaths where you are a bit over ventilating too but it should go away after your body gets used to the therapy.

And don't overthink it. You will always have some arousal even after resolving most of your flow limitations.  You shouldn't try to have a perfect waveform everywhere but have some long sequences were nothing special seem to be happening. Before getting ride of my flow limitations, I think my longest regular breathing sequence was like 5 minutes long. Now I have 30 minutes sometimes even 1 hour long sequences in which I just see regular breathing and nothing that looks like an arousal.

Also, you are starting to experience lot of centrals. I know you said most of them are only SWJ (or were you awake?) but your body seems to have trouble to adapt to the increased pressure support. I would decrease it and raise it more gradually so your body has more time to become accustomed to this way of breathing. You can also wait couple of weeks to see if this number goes down.

[slowriter]

Good if your flow limitations are gone. The question is how do you feel? Do you feel it's making a difference?

So far, not at all. None of these changes have any impact on my quality of life, and I don't feel particularly good any day.

And don't overthink it. You will always have some arousal even after resolving most of your flow limitations.  You shouldn't try to have a perfect waveform everywhere but have some long sequences were nothing special seem to be happening. Before getting ride of my flow limitations, I think my longest regular breathing sequence was like 5 minutes long. Now I have 30 minutes sometimes even 1 hour long sequences in which I just see regular breathing and nothing that looks like an arousal.

Right. My goal is to eliminate (breathing-related) arousals and sleep through the night.

I do see pretty long stretches of normal breathing.

... you are starting to experience lot of centrals. I know you said most of them are only SWJ (or were you awake?) but your body seems to have trouble to adapt to the increased pressure support.

In all of the graphs I've posted in this thread, there's a consistent pattern: around when I wake up and turn off the machine, there are clusters of "cemtrals." For example, see this post.

But the CA numbers reported on on the left sidebar seem to vary without an obvious (to me) pattern.

Am not sure what to make of that.

I would decrease it and raise it more gradually so your body has more time to become accustomed to this way of breathing. You can also wait couple of weeks to see if this number goes down.

I will say that subjectively, I find the bilevel more comfortable.

[Gideon]

Can't resist. You are the first person on this forum that wanted to remove/eliminate both sleep and arousals thru the night.

" My goal is to eliminate (breathing-related) arousals and sleep through the night."

Your detail is not a RERA as it lacks a Arousal.. that is some very mild flow restriction that is IMHO insignificant that ends in a likely obstructive Apnea without a recovery breath.

[slowriter]

Gotcha.

Any suggestions of where I go from here?

[Sleeprider]

I think you are sensitive to pressure changes, and that you don't benefit a great deal from pressures above 7.0/4.0.

I wonder if we could go back to this, sleeprider?

Why the above two conclusions, and what does the subsequent data I've posted suggest to you?

My response quoted here is from two weeks ago, and prior to additional data you posted.  My impression is that with EPR at 3 you have essentially no flow limitations or RERA. Your events are predominately CA.  I don't see consistent differences in the pressure range from 7 to 9, but I think the fixed pressure is working better than variable pressure you were using previously.  Your therapy sessions are longer and seem less disrupted using fixed pressure, and since you have very little in terms of obstructive events, the choice of pressure setting should be based on comfort, as efficacy seems unaffected in the range of 7/4 to 9/6.  I have not looked closely at whether central events are lower with lower pressure, but I think your recent results at 12/9 do suggest this is true.  I still see no therapeutic benefit to pressures above 7/4, but your comfort should drive your decision.

You seem to benefit from pressure support, or in your case, EPR.  If you had an Aircurve 10 machine, you would have considerably more control over trigger and cycle sensitivity, minimum and maximum time of inspiration for IPAP, and of course a finer control of pressure support at 0.2 cm increments, rather than EPR settings of 1, 2 or 3.  I think if you have found a pressure that feels most comfortable to you, it might be worth trying an EPR setting of 2 to evaluate if flow limitation increases or CA events are decreased.

[slowriter]

You seem to benefit from pressure support, or in your case, EPR.  If you had an Aircurve 10 machine, you would have considerably more control over trigger and cycle sensitivity, minimum and maximum time of inspiration for IPAP, and of course a finer control of pressure support at 0.2 cm increments, rather than EPR settings of 1, 2 or 3.  I think if you have found a pressure that feels most comfortable to you, it might be worth trying an EPR setting of 2 to evaluate if flow limitation increases or CA events are decreased.

Thanks for the explanation.

Key point: I now (as of two days ago; see above) have an Aircurve 10 VAuto!