Vauto, PLM, FL & Mixed Apnea

[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

...apologies, sheepless. There was a minor mistake on the blue phrase above, which should be, instead:
_we would have to take just one more step, maybe, playing with 8.4/4.8/4.6/5.2----13.2/13.0/13.6, and adjusting your medication to see if got the absolute zero on flagged FLmax.
Concerning pressures, tiny moves can be very important;no more, no less.
all the best

[mper6794]

I can't say I understand non-waking 'fake' events.  a pause in breathing is a pause in breathing....yes, results could be completely distinct if occur while sleeping, true CA, or in arousal/awakening-sleep transition, fake CA, Could not? 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....for sure, they are telling you your are arousal/awakening too much....and I think CA’s in general, like virus, are kind of opportunistic thing, they take advantage of weakness and insert in/follow in. In our cases, such weak points would be following up of PLMS-driven arousal/awakenings. Then, should you awake less, you would have less CA’s...then, also, fake CA's are just syntoms; cause are arousal/awakenings, things should be tackled firs of all .  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.

[sheepless]

vauto. 11/22/19. ps 5.0 over 8.4 - 13.4, second night.

the reason I'm posting these is because I think the two 10 minute segments hint that the pb is a variation of my previously typical plm pattern.  note for example, how the pattern evolves from typical to more pb-looking at 23:13 and how relatively un-csr looking the pattern is in the midst of repeated events.  which further supports the idea that the events (ca, oa, h & fl) that occur during these pb episodes may be plm induced.

I take (3) 0.25 mg ripinirol tablets for plm at bedtime.  last night I took 2, intending to take the 3rd when I woke up sometime between 1 and 3 am.  (un?)fortunately, I slept through the night!  well I woke up at least a few times but never enough to mask off.  I think the reason for that is because I screwed up and over-measured the amount of the cannabis concentrate that I usually take to help me sleep through the plm.  8 more or less uninterrupted hours of sleep is heaven, but the amount of concentrate needed to get there sometimes leaves me feeling even more thick headed and sluggish than usual the next day.  I haven't noticed much difference in my flow rate after 1 night with a lower dose of ripinirole.

[mper6794]

Hi,
Again, I would interpret that Ropinorole did not go beyond some 4:00hs, because of the repetitive general reduction on RR, as always, reflecting concentration of fake CA's an others.
Therefore, my suggestion for today would be keep the settings and try to take second dose once you wake up midnight.

all the best.

[mper6794]

Hi, sheepless

I was wondering  whether could be worth a follow up in  your current situation...if you are willing to, of course. May want waiting for sometime more, etc, or just give up searching for further improvement?

Yet intriguing and challenging, I have the impression your situation could still be improved, by proper balancing settings, medications, and sleep hygiene.

just in case, this could be waveform we would need, as before... attached..

all the best

[sheepless]

I'm game.

after about 28 nights with vauto I've had about 5 back on asv, attempting to reproduce lower flow limitations while evening out the periodic breathing that's not obviously periodic limb movement (i.e., the more sinusiodal pattern). I can't say I've been thrilled by the results so far because asv has limited ability to restrict ps and I'm leaning toward concluding the csr-like flow rate pattern is just another variation of my respiratory response to periodic limb movement anyway, implying the possibility that the machine isn't capable of resolving this pattern of plm induced disordered breathing any more than my more typical plm pattern.

limiting pressure support on the asv is problematic because it requires a 5 cmw difference between min and max ps. so far I've run only asv mode. best setting for ahi has been epap 7.6, ps 0-5. the only 95% flow limitation entry so far i s 0.11 at epap 6, ps 0-5. other nights at epap 6, ps 1-6 and epap 6, ps 2.4-7.4 produced no 95% fl. not surprisingly, overall ahi is lower with asv than with vauto.

interestingly, the csr-like pb is showing up in asv mode now. I'll have to confirm this is the case in asvauto mode; there used to be very little of that pattern in asvauto mode except at the very beginning of a session. now seeing it throughout. still seeing my regular plm pattern as well. I theorize that the ripinirole is affecting plm to the extent that it is showing up in more than one respiratory response pattern. again telling me I really need to get a video camera to verify this stuff.

to get the most of this new asv trial I should continue it for awhile but don't really care if it's now or later. if you have a procedure and goal in mind, let's have at it. the hardest part will be giving up naps.

edit: to be fair, I should also consider the possibility that seeing pb in asv now when not so much a month ago could be developing heart problems but I'd rather deal first with the more obvious and less traumatic possibility that it's a variation of my response to plm.

[Gideon]

I'll point out that CSR and the CSR like details you posted earlier should be able to be managed with EERS

[sheepless]

good point. thanks for your input, bonjour. hadn't thought of that. I have a sneaking suspicion it'll prove ineffective against plm induced disordered breathing, if that's what it is, but it's certainly worth a try. I did successfully reduce ca with vauto by setting trigger to very high and one of the ti settings to 0.8, but I don't remember that those had any effect on the csr-like pb (again suggesting the pb is from plm). but no point in leaping to conclusions. I'll keep EERS in mind. if I can galvanize myself into action, the first thing is to get a camera.

[Gideon]

FYI I recently read a medical article that said CO2 manipulation (EERS) will treat People Primary Central Apnea

[sheepless]

very good to know!