[CPAP] tuning cpap for csr/ca

[harry3]

Last night: lowered pressure to 6.6 and added in soft collar*
Best night yet AHI=1.55

I heard back from sleep Dr yesterday afternoonb. He is seeing my Oscar plots that I send him. He will ring me Mon to decide whether to proceed with ASV titration. Based on last night, shouldn't I be satisfied with CPAP?

*Had to remove collar at 3AM due to sweat-saturated neck and neck pain. Clearly I don't have it set up right. By my measure, I have to use the smallest available collar at our chemist  (9cm) but then need to add a  7cm velcro extension. Is the collar supposed to sit completely under your chin?

[Jay51]

That is an incredibly tough question to answer.  I have never seen anything like this.  Your sleep study had the majority of events as CA's.  The 1st chart you posted in this thread looked terrible (literally littered with CA's).  Somehow you have gotten your therapy on cpap to become very respectable (looks good with few CA's - they are spread out and not even clustered together).  

In theory, ASV should reduce CA's to zero.  Every night.  Hopefully your Dr. goes through with the ASV titration.  

If anyone has any comments for harry3, please feel free to post.

[harry3]

Hi, somehow the message I composed hastily yesterday morning didn't get sent. And, then to continue the mess-up, I forgot to put card back in last night so only have the numbers off the machine. To recap:

Night of 11 Aug: set pressure lower again down to P=6.6 and used a neck collar. But, I took collar  off at 3am due to sweat and neck pain. It was not on tight, but I did have to modify a standard small collar (which matched my measured 9cm neck space) by adding 7-8cm of extra velcro. But, clearly not ideal. I have tried looking online here in Australia, and all the recommended collar models from the wiki are sold out. I will be in USA 14 Sep, so I might have to wait until then to get a recommended model. But, results from 11 Aug are best yet:

11 Aug, P=6.6 AHI=1.55 with  OSA=0.39.
Plot attached.

For night of 12 Aug, I continued the lower pressure experiment  with P=5.6. But, AHI jumped to 5.4. As I said, I forgot to put card back in, so no more detail, but we can assume OSA came back up.

I have one more night before decision on ASV study, so will put P back to 6.6 to see if 11 Aug results can be reproduced.

Plan is that sleep Dr will ring me at noon tomorrow and will discuss whether to go ahead with ASV titration or stick with CPAP. I can imagine if the results from 11 Aug can be reproduced (with P=6.6, AHI<2) he might make the case to not bother with the ASV study.

[Jay51]

Good plan.  It is nice to possibly have 2 good options.  The decision is your and your Dr.'s to make.  I hope you make the right decision Harry.

[harry3]

Hi, some updates and need for more advice:

1) I had the supposed ASV titration 3 days ago. When I got to the hospital, my sleep dr had discussed with them and decided to start out titrating CPAP and then go onto ASV if not getting good results with CPAP. Long story short, for a variety of reasons, they got no usable data for the CPAP titration so no data for the ASV titration either. Probably no point in going into what happened (other than I only slept for 1 hr), but maybe the details of what happened might be relevant  if advice is to redo the overnight titration.

2) The official results of the overnight study take 3-4 days to be processed so I have not heard back from my dr yet. I imagine it will be earlier next week.

3) I had a complete misunderstanding with my the cpap clinic here regarding ability to rent a machine short term. So, I now have a Resmed 9 on a week to week basis, until we decide what to do. Seems to behave exactly like the model 10 but the interface is not as slick and the only way to get data is on the sd card, but not an issue with availability Oscar.

So, cpap was set  up again to fixed P=8 EPR=1 and I will use until I hear from sleep Dr. The first night was not so good, maybe a little worse than normal (AHI=24 but OSA=1). I was exhausted from the lack of sleep due to previous night titration study, which maybe contributed. Then last night: unbelievable to me: AHI=3.5 but OSA =0.0. There was zero change to the settings. Recall, this happened before when I first tried lowering the pressure myself. So, it is not unprecedented for me.

