Appreciate help adjusting settings (UARS)

[cmcphee]

@bonjour @slowriter - ahhh ok. Thank you for clarifying. I am still struggling to get my head around the difference between and physiological pros/cons (balancing aerophagia, flow limitation, OAs, CAs) for these three scenarios:

• an APAP machine with a min of 9, max of 12 and EPR of 3 versus...
  
• a bipap machine with a min epap of 6, max ipap of 12, and PS of 3 versus...
  
• a bipap machine with a min epap of 4, max ipap of 12, and PS of 5
  

Thanks again for getting me up to speed!

[alexp]

Ok thanks @alexp for the thoughtful explanation. I can definitely count some of the CAs out from your description. However, I think I'm still seeing a lot more two nights ago than normal. Am I interpreting the attached graph correctly that these are CAs because my respiratory rate and tidal volume are steady?

Yes these ones look definitely like real central apnea events. See how the breathing is regular and out of the blue you just stop breathing? They are probably treatment emergent central apneas and may resolve on their own given enough time. I would lower my PS and re-evaluate in a week.

[Gideon]

What I have suggested is a very standard treatment following established procedures. I am not familiar with the techniques mper6794 has proposed but am curious.
What I suggest works for the majority of people. I would encourage mper6794 to start a new thread and present/teach his technique and include evidence of its success. We have had things like this that we have adopted in the past. The soft cervical collar for positional apnea from chin tucking.

[cmcphee]

@bonjour apologies for the delay - lonnng day. PS 3.2, Max IPAP 9, Min EPAP 4. Took it way down (see data attached below for why). What I don't understand is why I still had aerophagia again last night despite the significant pressure drop to a level that was consistently OK in the past.  What adjustments would you recommend?

Attached are my full night graphs, as well as close ups around my two wake-ups (maybe leak-related? not seeing anything else...). Please let me know if any other views would be helpful?
    [attachment=15574][attachment=15575]

I also attached some data that might be useful from both this machine and my previous machine's auto titration trends over the past month.
       

Thank you!!

[mper6794]

Hi, cmcphee, good morning

_ 4:21....possible PLM
_4:23:15 ----typical PLM leg jerk awakenings (those like this, are properly audio-recorded calibrated in my every day  charts....look at how often it repeat on your charts.....
_based on charts you posted, I have started up your PS x RR graph...what would be your normal rate (lab studies, etc)?

good luck

[mper6794]

The idea is that if you draw more air in your lungs, your desire to breath is reduced for a little while. Try it while awake, take a couple of very deep breaths and you'll see that you don't need to breath for some time. It's perfectly normal. That's not a central apnea. The same thing happen when you sigh during your sleep. In fact, if I wear the mask while awake and turn on the machine, the machine will report some central apneas. Therefore that's mean an arousal during my sleep might be reported as a CA as well. 

Without EEG, there is no way to distinguish an arousal from a CA except scoring the events manually and even then there is no certainty. It's important to understand that people move, sigh or wake up during their sleep and the machine can flag these events as CA. REM breathing is also quite irregular and can look like CA especially when you are dreaming.

A real central apnea happens without a big increase in flow rate or tidal volume. You are breathing normally when all the sudden you stop for no apparent reason.

In my case, when I increase the PS too quickly, I get an increase in CA events. Most of these events usually follow a series of deep breaths. I think it's my body just trying to figure how to breath with all this air coming in. It's usually goes away after a week or two. Might not be the same for everyone though.

I think in your case you should definitely lower your PS to 3 or even lower and rise it gradually in a week or two if you are still experiencing some flow limitations.

.........
That's is great, Alex! Very good rationale, even for the laymen!
GL

[mper6794]

Hi, cmcphee, good morning

_ 4:21....possible PLM
_4:23:15 ----typical PLM leg jerk awakenings (those like this, are properly audio-recorded calibrated in my every day  charts....look at how often it repeat on your charts.....
_based on charts you posted, I have started up your PS x RR graph...what would be your normal rate (lab studies, etc)?

good luck

...in time: such PLM leg jerk/arousal-aw in this case was very short in time, which would not harm that much. However, these sudden ar/aw/wk may take longer, say, from 2.0 min to 30 mins.... this more significant tend to occur in certain times, episodically; sometime you may observe they are preceded by minor periodic spikes (no arousal) in FR, TV, and Leak. 
 From my gross statistics in this Forum, and literature, people with UARS have large chances of having PLM's associated, including my Guru/God, the Physician Barry Krakow.
Hopefuly, you are going to be an exception!!

Good luck

[cmcphee]

@mper6794 my median RR on a machine seems to range from 12-15 - it was not included on my sleep study (previously posted).

@bonjour Thank you. I went with the same settings as last night and didn't have aerophagia this time (?). I slept with a cervical collar on for the first part of the night again, but have gotten into the bad habit of taking it off in my sleep somehow.

My FL was a record low and the centrals greatly subsided. I woke up 4 times however (two of which were because my husband woke me because he said I was "breathing really weirdly"). I feel more tired now than on the previous machine, but that could be because I slept so poorly the past few nights and woke up 4x last night? Should I continue to stay at these low settings or start moving back up?

                   

[alexp]

My FL was a record low and the centrals greatly subsided. I woke up 4 times however (two of which were because my husband woke me because he said I was "breathing really weirdly").

You woke up in your REM sleep or right after it according to the images you posted. See how the breathing is irregular and the tidal volume is all over the place. Maybe you were dreaming. That's probably why you were breathing weirdly. REM breathing is always messy. It's normal to wake up after a sleep cycle (at the end of REM sleep) but most of the times we don't remember it and go right back to sleep.

[slowriter]

My FL was a record low and the centrals greatly subsided. I woke up 4 times however (two of which were because my husband woke me because he said I was "breathing really weirdly"). I feel more tired now than on the previous machine, but that could be because I slept so poorly the past few nights and woke up 4x last night? Should I continue to stay at these low settings or start moving back up?

It's striking how much your journey mirrors mine. There's all these different variables we're trying to align, with only imperfect data. So sometimes it's one step forward and two steps back, etc.

I would wait a bit to change so that you can be more confident in any obvious pattern. Plus gives your body time to adjust.

I think my first few nights on the vauto were OK, but the numbers and quality of sleep improved over more time.

And tell your husband not to wake you ;-)