Just getting into this . . .

[TSVanwinkle]

Hi,
Yep, did not see your last post until this morning.  The increased EPAP and PS min, do appear to have raised my TV level.  Last night was a little more restless for me and I managed to knock my mask loose a couple of times.  I  took a WC break around 3:30a and the last time I looked at the clock before getting back to sleep was around 4:30a.  I did have a few events with an  ASI of .82.  I've posted three screen shots; overall and two expanded areas where the events were taking place.

Don't know if I'll have time to do a one hour sit today, but will change the Min EPAP back to 7 and Min PS up to 5.

-Tim

[ajack]

If you look at the tidal volume, you are still getting enough air during the obstructive H. They are within the area that is using the high pressure. From a leaky mask that is pumping up pressure? Is there a good seal or is there defusion under the seal on test pressure and not breathing. Or a positional restriction of the airway. Try and decide which and you fix that and then see the chart. At a guess it looks like you are getting microarousals that momentarily clear the airway and then obstruct again as you return to sleep. To be again hit with high pressure to try and clear. I think it's mask or positional. It would be worth working on and may be a factor in the dips in the minute vent.

What I am trying to do is get a reasonable straight line on epap, that will vary and is associated with min PS minEPAP+minPS=ipap to clear base obstructions and an alright tidal. It is ok on 8 from last night, I don't think it will need to go up more, it may be able to come down later. On the other hand when you are running in the 20's cm, what's 7, 8 or even 9. It's a non issue as far as comfort goes.
I'm also trying to get a bit of a straight line sometimes on the min ps or the bottom of the wriggly area on the pressure chart, about 14-16cm. Try the min PS5cm and see.
Then see if there is enough tidal volume and adjust min ps and min epap to suit.
Then see if the minute vent is tracking fairly straight, without too many dips. The machine tries to follow the last few minutes of breathing, so it's to determine what could be causing the dips, how far and how long it dips and if it can be resolved. You are dipping to around MV 4 lt per min and worth working on, as above. It may help to also post the resp. rate chart.

I would keep 8cm and have min ps5 and see. This will take min ipap to the 13 and should be close. The overall tidal volume doesn't dip and you could leave it at this. The only reason to go to PS6 would be for more tidal volume.

You will be able to adjust it yourself soon. It really isn't that hard as you have seen. I sort of try to do 'S' mode titration on the min epap and min PS and with the max epap and PS opened up for the ASV to adjust and then see what problems are left.
https://www.resmed.com/us/dam/documents/...er_eng.pdf

[TSVanwinkle]

G'day,

Hadn't realized earlier that your location is Australia, so yes, we have a few time zones separating us.  I was there for nearly six months for the olympic games and loved it!     

re positional:  yes, I've got some work to do there.  I incrementally began tightening the mask last night due to "face farts" occurring when the mask pressure came up.  I'll double check the seal in mask fit mode to be sure it isn't leaking.  Looks like a cervical collar may become a needed item if I can't get the obstructions minimized.  In this process I have found that the obstruction stuff minimizes when on my left side.  Problem is, even with the extra side- sleeper topper,  my shoulder begins to hurt after a few hours and I have to roll over and re-adjust head, pillow, knee pillow, blankets, etc --which wakes me up.


Thank you for the link to the clinicians CPAP guide the explanations help me better understand how ASV works. 

So, tonight I'll set PS min to 5, leaving EPAP Min at 8.  Will see how this goes.

Good on you!

With regards,
Tim

[ajack]

G-day mate. You're a friggin slow runner, if it took you 6 mths to complete the olympic distance run. (seeing you were her for 6 mths, you'd get the humour)

so it may be a bit of both, mask and position. You have some homework to do. You can buy a new pillow or tie a belt around it, to look like a bowtie. you put your head in the middle. You basically want to support your neck and let the top of your head dangle.

I'm glad the link helps, It really isn't rocket science.

[TSVanwinkle]

G-day,

Last night's experience was pretty interesting.  I slept better and the few times I rose to the surface, I noted how  smooth and slow my breathing was.  Ironically, my AHI events went a bit higher.  I had no mask leaks and woke up in the same position I started with.

re the "friggin slow run",yes, I can see how you might think that. But-- it was one of the endurance events; only 10 laps.  (Sydney Harbor to Ayer's rock and back)..  I stopped for a few pints along the way and possibly took a few wrong turns. 

