[Treatment] Still fatigued, history, are these CAs real?

[Gideon]

There is no therapeutical reason to raise the pressure, comfort is a reason.
There is no CA thus no therapeutical reason to lower EPR, there is a therapeutical reason to have EPR at 3 or higher (on BiLevel), reducing flow limits. Again comfort is a reason for change.

With EERS we will try EPR=3 and see how the flow rate is affected, The main goal is to smooth out your breathing minimizing/eliminating the waxing and waning. Not unreasonable to try different EPR levels and different coraflex lengths to find your sweet spot.

[sheepless]

if they looked for it in your sleep test (not all do) and you read past the summary info, I'd be inclined to believe them without additional evidence. however, like ca, plm is inconsistent and as we know, a single night (wired up) isn't necessarily representative. the flow rate pattern is a hint but not definitive by itself.

I have both rls and plm. I'm aware of rls when awake. sometimes plm follows waking rls but there doesn't seem to be a consistent correlation between them. with rls, I feel compelled to voluntarily move my legs to relieve the agitated feeling. as a child I called it "getting the tired out", i.e., stretching, contracting the muscles, much like a yawn and stretch of the arms/back/shoulders. otoh, I am completely unaware of plm. my wife complains more often about the non-stop voluntary moving of my legs before I fall asleep, than about plm. for some reason I just can't get her to rouse herself enough to give me detailed reports, but a few years ago she noticed my body jerking. she thinks it begins in the ankles or legs and she thinks it often becomes full body motion. sometimes she counts the intervals between them to help her get back to sleep, like counting sheep. the intervals for any given episode are of more or less equal duration, usually from ~ 10-20 seconds, occasionally 30-60 seconds (judging by what I see in my flow rate). for me, an episode can be less than a minute to more than an hour. twice my wife managed to audio record it with her phone. I can hear the kick (sheets rustling), a quick sharp inhale followed by a moan/groan, several breaths, then another kick, repeat, repeat. I attribute my lingering fatigue and many of my events and leaks to plm. ropinirole has reduced but not eliminated my plm pattern. I'd like to find a better treatment but in the meantime there's no question I feel a lot less sick and tired and I have a lot fewer, longer sessions between awakenings. hopefully I'm raising a false alarm and EERS will help you. it might even if plm is present. I've just started thinking for the first time about trying EERS myself, since giving up asv.

btw, I don't know what the resmed criteria are for csr but I notice your machine isn't flagging your periodic pattern as such. in the arena of pure speculation, I wonder if that suggests against the pattern being an apneic threshold issue?

[GuyScharf]

I appreciate your suggestions.  However, the sleep study said the following, so I read this as saying they looked for PLM and didn't find any:

Procedure: The study was attended by a technologist
and data were accumulated and analyzed using X L T E K Sleepworks digital acquisition and analysis software. The following
parameters were recorded: EEG (frontal, central, occipital), EOG, mentalis and anterior tibial EMG, ECG, oximetry, nasal-oral
airflow, nasal pressure, chest and abdominal wall movements by respiratory inductance plethysmography (RIP) and audiovisual.
Variations in the recording montage were implemented in accordance with patient history gathered from the referring physician's
notes and the laboratory's symptom screening questionnaire.

....
Results:

EMG: The E M G showed no periodic leg movements.

Zero PLM events are shown in the detailed list of events.

RLS is an interesting question.  I just read the NIH page on that to see what it was.  I've always paced a lot, especially when working.  But I've always viewed that pacing as a way to clear my mind so that I can see the problem I am working at better and solve it.  I do tend to be a bit restless if I am having trouble falling asleep.  I may toss and turn a few times when sleeping, but it does not seem excessive.  (I have made a video of a night sleeping, but didn't count the number of turns and don't have a recent video.)  I'll put RLS on the back burner as an idea not to forget.

I am looking forward to trying EERS and see if this helps my sleep.

[GuyScharf]

I have a question about EERS.

What is a suitable material to block the vent holes with? For the F30 mask, the "obvious" place to block the holes is from the inside, since the outside is covered by the quiet-flow mechanism (which I could not remove). I thought of silicone caulk, but then realized that the material would be near the airflow even if not directly in it. There would still be eddies of air reaching the blocking material, and I am worried about any long-term effects of that exposure. I notice that the EERS Wiki page mentions Mack's Putty -- which I think is a reference to Mack's silicone putty earplugs. At least that's FDA rated for skin contact.

[Sleeprider]

I never looked into this Guy. I think you're right, and using these would be reversible by simply removing the putty. I revised the wiki with this information. Thanks.

[Gideon]

I too never looked into this.
I did a google search for "Oxygen Leak sealants"
and found a link for "medical" use on themedicalgas site

I sent you a link via PM

Putty sounds good.

[Jeff8356]

The Macks silicine ear putty is the one i have seen/read for blocking the ports. Use it to block the exhasust ports at the swivvel, but leave the anti-asphyxian valve alone.. Add your polyflex, new vent valve and yor mask, should be good to go,

[GuyScharf]

In your first posts, you said you would like to see what would happen with a VAuto at PS=4. Since I don't have a VAuto, I thought I might try moving PS in the opposite direction to see what would happen. Yesterday, I used 9.4-9.4 EPR=3 and saw the usual flow graph. Last night, I tried EPR=1 and set the range as 7.4 - 9.2, under the assumption that would keep the EPAP the same.

It was not a good night. I found EPR=1 less comfortable. Not surprisingly, the pressure chart showed pressure increased to 9.2 and stayed there. AHI=3.2 mostly with Hs amidst the oscillatory breathing as before. However, I did notice that the 95% measure for Flow Limits increased from about 0.10 to 0.21. Would you have expected PS=4 to have decreased flow limits, or what would you have expected from using PS=4?

Looking back at older records, the same oscillatory breathing pattern was present when I used two different nasal masks.

[Gideon]

an increase in PS to
1. further reduce flow limits (possibly to go higher than 4 later, but based on what we see, not what we think)
2. possible increase in comfort.
3. possible increase in CAI

The question is at PS=4 where will the balance be between CAI and OAHI

[GuyScharf]

I'll be trying EERS tonight with 6 inches of Corr-A-Flex. Assembly was easy and Mack's Putty was very easy to work with. I did find the tubing to be a very tight fit, so it's unlikely to come off on its own. I'll post details on assembly later.

What statistics, besides shape of the flow curve, are important to watch? I'll also be using my CMS50F so will have SpO2 monitoring as well.

fwiw, last night I used 9.2 - 9.2 and EPR=3. Had two H events, one clearly associated with oscillatory breathing. After 8.5 hours of sleep, still needed a 3-hour "nap" in the morning to feel more awake.