So, how is this possible to go from one night with enormous amount of continuous CA and then next night almost zero. The sleep tech said I should see a psychologist (?)

My plan is to leave the cpap exactly as is until I hear from sleep Dr. I have no idea what he will say, especially now that I had another night with  AHI=~3 and no OSA.  I am guessing there is no new advice to change any settings but maybe there is advice about redoing an overnight titration. No idea how common it is to not get any usable data.

[jwest]

hey harry3,

that's unfortunate what played out with your sleep study. I believe it's worthwhile to push for another one.

Your therapy is a bit all over the place. It looks like you're responding well in relation to obstructions at low pressure, but then it seems like some nights you're getting CAs/CSR. Typically, with PAP therapy it can help to move slowly. So many variables play a role in how we sleep, from how much natural light exposure you received in the preceding days, to your general levels of stress, to how much physical exertion your day entailed, to your diet, etc. In my opinion, we should run you a few more days when we see some settings that show marked improvement from those before them.

Not sure how a psychologist comes into play here. Just ask your sleep doctor what their take is on the sleep tech's recommendation.

tldr; I would get the ASV titration again, if available. Let's get more data points per settings profile.

[Jay51]

jwest makes some good points.  The CA issue looks simple to me:  when you have a very large amount of leaks, you have a very large amount of CA's.  When you don't have many leaks, you don't have many CA's (and they are spread out more and not clustered together).  At least that is what I see in your 2 new uploaded charts.  It takes a little time to adapt to cpap therapy and decrease or even get rid of completely treatment emergent CA's.  

Maybe you can get another titration with ASV (and even cpap).

[harry3]

Hi, thanks for the input. Haven't yet heard back from Dr yet.

Regarding the recommendation for psych: I think she was implying that things like stress are contributing, which maybe can't be addressed with the cpap treatment. I think she was expressing that I was getting too worked up about looking at data every night using Oscar and that I should just relax and use the therapy for longer to see if it settles down (I think you also expressed that).

Regarding the leaks: I am aware of leaks that I can feel on my eyes. I have been using Eson2 as it was the most comfortable in original trial. But  at the hospital for the titration study they  said I was getting better seal with the Phillips Dreamwear. I opted not to use it at titration because I had experience with the Eson2. So, maybe I need to retry another mask?


For the leaks, what is cause and what is effect? In 2 of the zoomed in images from last night (20 Aug)  and the night before (19 Aug), it looks like leak rate lags the CA. That is, after the episode no respiration, then the leak rate goes up.

Also, in the other zoomed in image for last night (aug20_zoom2), which is before a flagged episode of the CAs, doesn't the asymmetric shape of the pressure curve indicate leaking on expiration?  So, it's happening all the time? At the titration, in the middle of the night the nurse said I was leaking out of my mouth, which I am pretty sure I wasn't because I could feel the leak on my eyes. But, maybe he was right.  He slapped on (literally) a chin strap  but I don't think that changed anything as he took it off after a couple of hours.

Nonetheless, with  the setting fixed at P=8, I've now had 3 good days in a row.

Let me know if there are more informative images to show.

[Jay51]

Keep working on those leaks.  I had to go through several masks to find the right one(s).  

Good points about your CA's.  Not all of your CA's come from leaks obviously.  The reason I mentioned leaks causing your CA's were the charts you posted before these 2.  You had a cluster of CA's immediately before and immediately after a large leak that was too big to record data.  To me, I interpreted this as your leak started getting bigger and bigger (and your CA's started increasing).  Then was the large leak area on the chart with no data (you probably would have had many CA's here also if it could interpret data with such high leaks).  Then you get the leaks down just enough for the data to start coming again (and also clusters of CA's) until leaks got low enough that the CA's stopped.  That was just my interpretation of that particular OSCAR for that night.  


I hope you can relax if you get another titration study.

[harry3]

I just received a message from sleep Dr that he has looked at the titration study data and that there was enough for him to figure out what's going on. We haven't spoken yet, but I am betting it will just as you said: leaks.  I'll let you know what he says. I sure hope he can sort it out without another over night study.