mtueckcr - Sleep Journal

[Jay51]

You pose an excellent question:  "Do you think these settings make sense and I should get the leaks fixed or do they need tweaking?"

You do continue to have a significant amount of cumulative events (they could be decreases), BUT, it is hard to tell how much fixing your leaks would reduce them.  I guess I would recommend trying to get your leaks down to normal (so you don't have any major leaks during the night).  I guess keep pressure the same until then.  Then, of course, if you do get leaks resolved and still have significant events, it would then be time to better optimize your pressures.  

If you can't get leaks down, it may be time to try a different mask also.  

I know a little bit about the Lowenstein Prisma series from what I have read here at ApneaBoard.  Any Lowenstein experts are welcome to post also.  

[mtueckcr]

I will keep that in mind and keep improving. I am unsure about other masks since I sleep on my stomach and most have hard Plastic in the front which is very uncomfortable or doesn't fit well when I lay on my stomach. I have tried other positions but naturally turn on my stomach at night. Do you have any other mask models which I could check out for stomach sleeping?

[CPAPfriend]

hey mtueckcr

perhaps it doesn't even warrant being repeated, but you do have a very serious leak problem, and the issue with leaks is that they are a confounding variable that destroy the signal-to-noise ratio, preventing us from figuring out what precisely is going on. Nothing is more important than taming leaks for that reason. 

That said, even during periods of the nights without leak, your breathing is still off; there is a legitimate issue going on and you're not crazy to believe so. In support of this, your pulse rate is spiking all night, your O2 is dropping, your waveforms look terrible in many spots, and your PLM index is elevated. I'm not a PLM expert, and of course we both recognize the rational applied to separating PLM with arousal versus PLM without arousal. However, I believe that therein lies some or all of our answer. Let me emphasize that I am speculating, and that there are some important considerations here, such as: how did they define a PLM? how did they define an arousal? what other objective data changes can or cannot be seen coinciding with these PLMs without arousal? I, like everyone else, am still learning, but my rough understanding at this specific moment is that there are microarousals as well, which come with consequences but do not meet the criteria of the traditionally scored arousals. I intend to do a video on this subject in the near future once I've read enough of the literature and am able to present it accurately.

You do seem to be able to have good bouts of breathing, for example on June 27th between 140AM and 215AM, where everything stabilizes and calms down, but overall there is almost constant disordered breathing.

As an aside, June 28th is a perfect example of a disaster from leak. The data is not actionable. We basically have to throw it away. So if it looks anything like that or in that direction, keep in mind that it's priority number 1 to be resolved.

A couple other points / requests, and please forgive me if I'm asking something I asked earlier; I speak with a lot of patients. What settings have you tried so far on CPAP and what settings on BIPAP? Please share a screenshot of your overview and statistics tabs that best presents that data. Have all healthcare professionals who you have seen dismissed you? If not, what, if any, diagnoses have you received? For what it's worth, as it bears repeating, your pulse profile is a dead giveaway that there's an issue. What can be seen is not normal. Also, in the context of PLMs, and let me here mention parenthetically that I need to strengthen my understanding on this claim, but I believe I read a study that demonstrated that of all metrics for severity of daytime symptoms from SDB, movement was number one. Food for thought.

[mtueckcr]

I have fixed the leak problem by sleeping with a different mask. I am using an F30i now. Pressure setting is still off and I still don't feel rested after waking.
Pressures I have tried on Bilevel are: IPAP 7 & EPAP 11; IPAP 8 & EPAP 12.
One ENT referred me to the sleep lab because of my symptoms. The sleep lab dismissed me and said I don't have a breathing problem and should do psychotherapy. The clinic that did the CBCT scan does bimax surgeries and said it looks as though I could have a breathing disorder but are waiting on what the sleep lab says.
I have booked 2 nights at somnolab Dortmund which supposedly are "the" experts in sleep medicine in Germany and I sleep there 26-28th of August. Since I pay for it myself they do a lot more test than the other lab and I am hoping they are better at analyzing the data.

[mtueckcr]

I adjusted the pressure to IPAP 12.5 & EPAP 8.5 for last night. I do not feel rested at all and feel cognitively impaired today. Having trouble focusing on things like reading a letter.
I have attached the overview of last night, some irregular breathing and some breathing in between.

[Jay51]

The problem may be higher than normal flow limitations.  The close up of your breathing waves shows some spikey looking tops to them.  They should be more rounded.  Your inspiration time is still greater than your expiration time (they should be at least equal, or the inspiration time should be less than the expiration time.  You are still having some H's.  Lowering your pillow height, sleeping on your side vs. your back, or even using a soft cervical collar if the first 2 things don't work might help stop all of the H's.  

Your OSCAR chart shows that your min was 4.  Are you using a ramp?  4 is too low for most people to breathe.  You stated that you raised your EPAP to 8.25 I think.  

You can try raising EPAP a little bit more.  You can even try increasing your IPAP a little bit if you can tolerate it.  

Try these things and post again.  Anyone with more experience with the Lowenstein Prisma series can post as well.

[mtueckcr]

Thank you for your reply. I am sorry I mixed up IPAP and EPAP in the previous post. My expiration pressure was 8.5 last night and my inspiration pressure was 12.5 it has always been 4 pressure difference on Bilevel.
The overview tab shows all pressures I have tried on CPAP since I don't have a formal diagnosis yet and have been using OSCAR to diagnose and treat myself. I used 4 in the very beginning since I was not sure about pressure and wanted some data.
I am pretty sure my Hs are due to my upper airway being extremely narrow with only 34mm². I can only sleep on my stomach as I don't breathe well in other positions.

[Jay51]

Thank you for explaining that.  Your flow chart has some strange things in it.  You have some very large spikes in it every once in awhile.  Also, your tops of your respiratory waves are not all rounded (most, if not all should be).  

I guess I would suggest upping both pressures slowly:  increase EPAP slowly and IPAP slowly.   If you can tolerate these pressure increases, then it might help your therapy.  

Is your machine always set to only a 4 pressure difference between EPAP and IPAP?  If that can be increased to 5 and maybe even higher, that could help you also.

[mtueckcr]

The pressure I have been using was just for testing. I can change it to be whatever is needed anywhere between 4 and 25. Both pressures can be set completely Separate from each other.
What pressure do you think I should try for tonight? 
Thank you for taking the time to understand my case and helping me with titration. It means a lot to me.

[Jay51]

There are 2 ways that I personally would go from here:

1.  Start with 9 EPAP and 13 IPAP (your 95% values).  Slowly keep increasing both of these numbers until your charts look better (and most importantly, you feel better after a night of sleep).  Keep PS constant at 4 (the difference between EPAP and IPAP).

2.  Or, you could keep the EPAP at say, 9, and then start increasing the PS.  So you could have EPAP 9 and IPAP 14 (PS of 5).  Or EPAP 9 and IPAP 15 (PS of 6).  And so on as you keep increasing only the PS until your charts look better and you feel better.  

Try both methods and repost again if either of these suggestions work for you.