Fresh Start

[zzzZorro]

This is a different thread from the previous ones that used use a number of various machines, masks, chin straps and C-collars.

Let's start from here and disregard any prior knowledge of my conditions/afflictions and concentrate on this chart alone.

With that in mind what changes would you suggest making and please explain why?. 
(there are 2 brief segments closed as they were SWJ caused by pesky leakage from a FF mask I switched from to a QuattroAir- waiting on a Simplus)

[attachment=4856]

  "Sock it to me!"   

 

[Walla Walla]

A quick glance it looks like you had two groups of OA events that look positional.

[Gideon]

I would want to see your sleep report before making recommendations. Looks like you might have complex or mixed apnea.

[Sleeprider]

Well, you have a fairly even distribution of CA, OA and H. Your machine is putting out PS2 over 13 to 19 EPAP (15/13 to 21/19), and pressure is mainly responding to flow limitations. My normal suggestions would be positional therapy for the obstructive clusters and higher pressure support to suppress hypopnea and flow limitations, but I can't ignore your past, and that would cause a significant increase in CA. That leaves me with the positional therapy and perhaps limiting that upper pressure being driven by the flow limits.

[Matt00926]

If this were my own chart, I would raise both EPAP min and IPAP min by 1cm h2o each, and then reduce PS to 1.0


Rationale:

I for hypopneas and flow limitation
E for obstructive apneas
Lesser PS to reduce clear airways

[zzzZorro]

A quick glance it looks like you had two groups of OA events that look positional.

Thanks Walla;  That would have been my guess nice to have a second opinion.  I think tossing around in my sleep has been a big problem affecting my data all along.
BTW: Thinking of you when I change the avatar
 

I would want to see your sleep report before making recommendations.  Looks like you might have complex or mixed apnea.

    Thanks for looking bonjour; Appreciated.

Well, you have a fairly even distribution of CA, OA and H.  Your machine is putting out PS2 over 13 to 19 EPAP (15/13 to 21/19), and pressure is mainly responding to flow limitations. My normal suggestions would be positional therapy for the obstructive clusters and higher pressure support to suppress hypopnea and flow limitations, but I can't ignore your past, and that would cause a significant increase in CA.  That leaves me with the positional therapy and perhaps limiting that upper pressure being driven by the flow limits.

SR;  As you said early-on "consistently inconsistent".  I have been quietly lurking as I work on trying to work up acceptable therapy.  Did wring-out the CPAP mode and did a 6-day run at same settings (14.4 cm) but it proved to be an exercise in futility.. roller coaster results:

           
So decided to go with Auto mode and see if the events could be better addressed with it.  It has been two days now and this one was last night:

[attachment=4879]
Massive improvements over CPAP but expecting the 'consistently inconsistent' factor to rare it's ugly head.  I have settled on the absolute necessity for a FF mask and a c-collar.  The collar makes a world of difference on O/R emergence and length of time (proofed).  Have a Simplus mask arriving in a couple days to hopefully mitigate the nose area irritation.  Going to probably the last appointment with the Doc in a couple days.  Trying to learn enough to resolve the problems without having to have y'all beat a dead horse.  A little guidance now and again is very much appreciated.

If this were my own chart, I would raise both EPAP min and IPAP min by 1cm h2o each, and then reduce PS to 1.0


Rationale:

I for hypopneas and flow limitation
E for obstructive apneas
Lesser PS to reduce clear airways

Matt; Appreciate the post and information- especially the Rationale (helps me learn).  Will leave it where it is a while to see if it goes nutz or settles down more- as stated above I see the Doc on Thursday, probably the last scheduled appointment.  If the Auto mode goes haywire will try your suggestion, could be the key..

[Shin Ryoku]

... I can't ignore your past, and that would cause a significant increase in CA.

Same here. Can't really ignore past posts.

If I recall correctly, ASV was not an option? I'm wondering whether any of the "alternative" therapies could be a helpful adjunct to your CPAP/APAP therapy: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3998090/

For example, an oral appliance might help you treat the OAs with lower PAP pressures, and the lower PAP pressures may help your CAs. Other therapeutic approaches which can be helpful in some patients include the use of nonvented masks (not something to try on your own), certain medications (eg, acetazolamide), head of bed elevation, oxygen supplementation, etc.

I don't know where you are located in the US, but the author of that article (Robert Thomas at BIDMC in Boston) seems to have a very thoughtful and comprehensive approach to the treatment of patients with CSA or a mixed picture of CSA and OSA. It may be helpful if you can go see him or someone with a similar approach.

[zzzZorro]

Shin; The article is interesting- Thanks for the link.
In answer to your questions: I am on the West Coast- nowhere near Boston; Not allowed ASV; Not a fan of drugs; Use a c-collar as it has 'proofed' itself; Aware of positional therapy as much as possible- always has to be supine or Quarter-L or Quarter-R; Doc said 'he is not inclined to prescribe o2 to anyone who does not have to have it and my o2 never gets to that point'.  The oral device in conjunction with the Vauto is a consideration I will bring up at my next appointment.

My appointment was moved out a week (by them).  I suspect he will be pleased if I can keep this 'roll' going and under AHI-5 as that was his initial target given my particular case.  SR and Matt gave me their thoughts yesterday for tweeks but they go in opposite directions (SR apparently was more familiar with my quirks).  I just got a Simplus FF mask today to see if it will be more nose-friendly so will not be surprised to see the AHI change.  Probably wise to keep the settings where they are till I get to the Doc to see if they maintain.

Below is the third session at this setting on the Vauto:

[attachment=4906]

[Walla Walla]

zzzZorro, Tell me how you like the Simplus after you've had a chance to try it.

[zzzZorro]

zzzZorro, Tell me how you like the Simplus after you've had a chance to try it.

Walla;  I can only speak from about 45 minutes putzing with it and will have to revisit the issue for confirmation.  Could comment at this point 'I do not like it', but that is not my final judgement.  Hung it up and donned the 'ole QuattroAir.   If interested here's a premature elaboration:
_____________________________________________________________________________________________________________________

Initial thoughts:  I like the different way the cushion is designed at the nose- supposedly to seal better around the eyes.  My nose is apparently more difficult to seal than others as generally overtightening is the norm requirement with all FF masks I have tried. Has nice headgear. Don't know if it is actually my face structure or the IPAP pressures that usually dance around 20cm. 
First impression that put it back in the drawer last night was a small air leakage into the eyes.  Not much but enough to annoy and effect my going to sleep.  Could not specifically tell if it was coming from between the seal and my nose or if it was being deflected back from the seal vents.  Placing a small microfiber eye-glass cloth under the forehead support over the eyes appeared to indicate it was coming back from the vents- but the cloth being there was too annoying left against the eyes.  The forehead brace/support I find to be unfinished as when the forehead band is tightened sufficiently to seal it presses into the forehead, unlike the ResMed Quattros.  Also I'm not sure it passes air to the user quite as well as does the Quattro (percieved air flow)? I know it is mostly liked by others and that is why I wanted to try it.
Zorro