 

So....I've posted three screen shots from last night.  One overall, one during a period of no Hyponeas, but an interesting array of dynamics.  I can see the direct relationship between Tidal Flow and respiration rate.  Since raising the Tital Flow rate, my average respiration has gone lower.  Maybe that's why I'm more comfortable.  I didn't feel like I was having to keep up.  Their were a number of flow limit hits dispersed through the night.  Some coincident with the Hypop events, some not.  Discovered the nasal strip I had applied had come off on one side, so that might explain the upper airway stuff.   THe third one is looking at the Hypop events.  Obviously I have more work to do on the upper airway and will look at getting a collar.

Cheers,
- Tim

[ajack]

That's just a real messy chart and a head scratcher, isn't it. 
The normal resp. rate coincides to the lower PS area and good minute V. 
The low resp. rate coincides to the high PS and low minute V 

From your chart post 11, epap8 PS4, You can see how the tidal volume looked ok, but the dips in the minute vent were there. I thought the resp.rate may show something, but that's a league of it's own. It is like a switch is thrown between low and normal respiration rates. 

You could back off to epap6 PS4 and review. The PS4 did help your tidal from 460 to 520. The epap8, PS5 may have triggered something with your respiration, or it may be unrelated. The sensible thing is to go back to the last know and review. Once the mask and positional is ruled out, it may be clearer about the resp. rate.

[TSVanwinkle]

Ohhhhhkaaaaay,

I'll make changes back to EPAP 6  and PS 4.  Even though I felt more relaxed and that things were smoother, cruising at that low of a breath rate from what I have read, isn't  a good thing.  I seem to be a little complicated.  I probably need to come back to Australia and do another couple of laps between Sydney and Ayer's rock to get back into shape . . . . .

[ajack]

Yes, you are obviously suffering from an alcohol deficiency. Come back and we'll fix that.

It just to back off pressure and see the result. I don't have a reason why 8 ps5 would trigger the resp. pattern. When you felt ok it was running at a steady 8+PS9 =17, from about 3:45 to 5, with only a couple of spikes. I just didn't like the low minute vent for a longer period. You may not need a CMS50f overnight recording o2 meter for around $80, but they are fun to play with in oscar.

From post number 10, if you get a chance to watch TV in cpap mode and 5cm, it will give your base line awake stats. The TV is just to distract you.

[TSVanwinkle]

Here we go!  

First slide up is a screenshot watching the tele for an hour.  Used my ResMed 9 set at 5CM Cpap mode.  Looks like TIdal Vol median is 420, Respiration median 18 bph. 

Last night's results were, interesting.  Settings Min EPAP 6  Min PS4.  It was a peaceful night with no leaks and one Hpopnea.  What is interesting is the cycles that occur.  10 20 and 30 periods where my breathing is smooth and even.  Expanding the flow rate during the calm periods shows a reasonably symmetrical sine wave looking graph.  Then a breathing glitch hits and a rough period begins whee tital flow comes up, respiration tanks.  Things bounce around for a while somewhere in the 10 minute range and then it settles down for another 5 or 10 minutes before the next trigger. When the breathing glitches occur, there is nothing to indicate an obstruction, or leak.  There are some flow limitation hits, but they occur when the PS and tital volume spike.  So, I'm thinking the trigger may be a central oriented in absence of anything else?  Looking too at the expanded flow rate after an event starts, the in-breath length of time stretches out and the symmetry has changed.  Don't know what to make of it other than its interesting.

Will be very interested in your thoughts.

- Tim

[ajack]

From your first chart, what was and still is a consideration is the low minute vent sections. The idea to get the PS up. To see if more support helped minute vent and the tidal. The ASV follows the last few minutes of breathing, as the link showed and will cycle down. It's not designed to maintain a fixed value, like ST and iVaps. The pattern was on all the charts, increase PS made the central event longer and defeated the purpose. I'd return to ps1 until your next doctor appointment and review.

I am speculating, but I agree. It looks like you central and the ASV takes over. The minute vent drops because it cycles down, It follows the last minutes of breathing. The machine min breath rate might be 8 and a min minute vent 5 lt/m needs about PS9 to achieve it. The co2 builds up, triggers an awakening and the cycle repeats, The higher PS delays the co2 build up. There is no mention of min breath rate or min minute vent in the literature available, so it's a guess. ASV mode isn't designed to treat this type of thing for a sustained period.

It's good to know your awake resting stats, It gives something to measure by.