Need Help trying to make things "perfect"

[chill]

A note about your surgery.  I had this done about one year ago.  Seven weeks is still the early days.  You can expect more changes and increasing better breathing over the next several months.  It is gradual and I only noticed it when looking back.

[ajack]

I'm only a novice and I'm thinking out loud... but if it was my chart, I'd have my minimum close to around the median number, 13-14 and the max I'd lift to 20 for now, to see where it lands

[doickle]

I want to thank everyone who replied and provided some insight. I changed my settings as suggested and I believe it has worked out exactly as thought.My AHI is still hovering between 1-3 but if you notice in the attached chart my flow limitation is a much less noisy curve, quite noticeably less noisy. It also seems that my machine is not maxing out most of the time as it was when my max was 15 and the average pressure is actually lower. Thanks especially to Robysue for the extremely detailed and accurate analysis of everything I posted. Apologies for taking so long to respond but I needed some time to digest everything. Below are my responses to your post.


1) Since you are feeling good now, what do you want to accomplish by lowering your already acceptably low AHI to the Less than 1.0 range?  Do you think you will actually feel any better? Or is it just for bragging rights?

I am feeling good and I am not necessarily just trying to lower AHI, I am trying to make sure my therapy is the best it can be. I guess since I am still fairly new and trying to understand CPAP intricacies I have been focused on AHI but as I have seen over the past few days there are other parts to tweak that can also have significant effects. 

2) At a certain point, lowering the AHI often requires stuff that can marginally increase comfort problems. And increased comfort problems can lead to poorer sleep even if the numbers look better. So what kinds of adjustment problems did you have?  Are there things that you are simply unwilling to do because you know that they will cause you discomfort?

I didn't have many adjustment problems and I really don't think any other measures are required in addition to dialing in the CPAP settings.

Having said those things, here's what I think about your data.

Leaks
Most of the time your leaks are under excellent control. Resmed's engineers' Happy Face icon should be showing up night after night.  But there is evidence of some mouth breathing here and there.  In particular, the official Large Leaks on May 8 are probably mouth breathing. And there's probably some mouth breathing May 6 and May 7 as well.  Whether perfecting your leak line by adding a chin strap or cervical collar will improve your AHI or your sleep, however, is an open question.  You may find that the work needed to eliminate the short bits of mouth breathing cause you more discomfort than they are worth.  In other words, if adding a chin strap or soft cervical collar improves your AHI, but at the same time makes it more difficult to get to sleep and to stay asleep, the work to fix the minor leak problem may not be worth doing.

Thanks. Although I do see some leaks my average leak rate for the past 30 days is 2.03 and my % over leak threshold is 0.66%. I'm sure that I do have some mouth breathing as it is just the past 6 weeks since the Sinuplasty that I have been able to breathe properly through my nose.

The AHI and the pressure range
The current pressure range seems to be good at controlling the obstructive events.  The OAs and Hs that are recorded are usually, but not always, isolated rather than occurring in thick clusters.  There may be a tiny bit of small REM-clusters involving 3-6 events on a few nights, but nothing particularly significant.  However, those possible REM-miniclusters do seem to occur when your machine is maxed out near 15cm.  It could be that you need a smidgeon of an increase in the max pressure.

As suggested I have increased my Max Pressure to 16. I believe this has helped over the past few days, (see the graph from last night posted below). During my therapy I have noticed that my events are mixed with some nights events happening randomly and others seeming to happen in clusters depending on the sleep stage. I'm not sure what the difference is and why it is not the same every night.


The RERAs, the flow limitation graph and the pressure range
The most "negative" thing in your data are the consistently ragged flow limitation graphs.  There is a lot of activity in these graphs indicating that your machine thinks it is seeing a lot of flow limited breathing.  Whether those flow limitations represent an airway that is threatening to collapse or just some kind of anomaly in the way your airway is physically put together is a different question.  If the flow limitations are indeed being caused by your airway starting to collapse, then increasing the pressure a bit should smooth out the flow limitation curve.  If, however, the flow limitations are caused by something other than an airway that is starting to collapse, more pressure is unlikely to do much about the flow limitations.  (In my own case, the flow limitations recorded by my PR Dreamstation BiPAP do not decrease with additional pressure, and too much pressure seems to make them get worse.)

Again, since your machine is hanging out right at its max pressure for most of the night, it is possible that an increase in the max pressure may help. But because your minimum pressure is 5cm below your current max pressure, you may find that an increase in your minimum pressure may do more to tame your flow limitation curve than an increase in your max pressure does.  

RERAs are a special type of flow limitation. If you can get the flow limitation graph to be less busy, the number of RERAs should drop.

For many people a modest 1-2 increase in both the minimum and maximum pressure settings doesn't disrupt their sleep or create problems with aerophagia or increase problems with large leaks.  But for a few people, even a modest 1-2 increase in the pressure range does create problems with sleep disruption caused by either aerophagia or additional significant leaks or increased mouth breathing.  So you could try a pressure range that is more like 11-16 or 12-17 instead of your current 10-15 range in an effort to smooth out your flow limitation curve.  Whether the pressure increase needed to smooth out the flow limitation curve is worth it in terms of how you feel (both during the night and during the day) is a different question.

I believe you nailed it with this one. I made the change to 11-16 and now my Flow limitation graphs are a lot less noisy and the RERA has reduced as well. There are still some nights with higher AHI but it seems more Hypopnea rather than Apnea events.


