Brazen Therapy Thread

[Brazen]

@Dog Slobber
Thank you, I appreciate that!
I'll just sit tight and try to be patient.

[Brazen]

@ Gideon @DogSlobber

I meet with my sleep doc in a few weeks.
Are my charts still looking like I could benefit from a Bi-level?  What is it that suggests that? or what do I say to back that up to the sleep doc?  I can send her my OSCAR charts.

Does anything in my charts look like I could be further optimized with my current machine?
I'm set to 7-9.6cmw with EPR 3.

[Brazen]

Almost 30mins of what my machine flagged as CSR. That's way too long to be REM related and I wasn't consciously awake, what is it? Positional?

[Gideon]

On the CSR include the rest of the charts.

[Brazen]

@Gideon - what do you mean? I posted the daily and the zoomed for the csr night. Do you need different sections or a different zoomed time? What screenshots would be helpful?

What do I look at/say to doc to support the idea of bi-level?

[Brazen]

I think the more I look into this stuff, the more confused I get. If I felt better I think I could just roll with it and trust the process. How do you just roll with a treatment that isn't working?

So, according to the wiki, the Resmed machines flag periodic breathing as CSRs.
"Periodic breathing is defined as three or more episodes of central apnea lasting at least 3 seconds, separated by no more than 20 seconds of normal breathing."

So... repeat CAs basically continously for 30mins?
Why?
CAs are not my norm and have been limited for months.

Sigh.

[Gideon]

I'm looking for other signs of disruptive breathing. Thus the normal charts which include flow limit, pressure and leak, also events, and the flow rate. Why? Because it gives a broader recognition of what is happening during the periodic breathing.

ResMed, incorrectly, calls ALL periodic breathing CSR. The scale is too long to read the zoom of the periodic breathing other than the fact that it is irregular, with wide spacing of logged obstructive events wider than typical of positional, but I can't rule that out. There is some evidence of CO2 influencing this cycle but it is not as smooth as typical CO2 driven occilations. Are flow limits driving it? I can't tell.

Doctor, which I am not, hat going on, you have excellent AHI and therefore are well treated with a consistent AHI of under 5. This machine an APAP, is working for you. I can't recommend a BiLevel. Doctor hat off.

To get a BiLevel you have to convince the doctor that your symptoms warrant a BiLevel even though your AHI does not. Symptoms are subjective.
Earlier you showed yourself as capable of identifying arousals, take screenshot of your overall night then a screen shot of every arousal that happened thru the sleeping night that did not have a logged event, circle them in red so they stand out. Volume, number of sheets of paper will help. Calculate a arousal index and on a second copy of the initial screenshot put a vertical red line for every arousal that happened thru the night. Flow limits prior to will help you. The point is to present evidence that even with good AHI that you still have a problem that requires more than your APAP.

The fact that you have a ResMed AutoSet is actually working against you since effectively that machine IS a BiLevel with a PS that is limited to 3.

[Brazen]

@Gideon
Thank you so much!  I really do appreciate you trying to help cranky me.

Okay... so to try to convince doc to consider bi-level I need to show unflagged arousals with matching high flow limits and calculate arousal index?  Got it.  I can mark-up loads of charts for that. 
I fear she's going to suggest an in-clinic titration study (she mentioned it at my last appointment). That guarantees an extra terrible night of sleep and absolutely worthless day after. But, IF it would mean better treatment and feeling better in the long run it's worth it.  Big IF.

Re: CSR/PR flagged stuff.
I took some more screenshots including zooms with flow limit, flow rate, pressure, and leak.
I actually had very little leak that night, unusual for me.
What seems weird is the long period before what the machine flagged as CSR looks just as messy in the flow rate chart?

I could probably just chalk it up to a one-off rough night and move on. 
But, I'm trying to understand what I'm looking at to try to explain my subjective symptoms. (and ultimately fix it!)

[Gideon]

Spend a couple of days, say a week and write down your symptoms. Don't worry about correlating the 2. Most symptoms are because of poor treatment and are long term and not tied to specific events. For this don't even think of what is happening in the charts.

A completely separate step is showing how even with good AHI you are still having issues. These will be minor iss compared to flagged events. This is just showing that your flow limits and arousals are not being resolved. Two different activities.

If your sleep is symptomless it means everything is adequate as is. You need both.

[Brazen]

@Gideon
My symptoms are exactly the same as prior to APAP.
Fatigue, never feeling rested or refreshed upon awakening, brain fog, headache most days.
Many nights my whole body periodically twitches - partner explains it like that twitch/startle many people have once or twice right as they are falling asleep but I do it all night long.

I don't consciously awaken during the night, per my partner I don't often snore loudly, don't gasp for air or have noticeable gaps in breathing. I don't have PLM/RLS. 

I'm tolerating the mask/headgear okay even though it takes me a little longer to fall asleep (still less than 15mins most nights).

The only subjective change is that my dreams disappeared with treatment. 
I know, they likely didn't disappear, I'm just "not being awoken by OA during REM so I'm not remembering them" -- in quotes because, really?  There is no way to prove that is actually true without a PSG/EEG.
I miss my dreams.

I'll fight for a bi-level if it looks warranted and there is even a slight chance it could improve my energy level. It would be awesome to feel improvement sooner rather than later.