Unusual flow

[estgad]

Reviewed my data last night and saw this unusual episode and was wondering if it was positional, a chin tuck, or something else.  
I attached 3 screen shots, the first 2 are an overview of the half hour episode, with all the graphs and machine settings.  The 3rd is a close up where the flow rate is easier to make out.

I am not sure what to make of it so that is why I thought about asking here to get some input from those that are much more knowledgeable about it than me.  
Thanks.

[G. Szabo]

You had some recovery breathings flowed by Hs. But these might not be classified as true Hs.
I suggest increasing your maximum pressure because you are close to it or hitting the ceiling sometimes. What about setting the maximum to 10.4 cm?

[estgad]

I suggest increasing your maximum pressure because you are close to it or hitting the ceiling sometimes. What about setting the maximum to 10.4 cm?

Thank you for the reply.  I have been very slowly increasing the pressure, I make a small change and give it time for my body to adapt.  I am at around 35 days at these current settings.  This past month has been the best results so far.  But I know it should be better.

The epap is one roadblock for me, the last time I did an increase it took the epap to above 5 and produced worse results, so I increased the ps so the epap would max out at 5, so that is why there is a 4.4 difference instead of just 4.

So my question is should I also increase the pressure support to cap epap at 5 or will that larger difference create problems or should I keep ps at the 4.4 and just go up by .2 increments for both max ipap and epap?

[G. Szabo]

I apologize for not being clearer.
I suggest setting PS= 4.4 under AUTO; min EPAP=4, max IPAP= 10.4. This will give you a wider pressure window, so the AUTO can increase the pressure when the flow limit occurs, and you might avoid the recovery breathing periods leading to Hs.

[estgad]

That is what I thought you meant.  I just got done changing the iPAP Max to 9.6. 
I am going to have to do this very slowly because with the PS at 4.4 when it reaches the max IPAP this will bring the EPAP up to 5.2. 
The last time I tried increasing EPAP above 5 it was causing problems.
The one graph that I didn't show in my previous screenshots was time at pressure, and the one thing I noticed that yet is it spends very little time at the max pressure so I think by doing a slow and steady change like this I might be able to adapt to it better and slowly work my way up. 

Thanks.

[estgad]

Just an update. I started with a .2 increase, PS= 4.4 under AUTO; min EPAP=4, max IPAP= 9.6 (bringing max epap to 5.2)
It was good. My usage remained about the same (and the last 2 days at this setting had real good first sessions), the ahi went down to very low readings between 0.5 - 0.98, so I thought that it was time for next bump.

Changed to PS= 4.4 under AUTO; min EPAP=4, max IPAP= 9.8 (bringing max epap to 5.4)
OMG, what a disaster and utter failure!

It destroyed my sleeping cycles and usage, and AHI shot up with several days between 3-6. It was the destruction of my sleep cycles that really made me miserable. Friday night I just could not go back to sleep, so I had only 5½ hours of sleep from the first session (2 hours of that with the machine) and Sat was a very terrible day.

For me a great night would be to sleep 4 hours, get up to use bathroom, take the 2nd half of sleep meds and go back to sleep for another 4 hours. And if I can use the machine for all of both sessions, that would be perfect. Most of the time it would be something like using machine for 3 to 3½ then getting up for bathroom, OR, sleep with machine for 1 to 2 hours, take off mask and fall back to sleep to finish out the first 4 hour session, use bathroom, and then have a second session that would also be a mixture of masked and no mask sleep for 3-4 hours.

What happened with that second change in pressure to 9.8 (max epap 5.4) was that my first session changed to where I slept for 2 hours with the mask, took it off and slept 3 more hours, pushing that first session total to 5 or a little past 5 hours.
Even with the second half of sleep meds, it was now harder to fall back to sleep, so I wound up not getting a good second session of sleep, plus my usage of the machine has really dropped.

I am going back to where I was at before these changes to see if I can get my sleep cycles back to the 4 hour sessions, and get the usage back up to most of the session. Once back to that I will try to first change to 9.8 (max epap of 5.2) as that change was positive.

So most likely my next update to this will be in a month or two, and hopefully it will be positive.

[G. Szabo]

Once your AHI is below 1, you should stop altering the settings unless your FL is high.
I agree that you should be able to sleep through the night without bathroom breaks. For a long while, I believed that these breaks came along with age. However, once I settled with my setting, they reduced significantly, and there are 2-4 days a week when I do not need them at all.

