Vauto, PLM, FL & Mixed Apnea

[sheepless]

3 more session ends.

edited by OP to remove faulty images.

[mper6794]

---- time of requip, dont forget....split?

[sheepless]

vauto.  11/21/19.  ps 5.0 over 8.4 - 13.4.

let's try these images...

[sheepless]

3 more.  hope I got it right this time.

[sheepless]

ripinirole at bedtime last night. will try taking less at bedtime and try to remember to take remainder before 2 or 3 am.

[mper6794]

Sheepless,

_Numbers wise, I think it was a great night, actually, maybe among the best ones in your journey of 36 months? Flagged Max Fl pretty much got our goal of absolute zero (0.07) (see attached), as appears to occur every time one approaches the ultimate fine-tuned/tailored parameters, EPAPmin, P.S, and IPAPmax (that was my case, with recurrent zero day after day). Not sure what you think, but your charts, yet strongly punctuated by PLMS, look smoother than ever; involving maybe some three REM stages, with settled FR, TV, and MV.

_ HYF wise, well, this could more a more complex issue. However, I am very optimistic your highest HYF index will follow very soon, following a proper approaching on taking your medication (this night, for instance, even following my suggestion to take it at bet time, rather than earlier, would have not work properly after some 4:30). Maybe splitting or changing it would be a good idea.

_ we would have to take just one more step, maybe, playing with 8.4/5.2 and adjusting your medication to see if got the absolute zero on flagged FLmax.

_ however, my experience suggests that even after we got absolute zero, still remain some persistent, may never ending, arousals/awakenings due to respiratory effort, not to say on PLMS-driven ones. That was my case, and looks is going to be yours. Among your main wake ups last night (including the definitive), just the first one, at some 23;10 would not be associated with respiratory effort, even the very minor one (can see this, by play close attention on FR, RR, and TV).

_ for this next night, or maybe another one, I would suggest keep parameters: 8.4/5.0/13.4, and splitting the medication at bed time and your first wake up, maybe (I used to this sometimes, aiming at staying on lowermost dose when I need it).

all the best

[sheepless]

yes, I would say that chart is relatively clean. tired, but feel pretty good. I can't tell you how much I appreciate your efforts. I felt I was at a dead end. this has been an education and in some ways I'd say an improvement. like an apparent increase of rem sleep for example. ultimately, will have to somehow conquer plm to do better though. I'm going to stay with vauto for a while but eventually I expect I'll try to get similar results from asv while also resolving residual ca & pb. time will tell.

[mper6794]

....well, sheepless, as you already known, my opinion is the same since i first came up with your charts, an august, this year. You would be a typical case of UARS-PLMS, masked by arousal/awakenings-sleep transition and fake CA's, with no true CA or PB to be treated, as maybe are illustrating your charts above. However, i am aware this is not 2+2:4. Your own observations on your charts, much closer and recurrent than mine, of course, would count a lot and may indicate you this possibility of coming back to ASV some day.
However, my suggestion, If i may, would be you move everytime closer to BPAP, get better understanding on the tricks of PLMS (effects on RR, heart beat, etc), on arousal/sleeping-transition and their effects gases on exchanges, etc, and maybe realize how this Very often lead to biased diagnoses and machines. And, maybe, more important, experience more on medications and supplements to care of PLMS. I do think, currently, after getting the best you could on UARS, you would have an issue with residual PLMS, rather than with residual centrals apneas.
I Will keep in touch.
All the best

[sheepless]

I can't say I understand non-waking 'fake' events. a pause in breathing is a pause in breathing and some may be relatively benign but they can't be good so I think they're still worth running down as long as I'm still not feeling properly rested. but I do believe plm is the problem at this point and afaik it's quite possible resolving plm will also reduce ca and pb. otoh, while there have been ups and downs, I feel generally better now than before vauto, even with the higher ahi, so I'll stay with current settings for a bit, posting dailies occasionally, especially if something different crops up. I'm glad you're willing to stay in touch, mper.

an afterthought: I think I'll take some time off ripinirole to see what if anything happens to my plm pattern(s?). subjectively I think it's made my waking rls worse just as I thought gabapentin did. interested to see if the pb eases, if it morphs into my typical plm pattern, if it continues to persist at the end of sleep sessions, if it has any effect on ca, etc.

[mper6794]

,... but I do believe plm is the problem at this point and afaik it's quite possible resolving plm will also reduce ca and pb.....that is it...just to eventually reinforce this..    Maybe in accordance with this Barrow Krakow’s: “Of further interest, research also has shown the opposite result, in which a PLMD patient with SDB was treated with a medication to eliminate leg jerks, which then stabilized sleep and eliminated".

_ And, one thing more, I forgot to mention. This about IPAPmax: my rationale behing keep it = EPAPmin+PS would be to avoid tha machine autobumps against mask. In times times of too many arousals/awakenings and the consequent very often generated false OA and FL, the machine would try to tame, may bring difficulties to get back to sleep. And, you know, I learned sleep efficiency (pretty much independent of number of arousal/awakenings) counts a lot, with strait correlation with HYF. 
For me, a hypersensitive UARS, those autobumps revealed unbereable; turning  out to be more deleterious than some true FL and OA untamed by the autobumps.

However, when one reaches a point when you don't arousal/awake too much and, consequently, has less false OA and FL, maybe like on your current chart, you may want to try to open up the roof and experience, observe, from time to time, IPAPmax > EPAPmin+PS. This eventually could improve even further your flagged FL, some H (PB?), and other things (does exist?) in the RESMED algoritim. 

all the best