Breathing variability
I'm lumping several things into this overly broad category.  Some of them are reflected in the tidal volume graphs, but mainly they show up directly in the flow rate graph as well.

If you look at the flow rate graphs, you will notice that on every night there are periods where things are nice and flat and the rate of air going into/out of your lungs is almost constant from breath to breath.  This is reflected by the parts of the flow rate that look like a nice flat black bar at the whole-night scale. If you zoomed in to the point where you see individual breaths, the breaths in these parts of the night would look identical to each other: The maxs and the mins would all be at the same heights and the period between the peak of each inhalation would be regular.  In math speak, the flow rate would look sinusoidal. This kind of super regular breathing represents the best of normal non-REM sleep breathing and it usually indicates that you are both really asleep and that the CPAP/APAP is doing its job very well.  The tidal volume graph during these periods of super stable breathing is also almost a horizontal straight line during these parts of the night.

But there are also other parts of your flow rate that look "ragged" even at the whole-night scale. You can tell there's a lot of breath-to-breath variability just by looking at the flow rate. As an example, look at the data from May 1 and the flow rate for 0:45-1:45 (lots of variability) and compare it to the really smooth flow rate 22:45 and 23:15.  Now the raggedy flow rate can mean a lot of different things.  

• Sometimes it just indicates that you might have hit a REM cycle; breathing in REM is less stable than breathing in Stage 2 and Stage 3 sleep.  
  
• Sometimes it means that you've woken up; normal wake breathing is less stable than breathing in Stage 2 and Stage 3 sleep.  
  
• Sometimes it indicates that you are really restless---you've woken up or aroused, but instead of quickly getting back to Stage 2 sleep, you get stuck going back and forth between wake and Stage 1 sleep.
  
• Sometimes it means that you're having a lot of trouble breathing; when people have dense clusters of obstructive events, the flow rate graph gets ragged because after many events you take several "recovery" inhalations that are larger than normal and these large inhalations correspond to the sharp spikes on the whole-night flow rate graph.
  

And it's not particularly easy to tease out what any particular ragged section of the whole-night flow rate graph might be caused by.

In general, if you remember a lot of tossing and turning during the night, much of this more ragged breathing may just be sleep-wake-junk: You're bouncing back and forth between wake and Stage 1 sleep.  Tweaking the PAP settings may not do anything to prevent that. In some circumstances, tweaking the PAP settings may increase the SWJ if you are physically less comfortable after the settings change.

If the ends of ragged breathing bits are spaced at roughly 90 minute intervals and they increase in length as the night goes on, that's indirect evidence that they may just be normal REM breathing. And if there are not any serious clusters of OAs and Hs during those times, then there's nothing to fix because there's nothing wrong.

In other words, tweaking things may or may not make your flow rate curve look any better. And improving the flow rate curve may or may not make you feel any better.

This info has helped my understand so much more about what I am seeing in my data. I really appreciate the time you took to analyze and explain this for me.

[PaytonA]

RERAs are a special type of flow limitation. If you can get the flow limitation graph to be less busy, the number of RERAs should drop.

I am getting old. My eyesight is getting dim. My memory is about gone. I can't find anywhere in doickle's data where any RERAs are indicated. Am I missing something??

Best Regards,

PaytonA

[xxyzx]

I am looking for some help from the forum.
I have been on CPAP for a few months now with good results. Definitely feeling much better than before and daytime sleepiness only occurs occasionally. Overall it is a big win and I am committed to it for the long haul.
I am also about 7 weeks out from a Septoplasty and Turbinate reduction which opened my airway tremedously. This did mess up my AHI for a few weeks but I think I am back in the swing of things now.
So, the purpose of my post is this:
My AHI for the past two weeks has been +/- 2 with the odd night 3 or 4. I want to ask the experts if they can look at my Sleepyhead data and make some suggestions to how I can get below AHI of 1 consistently. I'm sure that I can but I don't quite have the CPAP experience yet to get things dialed in.
Before I post a bunch of screen shots I want to first ask what you need to see specifically to help with this.
I have posted data before but I was wondering if you need more details or specific charts for this type of question.

Let me know and I will post them and hopefully there will be some suggestions from the group.

Thanks

perfection is not possible

go for the best you can achieve within a constraint of reasonable cost and effort  
and when the results are plenty good enough stop obsessing about making them better and get on with life

[OpalRose]

RERAs are a special type of flow limitation. If you can get the flow limitation graph to be less busy, the number of RERAs should drop.

I am getting old. My eyesight is getting dim. My memory is about gone.       I can't find anywhere in doickle's data where any RERAs are indicated. Am I missing something??

Best Regards,

PaytonA

I see that the RERA's line up with the rise in the flow limitation graph. Is that what robysue is referring to?

[PaytonA]

I see the RERAs now. They are very faint and I missed them.

[Marillion]

Some great info there by robysue!

[quiescence at last]

You can see that the remaining hypopneas are bunched together, and can be classified as flow limitation driven hypopnea.  They all appear to be at this short period of time when you are dancing at your selected maximum pressure.

When you are ready, you might increase your maximum pressure up by 0.5 to 1.0 [allowing 16.5 or 17.0].

You may also want to see if you can eliminate the OAs by increasing the min pressure in small doses, since your median pressure is about 12.5 cm, a couple of increases of 0.5 to 1.0 could be done without forcing the median higher.  Most of the remaining OA have been between 11 and 12.5.

Anyway, you are doing great, and need not go further in chasing that 0.0

Great sleep!

QAL