Long time CPAP user still fatigued

[Lucky7]

enigmatic, where is the positional data coming from? thanks! and....how'd you get your apple watch data in?

[Old Steve]

It appears to me in your flow rate (all the small spikes) that you are getting many small arousals. You may want to try running the machine in CPAP mode and set the pressure at 9 with with an EPR of 2 and see what happens.

[enigmatic]

@Lucky7. It isn't positional data, it's sleep state (deep sleep, core, rem, and awake) that apple watch provides. They have the data available to look at in health app. Don't have an easy answer I'm afraid, you can hand enter all of the values into an excel spreadsheet and look for some kind of template that OSCAR will accept. Very tedious to do by hand though.

I did make a literal positional time series by looking at the camera and tabulating every position overnight-again tedious.

@Old Steve. I was going to try that one. Seems reasonable. Thank you.

[dean406]

Thanks Dave.  Great info explaining EPR & minimal pressure settings.  I was referring to some recent research that appears to indicate ResMed's EPR has an inherent "bug" in the algorithm that makes it pretty-much flawed.

Some research comparing the EPR among manufacturers was performed and the consensus was that all of them require the pressure to be increased a small amount.  So if a person gets good therapy with a pressure of 10 cmH2O; they *might* need 10.5 with EPR to receive the same therapy.  For most of us, this small difference is too litle to make a difference and is mostly just academic. 

An exception was found with ResMed.  The research discovered that if EPR was used on ResMed devices, the additional pressure required was equal to the pressure relief setting.  So if a person needs 10 and turns on EPR of "2" on an AirSense machine.... They end-up getting the same pressure as-if the machine was configured for 8 cmH2O, instead of 10.  So a person who needs 10 and wished to use EPR on a ResMed machine may have to reconfigure the pressure to 12 (EPR set to 2) or 13 (EPR set to 3).  This makes the whole EPR feature somewhat counter-productive as the lowest pressure you would be getting is the same as-if the machine had EPR turned off.

reference:
https://www.youtube.com/watch?v=GaXA0ZIWj1Y

[enigmatic]

   

   

   


Something I was looking at is the expected tidal volume, a lot of the symptoms of the tough cases here seem to mirror low tidal volume (see image 2).

I calculate mine should be min 450 to max 600, which is fine when the night starts out, but during sleep it seems to drop on average to around 300. Is it normal to drop during sleep? Anywhere I can verify this? Thanks

Note, sPO2 looks great, so maybe it is fine. Doesn't seem like decreased oxygen levels in blood. So not sure I understand the tidal volume at night.

Another thing is I've read some people post that tidal volume goes up with REM. I can 100% correlate my drops/dips with REM in the sleep states (image 1). Spikes tend to correlate with arousals.

[Sleepy Quixote]

@enigmatic

Did your sleep study show PLMs? There should be a PLM index that lets you know how many arousals were caused by periodic limb movements. Frequently sleep Docs don't spend much time, if any, covering it when they go over the PSG with you. Just curious because I see some similarity in your charts to mine, lots of spikes in the flow rate chart, resp rate too.

[Old Mike]

Yes, your tidal volume is much lower than average for a man. Are you perhaps smaller than average? That might explain it.

[enigmatic]

   

@Sleepy Quixote. No PLM but I do turn a lot and confirmed most if not all arousals are due to this and things like itchy mask, change pillow, eetc.
@OldMike I calculated the expected flow rate range for my weight height 200lb,5 11 min 450 max 600 lb.

This is very interesting! since my recent worse feeling events correlate with when this tidal vol dropped historically (look back at the symptoms post for hypoventilation post listing worse feelings descriptions).

Notice both tidal vol and leak rate dropped dramatically around june 28. And its very consistent after. No significant pressure change there.
I'm trying to think back, maybe that is when they gave me a different phillips nasal cushion with a different type of plastic (manufacturuing change).
I thought the leak rate drop was amazing but now I'm thinking it did something else.
Also, I've mostly worn a medium phillips respironics dreamware nasal mask with a small gel pillow cushion.

Now i just remembered exactly what I changed on june 28! I replaced the blower with a third party OTC blower, because of high pitched whine.
I just bought a new machine, and I'm going to start using to see what happens. Could be the motor replacement was not sufficient.

This seems huge to me.

But if tidal vol is bad, and it was something like hypoxemia, I can't understand why sPO2 is still really good last 2 nights I started to measure.

[Old Mike]

We're about the same height and weight and my tidal volume is relatively low also - usually around 420-450. But I do a lot of partial mouth breathing which doesn't wake me but reduces my recorded tidal volume numbers. Your leak rate is low, so it's safe to assume that the reported tidal volume numbers are accurate. Your respiratory rate is also in the middle of the normal range. That only leaves one explanation for the relatively good SPO2 numbers. Does your SPO2 device also record heart rate? My guess is that it must be higher than average. If so, that's not necessarily an indication of any cardiac trouble (unless it gets into tachycardia territory), but it would at least give some confidence that the other figures are correct. For what it's worth, my resting heart rate during the day is usually 70-72 bpm, but falls to an average in the low 60's while sleeping and can dip into the 50's while in deep sleep. I'm in my late 60's and not particularly fit. I walk a couple of miles most mornings but that's about it due to arthritic feet.

[enigmatic]

   
   
   


@old mike. thank you. I have to think about it a bit more. I think the low flow rate doesn't necessarily affect sPO2 right away. I think it evolves from  hypoventilation (causing fatigue, lethargy, etc...) to hypoxemia (low sPO2).  Now the good news.

Don't want to jump for joy yet and too early to say... but...
Installed the new machine.  looks like my hypothesis is on the right track. First night no OA or CAs only UF2 (itched a few times). 
Tidal vol averaging closer to 400+. But weird things...

1) New machine felt like I was suffocating for air, like when I first started. I didn't realize that the new machine doesn't automatically start when you try to breath. Fixed that with manual start (anyone know to automate the start by breathing into mask?). And went to bed feeling fine, breathing wise.
2) Woke up very early (5am) as I felt I was struggling to breath in, so I increased pressure min to 8. Never really fell back asleep, But even weirder, 
3) All those breathing measurements dramatically shifted around 4 am (before I woke up). Tidal volume avg. jumped close to 7-800 and respiratory rate dropped 20 to 10 (img2).
Finally came back down as I added higher pillows and started to breath smoother I think (less sucking hard on air) around 7:45, then just got up. Never really slept
from 5 to wakeup. Very early for me both duration and timewise.

Anyone have any idea what happened there? I'm thinking it's a new machine, and I have to recalibrate settings. But that was very odd.
My nose also felt plugged (with mask) which I didn't have very often on the old machine. 
On the old machine, I think I was being slowly poisoned from (ultimately low flow rate) a non calibrated motor from 3rd party, and no doctor would have ever figured that out for a long long time. No thanks also to apria who refused to replace the machine after 5 or 6 years and two insurances (and I) fully paid twice over.

The other note is although I feel 'tired,' much of the fog, swollen eyes, dizzy, faintness seems to have lifted on today's wakeup. Too early to say for sure, but I think it's a huge jump. I'll probably try to nap mask free.