EERS Experiment Data (sherwoga)

[Geer1]

A night or two without the MAD would be interesting to see how it affects your results. I am a firm believer in only using what you need in order to get results, the more comfortable you are the better you will sleep.

OSCAR data is amazing and you can easily see whether or not the MAD is helping. If you sleep without it and have apneas, increased flow limitations etc then it is helping. If everything looks the same all it is doing is disrupting comfort and sleep.

[sherwoga]

Yes, I would raise EPAP again.

Looks, based on what the machine is doing (see the med and 95% EPAP numbers, for example), you probably want to end up somewhere between 7 and 9.

You'll have to use your judgment on how quickly you want inch up to that.

Changes:
Minimum EPAP: ↑ from 6 to 7
Ti Max: ↑ from 2.6 to 2.8

Not much bang for the buck.  CAI was only 0.29.  But OAI was ↑ to 2.28.  There were two periods of multiple OA events (total of 16).  Flow limits were 0.04 and 0.24 (95% and Max, respectively).  Pressure trace is not as smooth as night before last. EPAP Med and Max were 7.95 and 10.44.  

There other noteworthy observations in the mask pressures trace, but I don't have time to assemble anything to post here this AM.  My 89-year father goes in for surgery this AM and that takes priority.

[slowriter]

There were two periods of multiple OA events (total of 16). 

Good luck with the surgery.

When you get back to this, on the above, possible they were positional; caused by chin tucking or some such? Do you already wear a soft cervical collar?

[sherwoga]

I have not posted the last two nights data because of family issues keeping me busy.  This is a summary.  

Relevant settings from 3 nights ago
Minimum EPAP 6 and Ti Max 2.6.  Saw some improvement from the previous night with Minimum EPAP at 5).  

Changes for 2 nights ago
Minimum EPAP ↑ from 6 to 7 and Ti Max ↑ from 2.6 to 2.8  (Got weird flow patterns).

Changes for night before last  
Minimum EPAP ↑ from 7 to 8 and Ti Max ↓ from 2.6 to 2.8. (Thought weird flow patterns might be due to longer Ti Max  , flow patterns were back to normal.)

Changes for Last night
Minimum EPAP back ↓ from 8 to 6 (because increases the previous two nights lead to more AHIs, including OAs and CAs: also maxed IPAP out at limit multiple times both nights and OAs and flow limits occurred when pump pressure maxed out).  

Some Tabulated Data for the four days involved.  

   

Pressure Graphs from the four days involved.

   

Notice the number of events flagged at the pressure plateaus.

From Slowriter in Post # 150.

"Looks like you could start bumping your min EPAP a bit?

One strategy to titrate with the vuto is to adjust min EPAP and PS so that you smooth out pressure swings (I don't see your pressure graph), and of course eliminate the OAs."

That posting prompted me to think about the CPAP data differently and I proposed a logic for "bumping" min EPAP in my Post # 153.

"So what is the logic?  Is it correct to suggest that with a higher minimum EPAP, my airway is "splinted" open better during exhalation, thus reducing apneas and flow limits and, in turn, ensuring fewer pressure shifts occur, i.e., the pressure graph is expected to be smoothed out?"

I was thinking this made a lot of sense.  While Bonjour replied in the afirmative, he did express some caution.  His Response was in Post # 154.

"That is the theory, but we are all different.
The "Pressure" chart shows the pressure "Targets" or settings from the machine's algorithm.
The "Mask Pressure" chart shows the actual pressure at the mask, you can in a zoomed view actually see how the pressure is being applied. This data is much more detailed than the Pressure Chart.
In other words, in the Mask Pressure chart you should be able to see the difference, if any, for changes in the Ti Max."

So what's next?  Do you want more of the data?
Options I am considering:

1. Leave everything alone for a few nights.
   
2. Increase Max IPAP.
   
3. Increase both Min EPAP and Max IPAP by the same amount.
   
4. Reduce PS a little (to go after last few CA's).  It has been unchanged at 5.4 since my first night using the VAuto.
   
5. Other options one of you might suggest...
   

[slowriter]

What's your subjective impressions of sleep quality?

The numbers are a bit counter intuitive to me.

[Geer1]

You need to look at the data, not the numbers. OA's and H's can come in a number of forms and the machine can improperly flag events too. Either these OA's/H's are real and you need higher EPAP and max IPAP or they aren't and you need to make other changes.

If you post examples of the OA's/H's at 1:35 on the 11th and 00:30 on the 12th might be able to figure this out (lets see flow rate and mask pressure).

Also when posting these charts it is important to see the whole picture as some inferences can be made when able to see flow rates etc that get missed when only looking at what the pressure did. Just as an example one of my nights that looks the worst pressure and apnea wise was not actually due to sleep apnea (SWJ was wrongly being flagged as apneas and driving pressure up).

[sherwoga]

What's your subjective impressions of sleep quality?

The numbers are a bit counter intuitive to me.

I agree about the "counter intuitiveness".  I feel better today than either of the last two days.

[sherwoga]

Settings:
Mode         VAuto
Max IPAP   18
Min EPAP   6
PS             5.4
TI Max       2.8
TI Min        1.0 (only change made, up from 0.3)
Trigger       Very High
Cycle          Med
Mask          Full Face
EERS          12 inches
MAD           Y

Apnea Indices
AHI     0.75
CAI     0.00
OAI     0.75 (6 events with 4 between 4:11 and 4:23 AM)
HAI     0.00

Other observations:
Pressure trace smoother
Flow limits low, 0.00 and 0.12 for 95% and Max.
Flow patterns normal
Screen captures
Tidal volume has remained stable in range of 800 to 840 since I began using the VAuto with PS of 5.4.

             

Potential Experiments with Therapy going forward (looking for continued input from forum)

Increase PS gradually to see if I can decrease remaining obstructive events

• early on Bonjour had cautioned against pursuing zero
  
• is the current performance good enough?
  
• if so, have I arrived at acceptable therapy?
  

Not right away, nor at the same time, reduce the EERS from 12 to 6 inches to see impact on central events and tidal volume. 

Test current settings but without the MAD.  

[Geer1]

PS doesn't treat obstructive events, EPAP does. You still need to determine if they are a real, that will tell you if you need to make the change. By real I mean making sure that they aren't occurring post arousal or possibly being wrongly flagged centrals. If post arousal need to ignore and figure out what is causing arousal. If centrals reduce PS.

[slowriter]

• is the current performance good enough?
  
• if so, have I arrived at acceptable therapy?
  

What is YOUR answer to these questions?

Are you sleeping "well"? Do you feel better during the day?

I think personally 6 is a bit low for you on the min EPAP.