[estgad]

G. Szabo 

Thanks for the reply.

Last night I used my fitbit watch alarm to wake me at the first 4 hours to force me to get back to normal cycles.  In that first session I wore the mask for the first 2 hours, no apneas at all.
Used bathroom, took meds and started second session with the machine.
I didn't reach full sleep in the 20 minute ramp, and as soon as it upped the pressure I had a small cluster of 5 CA's and 1 OA within a 6 minute period that ended when I reached a full sleep stage.  Slept 3 hours with mask on, with only 2 H's.   Then slept the last hour without the machine.

So other than that transitional cluster I only had 2 H's in 5 hours of usage.  I still had plenty of the irregular patterns that I started this thread with.

As to the bathroom trip, that started as my heart condition worsened and I began to have fluid retention issues.  Perhaps treating the sleep problems will help, but I think a lot of the sleep problems are because of the heart problems.

[G. Szabo]

The 20-minute ramp is long and might lead to events. It would be best if you reduced it or eliminated it. 

I agree with your comments about the water retention issues. But frequent urination is also caused by a depletion of a hormone. There are some advanced medications prescribed by urologists which increase the said hormone level and reduce bathroom breaks.

[estgad]

The 20-minute ramp is long and might lead to events. It would be best if you reduced it or eliminated it. 

In my case my history would disagree with that recommendation.  Eliminating the ramp would be one of the worst things for me to do.  If anything adding 5 to 10 minutes would be a possibility for those occasions where I struggle a bit to get to sleep for the second session after that middle of night bathroom trip.

I am hyper-sensitive to the EPAP.  In the past I have NEVER been able to become compliant with using the machine.  The closest I ever came was when a sleep lab let me bring home an asv to trial it.  Regretfully during that week that damn study was released that disqualified me from using ASV.  so I was provided the bipap that I still have and am currently using.  The same machine that spent years on end in a corner of my closet because I could not adapt to it, the only time it was pulled out was in Dec 2020 when I had covid (thanks to some **** **** **** people that worked with my wife that just had to have their big family Thanksgiving get together.)  After my week in the hospital when I got back home after cleaning it up the machine went back into the closet, because I still was not able to adapt to it, even at the lowest vAuto setting.

At the beginning of this year I began to notice my breathing was causing me to have worse sleep.  So I dug out the machine and began to give it another try while setting up an appointment with a new sleep dr.

I kept quite the journal this time.  I started it with a little recap of what had happened previously, and noted that while it was a struggle to get to sleep with the epap at 4, during sleep when it increased pressure not long afterwards I would wake up and stop using it.  Plus the CA's were way too high.

One of the first things I did was I printed out the clinician manual and really studied it.  A few lightbulbs went off about how many different settings the AirCurve 10 VAuto has.  I realized the previous sleep labs/drs had not done me any favors by sticking to only the vAuto settings.

So I began by changing to S mode, which manually sets the pressure and it does not change.  My first setting was epap 3 Ipap 7.  I actually began to become compliant with the usage at those settings!  Fewer OA's, mostly CA's.  I know the general response to these low pressures is "but that is too low, it's not therapeutic".  Well, the machine setting in a closet isn't therapeutic either.  At least this way I was starting to use it and more importantly it created the bridge to where my body began to adapt to it.

I tested out a lot of the settings in that S mode, easy breathe off, rise time, tiMin, tiMax, cycle, trigger, and as I began to get these settings adjusted to where I was doing better at using the machine, I began to increase the pressures, and found using the ramp was needed.

Eventually I got back to where I could switch back to vAuto.  But I am still hyper sensitive to epap, and without the ramp it would be game over, I lose, because one other major obstacle I had to work through was the horrendous transitional clusters (mega CA's) as I went from conscience to unconscious breathing.  Now about the only time they show up is when ramp ends and I have not made that transition.
One thing I noted from reviewing the oscar graphs, is frequently when I do make the transition the pressure remains low for a while.  

So it has been quite the fight to get to where I am at.  My apneas are low, but my breathing is still erratic and irregular while I am sleeping.  
I am attaching 3 screenshots from last night.  The first 2 are the transitions on the 2 sessions.  For session 1 I fall asleep very fast.  For session 2 it takes longer, but I made it before the 20 minute ramp ended.  Notice how the pressure remained low after both transitions.  The 3rd is one of the episodes that didn't raise to being flagged as an apnea, but was not smooth breathing.

I am going to research about that hormone, would you mind sharing a link that you have on it?

Thanks.