Titrating RERAs

[Gideon]

What I had you do last night was to take a basic test and you passed. As SR pointed out you had virtually no events of any kind and the ever so important FlowLimit chart.

While the VAuto is without question the more capable machine I'll suggest making the Autoset your daily machine if you have it, because it will flag RERA events, and keep the VAuto as your backup. Believe me, we will have no problems going to the VAuto.

The settings would be Pressure 7 - 16 (what high you use really doesn't matter) and EPR of 3. The EPRof 3 coupled with the min pressure of 7 are the settings that are obviously treating you extremely well. As SR said I see no indication of RERA here.

BUT, one day does not make a trend, let's run for a week and then revisit.

Fred

[Sleeprider]

The definition of a RERA on CPAP is an increasing respiratory effort (restriction or flow limit) followed by an increase respiratory rate or volume indicating arousal. Your charts make very very clear that in the November 14 chart, that is exactly what is happening over and over again. It looks, and probably was disruptive to sleep, and the auto-pressure repeatedly went to higher pressure to try to resolve the flow limitation resulting in a 95% pressure of 11.74. By comparison January 31 looks tranquil, with nearly constant respiratory rate and tidal volume, that despite the much lower 95% pressure of 7.24/4.34, resulted in much higher tidal volume of 540 vs 480 mL and lower respiration rate of 13.2 vs 19.2 BPM. The difference is not in your head, this is a transformative development that is the direct result of EPR or pressure support. It may take some time for you to catch up on sleep, but it will certainly happen with these very positive results.

[logit]

Awesome, thank you SleepRider and Bonjour! I will report back after using these settings for a couple weeks.

[sleepyzzz]

thanks that was helpful

[logit]

It's been about 3 weeks since I adjusted my settings. The first two weeks I was traveling and I took my autoset, using settings EPAP 7, EPR 3 Full time. About half the nights were great, the other half had a lot of flow limitations / increased respiratory effort:


Great night:
[attachment=10461]

Flow limitations:
[attachment=10462]

When I got home I switched to my VAuto and bumped up pressure support to 4. The flow limitations pretty much went away completely, and things went reasonably well until last night. When I woke up this morning I felt horrible, almost like I hadn't slept at all despite having 8.5 straight hours of sleep.

Most nights this week, pretty good results:
[attachment=10463]

Last night, felt horrible this morning:
[attachment=10464]


I had 13 central apneas last night, which was quite a bit more than normal for me. I went back and counted my central apneas on the different machines:

Central Apnea counts:
autoset(EPAP 7, EPR 3): 1, 0, 3, 7 2, 4,1, 6, 2, 0, 1, 3, 3
vauto(EPAP 4, PS 4): 3, 3, 7, 8, 4, 4, 4, 13

It seems like I'm having slightly more central apneas with a PS 4 and occasionally a lot more. I can really feel 13 and this feels much worse than not using any form of pap therapy.

[Sleeprider]

I would just back off of the pressure support a bit. You can choose something like 3.6 cm and probably cut out the CA.

[logit]

The central apneas I was experiencing with PS of 3-4 resolved(I had 0 for 4 nights in a row), and I still don't feel better so I've been bumping up the pressures a bit. I was on EPAP 6 PS 5 the last two nights(The machine settings on sleepy are wrong) and noticed the following pattern on my flow rate graphs.


Two nights ago:

Gradual decreases in flow rate followed by a large inhale
[attachment=11777]

Last night, several flow limitations in a row followed by large inhales

Zoomed out:
[attachment=11778]
Zoomed in on flow rate:
[attachment=11779]

Couple of questions:

1. In the UARS wiki, Dr. Krakow talks about how most UARS patients are on PS gaps of 5/6 with some much higher. Do these graphs indicate that increasing the PS up to 6 might be helpful? 

2. When I was titrated in the sleep lab, my sleep doctor didn't increase PS over 4 because he was worried it might be counter productive(I assume because of causing central apneas), and treated the remaining signs of obstruction by increasing EPAP. Is a combination of PS and EPAP a reasonable approach to treating flow resistance?

3. When I have tried higher EPAPs, I absolutely cannot control leaks without a FFM. At higher EPAPs, a FFM puts a significant amount of backward pressure on my jaw, which SleepRider has previously mentioned can make things worse(wrt chin straps vs cervical collars). I have tried every FFM my provider has and the only way to get a proper seal on any of them applies this type of pressure. Can this backward pressure compress neck tissue and make things worse with a FFM the same way it does with a chin strap?

[Sleeprider]

I would avoid increasing PS for now. What is your trigger sensitivity?

[logit]

My trigger sensitivity is medium(the default).