Question about Flow Limitations

[SleepyDreamCatcher]

I'm fast approaching 4 months of using PAP. I wanted to wait until after my next appointment before trying any self initiated adjustments. However, that I was still sleepy during the day regardless of what my AHI said and realized that waiting on a visit to the doctor was only prolonging my misery. I decided to see what would happen changing the settings on my AutoSet from CPAP to AutoSet mode. I have been adjusting my pressures slowly for several weeks and have found that with my machine set at 9-14 cm H2O that my actual pressure usage cycles with that range during the night. I have been at this setting for 1 week. It is at 9 when I'm awake/falling asleep. Once sleep I vary from the mid to high 9.x to 13.x. It hasn't ever reached 14. Since doing this I have noticed an increase in my daily energy and less foggy thinking. The snore graphs in SleepyHead and ResScan have dwindled to nearly nothing, although what there is persists most of the night.

My question has to do with Flow Limitations. The graphs look better, no longer maxing out at the top of the graph.

On ResScan the lines jump around in the low and middle areas of the graph.

In SleepyHead The minimal number is 0.0, median number ranges from 0.0 to 0.02, 95% range from 0.09 to 0.12. The maximum numbers range from 0.31 to O.66.

What is considered normal? I seldom go longer than 15 seconds before another flow limitation is recorded, with a lot of the time spent between the median and 95% numbers. I'm thinking that this may be as good as I'm going to be able to get with my S9 since I'm not maxing out on my ceiling level of 14. I wish that the S10 AutoSet for Her had been available in May. I think that the RERAs were as much or more of a problem for me than the apneas/hypoaneas were.

[retired_guy]

I had just about an identical scenario to you Sleepy. Once I found my sweet spot as far as ahi, leak, pressure was concerned I noticed the Flow limitation graph was still kind of choppy. ..and although I was feeling good, I felt like I could actually be feeling better.

What I did was to increase my low limit by 3 points, then turn EPR on with a value of 3. As far as pressure was concerned the net effect was little if any. But the Flow limit graph nearly went away. Not only that, but I started getting those "wow was last night cool or what" sleeps.

Since doing all that crazy go nutz stuff my nightly events average from zero to 1. Last night was a bad night for me, I had 3 events. AHI? Very very low.

I don't know why. But it worked great.

[vsheline]

I wish that the S10 AutoSet for Her had been available in May. I think that the RERAs were as much or more of a problem for me than the apneas/hypoaneas were.

The optimal treatment for RERAs is often a bi-level machine. The ResMed AutoSet and Elite are acting like bi-level machines when we use EPR. Turning up EPR to its max (3) gives us the highest amount of bi-level we can get without having a true bi-level machine.

As R_G has found, sometimes it is helpful to raise the Min Pressure to compensate for how EPR lowers the pressure while we are exhaling.

In fact, even if the Min Pressure has already been adjusted higher to compensate for EPR, adjusting the pressure even higher often helps reduce RERAs, because RERAs are obstructive events, and raising the pressure helps avoid obstructive events.

The problem some patients have is, it is usually easier to tolerate high pressures when the Pressure Support (PS is similar to EPR but is for bi-level machines) is 4 or even higher. Another advantage of a true bi-level machine is it will be more adjustable in how soon or delayed, and how abruptly or smoothly, the transitions between EPAP and IPAP will be.

Have you been using the max amount of EPR (3)?

On the other hand, for a minority of patients higher EPR or higher Pressure Support or simply higher pressure can cause too many central apnea events, so keep an eye out for that, too.

Take care,
--- Vaughn

[SleepyDreamCatcher]

Good morning R.G. and Vsheline. Thank you for your replies.

Currently I'm not using any EPR. I am still seeing "mini" Obstutive events when I look at my data, although they are fewer and overall shorter than before. I'll try raising the minimal pressure up to 10.6 for the next few nights. After the first couple breathes on the machine at night I don't even notice the pressure while I'm exhaling. Do you think I should be turning the EPR on?

[retired_guy]

I do Sleepy. I would up the minimum by 2 points, turn EPR on at a setting of 2. That would be a good test to see how you do.

[zonk]

Do you think I should be turning the EPR on?

Only you can decide, matter of trail and error. I'm not using EPR either, I find it interfere with my breathing rhythm and pretty useless but for some its the best thing since sliced bread ... everyone is different

Avoiding sleeping on your back can helps, how is your leak numbers?

[SleepyDreamCatcher]

Do you think I should be turning the EPR on?

Only you can decide, matter of trail and error. I'm not using EPR either, I find it interfere with my breathing rhythm and pretty useless but for some its the best thing since sliced bread ... everyone is different

Avoiding sleeping on your back can helps, how is your leak numbers?

My leaks are minimal... Generally just small little leaks, probably while I'm changing sleeping positions. The few large ones I've had generally woke me up immediately and were fixed then. AHI is under .5 consistently since I started playing with my pressures. Most nights it's 0.00! I've had 2 flagged hypos over the past 8 nights at the current settings and no flagged obstructive apneas. But there are still obstructive looking events lasting 5 to 9 seconds. Shorter ones too, but it's the long flat lines that really catch my attention.

I know that back sleeping will increase apneas, but because I have limited options for controlling pain, I would like to see if I can't figure out appropriate settings that allow me to move while I'm asleep as my body wants. If that doesn't work, I'll tackle sleep positions.

[retired_guy]

I'm with you Sleepy. I love sleeping on my back. Very possibly I love it because it was always something I really could not do at all prior to therapy. My AHI runs 0 - .5 most of the time and I have not been able to determine any difference in side vs. back sleeping. They're both great.

[SleepyDreamCatcher]

Hi all,

Thanks for your suggestions. I'm sending you all great big banana splits as a thank you gift. I decided to change my settings to a minimal pressure of 11 and maximum pressure of 14 with an EPR of 2. That seems to be working well. AHI = 0.0, basically no leaks, continuing to see minimal snoring (still most of the night, but some time at zero). The Flow Limitations have decreased both in amount and volume. There are far less "mini" events happening with most under 5 seconds.

I felt more tired this week, but I think that's due to allergies rather than the sleep apnea. I think I will keep everything at the same settings for another five to ten days to see if my energy level will increase now that we have had some rain to wash the pollen away.

Retired Guy, will you explain why you suggested that I turn the EPR on?

[surferdude2]

I think the reasoning behind that is it allows you to have the higher minimum pressure while you are inhaling but lowers it by 2 cm when you exhale. Some people are bothered by having a high pressure pushing against them when they exhale. Others are not bothered at all. Leave it alone for now and let's see how it levels out. Sounds good so far.

I think R_G is busy eating that banana split.