Yet another new user needing advice!

[SleepyMac]

The AirCurve was delayed a couple of days due to shipping problem, but it came in yesterday.  I have to admit I'm a little wary of used medical equipment, but based on excellent reviews of supplier 2 on multiple websites, I took a leap of faith.  Only time will tell if it was a wise investment, but I'm hopeful!  I know it's the luck of the draw, but my new (to me anyway) AirCurve has < 50 hours on it!!!

Setup last night with settings - PS 4.0 over 9.0-18.0.  Starting out it did feel a little different, but it was a small change.  Whether it was the difference in machines, or that proverbial butterfly over tokyo, I slept fitfully.  Woke up several times, but rolled over and went right back to sleep.   Got up a couple of times, but that's not unusual.

I was going to give it the weekend to see if there was a pattern over 2-3 nights, but my number of SpO2 drops were high, and I spent over 20 minutes below 88% SpO2 -- since raising pressure to 12-13+ on my AirSense, I had been averaging < 1 minute.  I woke up with my first headache in weeks.  I'm willing to chalk this up to a bad night, and give it until Mon-Tues, but thought I would ask for input.

So, make any changes, or wait and see?


  Oscar 2020-09-18.pdf (Size: 1,011.23 KB / Downloads: 16)

[staceyburke]

Not a bad first night at all. The low pressure is at 4 (that is as low as you can go) and your PS is at 4 so that makes your low pressure 0. Raise your low pressure 8.

[Gideon]

Keep everything the same for a week unless you need to make a change, at that point, when we know this is consistent, we may suggest slowly lowering pressure.


Stacey, PS is always added to EPAP and the min pressure the VAuto is capable of is 4. There are some BiLevels with a min pressure of 3 but the only way to get a pressure of zero is to turn the machine off.

I think you are confusing EPR which is subtracted from the pressure/IPAP tp PS which is added to the Exhale pressure/EPAP

[staceyburke]

Sorry Bonjour, I do know it can’t go lower than 4. I thought setting at 8 the low would be 4, the lowest it can go.

[Sleeprider]

Stacey, we add PS to EPAP to get IPAP with the Vauto. With the Airsense 10 CPAP we subtract EPR from IPAP to get EPAP. We nearly always refer to the Airsense 10 in bilevel terms so it does get confusing.

SleepyMac, I think these are the settings I suggested earlier as a starting point, and I'm quite fond of that range of settings since I use them myself Anyway, this looks very promising to me with few events and the main task at hand is to become more comfortable and accustomed to the bilevel pressure. As Bonjour suggests, keep it the same. I'd like you to take some time and compare the summary results for median tidal volume (560 vs 680 mL), minute vent (7.75 vs 9.75 L/min), and 95% flow limitation (0.21 vs 0.03) as compared to your previously posted CPAP result. The differences are significant, and that is exactly what we were after. Also note that your pressure used to reach 18-19 cm, now just 16-17 cm. I think comfort will follow.

[staceyburke]

Thank you Sleeprider learning is slow with this one...

[SleepyMac]

I need help (or at least encouragement ;-)

I'm willing to concede that I'm starting over.  I have to get used to this new machine, and just be patient (I HATE the "p-word").  But I have had 5 of the worst nights sleep ever. 

Sleeprider, my AHI's are down (and they were good before), flow limits also down, Tidal volume and minute vent are up, and those are good things!  

BUT, SpO2 drops are way up, Time SpO2 below 88% is also up, I'm waking up multiple times in the night, and every morning with severe headaches, and I feel like crap.  I get up feeling exhausted, and I'm falling asleep more during the day (nodded off for a few minutes, typing this out).

Some other observations:
Saturday afternoon, I got out my AirSense and went back and forth several times for a few minutes with each machine just laying in bed.  With the AirSense, it feels like the air is being pushed at me, with the AirCurve, it feels like I'm pulling at it.  Maybe that doesn't make sense, but that's what it feels like.

Settings, for review --
AirSense: 14-20, EPR: 3
AirCurve: 9-18, PS: 4

As I understand it, that makes IPAP pressure range 14-20, and 13-22 respectively.

Both subjectively, and based on SpO2 data, it seems like I'm not getting enough air.  I've read where people often think the AirCurve cuts off their breathing/inhalation, and they increase their TiMax.  I haven't experienced that per se, but my inspiration times were averaging > 2.2 seconds with the AirSense, but have been < 1.7 with the AirCurve.  I do feel sometimes, like I'm working to suck in air, and I've noticed my chest aches when I get up in the morning.

Finally, this is probably irrelevant, but I'm throwing it out there because I'm trying to understand -- Long story short, I rec'd a copy of the settings my sleep doc sent supplier 2 (after it had already shipped).  I'm not impressed with my sleep doc (among other things, he thinks reviewing OSCAR data "is a waste of time")…  Sorry, I digress, I was looking at his numbers this weekend.  He put down 14-20 pressure support 5(??)  Wouldn't that make IPAP pressures 19-25?

OK, last paragraph aside, back to original question: Am I whining, and I just need to give AirCurve more time to acclimate to it, or do I need to change anything?

Thanks!

