Big Regression - high resp rates prior to multiple wake ups a night

[FordGuy84]

Hi all,

I'd been on a decent routine where i'd been sleeping well and dreaming since getting on my CPAP.  For the past month i've been having issues where i'm waking up multiple times a night for no apparent reason.  AHI is nice and low (usually around 1-1.5) and hasn't changed.  I've been wearing my pulseox and seeing significantly more ODI3 desats in this past month but they aren't correlating to an increase in AHI.  
I was looking at the graphs for the past month and seem to see a very strong correlation between the wake up times and large increases in respiration rate and accompaning increases in inspiration time and decreases in expiration time.  Not sure if it means anything but this period of chaos appears to always precede my wake ups.  

In other health stuff , i've had some heart issues i've been dealing with for the past year.  No doctor has not said heart failure as of yet, but a lot of the symptoms and some of the testing shows it trending in that direction. 

Any ideas?  My current setting is 7-11 with EPAP of 2.

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Adding one other chart.

[Sleeprider]

I can't see enough detail at this resolution to identify a problem. If you can cut the zoom in to about a 3-4 minute segment in the 03:00-03:15 time area we might see something. (i.e 03:00-03:04) Also, minimize the monthly calendar (click on triangle in the date line).

[FordGuy84]

Sure thing, I zoomed in on two 4-5 minute segments and one bigger one around that window you mentioned. 

[Sleeprider]

Inspiratory flow is limited with longer inspiration time, shallow peaks and some obstruction indicated by some double peaks and downward sloping flow off the peak ahead of expiration. Expiration is rapid and rebounds abruptly to zero. Your minimum pressure needs to be set to 7.0 for EPR 3 to be effective. Suggested setting is Autoset mode, minimum pressure 7.0, maximum pressure 8.0 EPR 3. No promises we see much difference, but we might relieve the inspiratory flow limit and hopefully reserve time for expiration. We have pretty limited ability to manipulate inspiration and expiration with this CPAP, but at this point we just need feedback if this is more comfortable or not, and see if some of the flow limits and arousals respond.

[FordGuy84]

Thanks for the response Sleeprider.  I can't admit that I understood everything you said, but as far as the change you suggested. 

I'm currently at 7-11 cm with autoset and EPR of 2
Are you recommending changing that to 7-8CM with autoset and EPR of 3 to somehow alleviate this issue?

Is this pattern indicative of anything or no silver bullet necessarily?

[Sleeprider]

Read the wiki on Flow limitation. https://www.apneaboard.com/wiki/index.ph...limitation It is present in your results, and it suggests you expend physical effort to get the breath volume you need. By using more EPR, which is analogous to bilevel pressure support, you can use less effort to get that breath and reduce the inspiration time. It is the respiratory effort that leads to respiratory effort related arousals that seem to be happening in your results. It's fine by me if you want to keep your current maximum pressure of 11.0, but I don't think you will see a lot of pressure variation. The key is a slightly higher minimum pressure and the higher EPR.

[FordGuy84]

Thanks for explaining. Assuming I understand , I'll try epr 3 and go 8-11 tonight (as opposed to 7-11 with epr of 2) and report back. Assuming 

It probably should be mentioned that I have shortness of breath during the day (with exertion and without at times). I'm sure that muddies the water even further...

[gainerfull]

Simply put, your minimum pressure minus EPR is currently between 5cmH20 and 9cmH20 (7cmH20 min minus EPR 2 & 11cmH20 minus EPR 2) and it's not sufficient enough to keep your airway open especially as you hit REM. It looks like in APAP mode it's able to resolve your obstructive events at around 8.5cmH20 w/ EPR 2 so if it were me I'd set minimum to 8cmH20 and see how it goes for a night. Ideally, you want your minimum pressure to be able to resolve your obstructive events so if you decide to make a change and stop seeing the light blue events then you'll know you're on the right track. Considering you're 95% flow limit data is 0.00 I'm personally not a fan of raising EPR.

The zoomed flow rates look like REM to me and should be expected. REM is every 90min or so.

[FordGuy84]

Hi all, tried the suggestion of going bumping minimum from 7 - 8.  It still feels like i'm waking up during every REM cycle as soon as I start to dream (it really does feel associated to that).  My initial sleep study showed most if not all of my mild apnea was during REM.  When I first started the CPAP (after the 1st month), I was having vivid long dreams for months on end and for the past month i've still been stuck in this waking up during the beginning of dreams constantly state.  

Anyways, some updated charts attached.  Should I be trying to raise the pressure further?  I tried to reach out to my sleep doc and hospital system and they said the earliest they can see me is January :-(

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Another zoomed in graph

[Sleeprider]

The outstanding feature of your therapy is a persistent flow limitation...so persistent it does not show up in the statistics. If this is typical through the night, I suggest you start looking for a bilevel Aircurve 10 Vauto.