P.S.  Out traveling today on business.  Tapping this out on iPad while riding.  I can post OSCAR data later when I get home, but the last 5 nights look pretty much the same as the night I already posted (to my untrained eye)… 

[Sleeprider]

SleepyMac, if SpO2 drops are a concern, then we want to look more closely at the conditions under which that occurs and see if there are any correlation to the pressure or your minute/tidal vent rates. There are some basic principles of positive pressure ventilation we can use to our advantage. While the pressure support increased ventilation and reduced flow limitation, it is a higher EPAP pressure that actually recruits increased oxygen exchange in the lungs. You can research this by searching for PEEP, Positive End Expiratory Pressure which is the ventilation analog to EPAP. That is an option, but I don't want to jump to conclusions. Of course if SpO2 drops to critical thresholds for long enough periods of time, the traditional option is to increase the fraction of inspired oxygen (FiO2) by using an oxygen bleed to the PAP circuit. I doubt we are going there, but plenty of members do have that, including StacyBurke above.

The pressure settings you mentioned between the Airsense 10 and the Aircurve 10 were,
AirSense: 14-20, EPR: 3
AirCurve: 9-18, PS: 4
This translates to EPAP min 11.0, PS 3 max pressure 20 for the Airsense. We can easily increase EPAP min in your case and that fits with the idea of increasing PEEP. I think we should still use the PS 4 which is working well. So if you want to try EPAP min 11.0, PS 4, Max pressure 20.0, that is certainly an option. You are unlikely to reach the maximum pressure.

[SleepyMac]

Sleeprider, I don't **think** I will need supplemental O2 (at least I hope not at this time).  With the Airsense, I was seeing more drops than I wanted (averaging 80-100 / night), but my SpO2 was staying above 90% and I had pretty much eliminated the headaches that were associated with low SpO2 by raising base pressure from 8 --> 14.  Still working on those numbers with the AirCurve, but I'm hopeful!!  That being said, I will be going over all this stuff with my sleep doc at next appointment in November.


I wanted to post results as I think I saw significant improvement even though it's only one night of data.  I didn't wake up feeling good, I know that's going to take some time!!  I woke up feeling a lot less bad… 

Side note: When I changed the AirCurve settings, I must have turned/clicked the dial at the same time when I entered Min EPAP, as OSCAR says min EPAP = 11.2, when I thought I put in 11.  Not going to worry about that…

Improvements:

     - Had trouble getting to sleep, but slept better once I did.

     - Big drops in SpO2 numbers!!!
     - Slight headache when I woke up, but went away within 10-15 minutes (usually takes 1-2 hours).

     - Even though base pressure started higher, I had lower maximum highs.

     - Flow limits were almost non-existent (95% - 0.00, Max 0.06)!!  

A couple of numbers went in the "wrong" direction, but were very close to the average.

Here is a breakdown of some of numbers:

AirCurve (with PS of 4) - 5 day average with EPAP @9-14       vs       last night @11-16

     - EPAP (low-high): 9-14     vs     11.2-12.5

     - AHI: 0.5     vs     0.6

     - Median Minute Vent: 9.0     vs     8.63

     - Median Tidal Volume: 640     vs     620

     - 95% Flow Limits: 0.09     vs     0.00

     - SpO2 Drops: 300     vs     49

     - Minutes SpO2 < 88%: 45     vs     6

It was only one night, so I'm assuming I will stay here for the next 5-7 nights to see if anything changes as I continue to get used to the AirCurve.

I would still like to get those SpO2 numbers even lower, but if this is the "new normal", I think I can deal with that, the lower EPAP was not working!




Finally, I've been trying to learn about flow rates and what the graph means.  It's pretty heady stuff, and I haven't wrapped my head around it yet, but I started playing with this with my Sept 18th data.  I included some zoom-ins with a couple from last night for comparison.    I can see some variance, but it may mean nothing.  If any of the experts here see a teachable moment I would love some input.

I tried grouping graphs a couple of ways, but settled on each PDF containing a before - after.  1st page is always from 9/18 (EPAP @9-18), 2nd is from 9/23 (EPAP @11-20)

For reference here is the OSCAR page 1 screenshot for 9/23, 9/18 is in a previous post:


  Sept 23.pdf (Size: 995.65 KB / Downloads: 3)

The first flow rate comparison is a section that is stable - no apneas, no SpO2 drops:


  18 vs 23 stable.pdf (Size: 379.2 KB / Downloads: 1)

Imported SpO2 data and OSCAR are not synchronized, times are close but not exact.
There are many drops where there is a stable flow rate, but there are quite a few sections where there are changes in flow rate at about the same time.
Anyway, here is where I zoomed in near an SpO2 drop:


  18 vs 23 variable.pdf (Size: 392.36 KB / Downloads: 1)

Thanks for all the continued help!!
If I need to change anything, let me know.

[Sleeprider]

The principles of PEEP will always work to increase SpO2. Slight changes in minute vent may be related to better ventilation at the higher pressure, at least that is how it usually works. As CO2 drops so does tidal volume. Therapy is usually predictable and if you need higher SpO2, then higher EPAP min (PEEP) is the way you get it. Ironically, people think more pressure support will improve tidal volume and minute vent, but since CO2 drops lower with more pressure support, that usually doesn't turn out to be the case, as respiratory drive becomes a bit depressed without the CO2, however it does have very positive effects on flow limitation. Once the flow limitation is gone, as yours is, additional pressure support has very little benefit.