mtueckcr - Sleep Journal

[mtueckcr]

I tried EPAP 9 & IPAP 15 and my AHI worsened and I feel worse aswell. See the attached data.

[Jay51]

Ok.  This was a worthwhile experiment though.  It shows that higher pressures on your current machine are not going to work.  They cause more CA's.  

So I suggest lowering your pressures to a more comfortable level and for better OSCAR results.  You may be in the "positional apnea" group.  Even at higher pressures, apneas don't resolve.  The best things to try are:  lowering pillow height, side sleeping instead of back sleeping, and a soft cervical collar if those 2 things don't work.  

There is also something call TECSA.  It happens frequently to new users of PAP.  The increases ventilation causes some CA's that go away in a few weeks or month or so as the brain learns to adapt to the new pap pressure every night.  

And lastly, members have come here who were prescribed a machine that was not able to effectively treat them.  We will try to optimize your therapy as best as possible on your current machine.  If we can't, then the solution will most likely be a higher level machine that can do more things with your therapy (possibly one that provides a back up rate if you continue to have a lot of central apneas with more pressure).  I assume this Prisma you have does not have a back up rate, Correct?   You are not alone here.

[CPAPfriend]

hey mtueckcr

It looks like the PS made things worse, which could partially be due to a rate of change, and we can't know for sure without further testing. Correct me if I'm wrong, but it sounds like up until now you have received no benefit from any of the PAP therapy settings you've trialed thus far. Please carefully consider this question, because if one set of settings provided greater improvement than others, then that's information we can work with.

Reviewing your overview tab, focusing on AHI, which is a piece of a larger picture and of course not comprehensive but nonetheless one metric we wish to reduce, your best therapy nights were on very low CPAP / APAP. Your airway is indeed small, provided that measurement was properly done. Unfortunately, there is still a lot of inconsistency across CBCT scans, and they've yet to standardize it, but even so, in the case that they way underestimated it and we have a huge margin of error, it would still be very small. 

Do you know what the trigger sensitivity is on your bilevel? Of all the patients' data I do review, your response to the slight increase in PS was quite drastic, which suggests you are very sensitive to CO2 levels. This is speculation. If so, however, you could be dealing with a loop gain issue together with a small, compromised airway. I think that your case is complicated, and I think what needs to be discussed, though is unfortunately beyond my purview, are your PLMs. I don't see indices that high very often. It's rather unusual, but again what matters is what is meant by a PLM and arousal. You could try an additional night or two on the increased-PS settings to see if things calm down, which does often occur and is just one of those things you have to try to find out. What are the other settings on your bilevel machine? What settings are you on now? What are you considering trying next?

[mtueckcr]

I tried going back to APAP with 8min 12 max and EPR 2 since that was the setting on which I had the best night looking at the stats. Unfortunately it made me feel miserable in the morning with a very high AHI and frequent events. This could be due to using a full face mask whereas I was using a nasal pillow before.

I have not noticed any benefit from APAP or Bilevel therapy until now. I have slept a couple of nights without it since the days with the machine where very hard to get through. The trigger setting on my Bilevel can go from 1-3 or auto and I had it on auto for all tests. There is a setting called "Ti/T goal" which can go from 25-67% and is currently set to 33% and I don't know what it means. Ramp in can be set between 1-3 and is set to 3 currently.
There is also a setting of TRIlevel  with IPAP, PDIFF, TRILevel, EPAP and EEPAP being settings I can adjust.

What does a sensitivity to Co2 mean? what are influences on my Co2 levels? I know I have elevated blood Co2 levels during the day while  not doing physical activities which normalizes if I breathe more. It was measured in a lung clinic. I am constantly thirsty which is likely due to my body trying to get rid of the elevated acidity that the extra Co2 creates.

On low pressure my tidal volume seems to be low as well which normalizes with higher pressures on Bilevel. I will keep trying Bilevel to see if my body gets used to it over several weeks. I am open to trying different settings and am keen to find clues in the data which could lead to any improvement. 

Since I have already bought a used APAP and Bilevel machine and have to pay 1900€ for the sleep study end of august I cannot buy a different machine at this time and will try to optimize the one I have. My hope is that I get a UARS diagnosis in the lab so that my insurance pays for any therapies in the future. 

I have attached the last night on APAP and the night of the 30th of may which was the best night of all judging by AHI.

[Jay51]

Your 2nd OSCAR chart looks much better than your 1st one.  

In regards to your questions, "What does a sensitivity to Co2 mean? what are influences on my Co2 levels? I know I have elevated blood Co2 levels during the day while  not doing physical activities which normalizes if I breathe more. It was measured in a lung clinic. I am constantly thirsty which is likely due to my body trying to get rid of the elevated acidity that the extra Co2 creates."

Sensitivity to Co2 can cause central apneas.  It can also build up in your lungs like it seems to be doing.  Several things can influence this. EPR and pressure support can both clear out more co2 on exhale (when the pressure comes down).  It can also aid in obtaining more oxygen on the inhale by giving a little boost.  

Co2 can accumulate in the body for several reasons (COPD, metabolic acidosis, etc.)  I have failed some capnography (cap/ox) tests in the past that measure how much (percentage wise) Co2 a person exhales.  You have already discovered a successful treatment:  breath more (increase ventilation).  That both brings in more oxygen and gets out more Co2.  This ventilator I have can be set for high differentials between inhale and exhale pressure to clear out more co2.  

I would suggest discussing it further with your Dr.'s.  

[mtueckcr]

Both of those nights where on the same settings.

I am currently on low pressure Bilevel with EPAP 6 & IPAP 9. My OSCAR data shows less events but there is still irregular breathing and obstruction events. I have attached the graphs below.

I was at the ENT today to speak about my issues and he gave me a watchpat to see if he can find anything. If he can he will be able to make a diagnosis which will facilitate my insurance paying for bilevel and possibly surgery if that seems like the right option. I am curious to see what the watchpat data shows and will wear my pulsoxymetre to compare the data. I won't sleep with Bilevel tonight to not interfere with the measurement.

[Jay51]

It seems like you have a good plan in place mtueckcr.

Your OSCAR charts look ok IMO.  Still some hypopneas though.  

One thing that I learned about ventilation I would like to pass on here.  At night when I wake up, my pressures have been EPAP 10 and IPAP 20 (a pressure support of around 10).  You have EPAP 6 and IPAP 9 (so that means a pressure support of 3).  The higher the pressure support (the difference between EPAP and IPAP), the more a person will ventilate (or breathe) and both take in more oxygen and expel more CO2.  Kind of like being on cruise control (or autopilot) with a car - it helps to breath much better with practically no effort needed. 

I am not suggesting that you need more pressure support, but if you want to experiment with this or ask your Dr.'s about this, it could help reduce the co2 build up in your body.  I base my above statements on the remarks of my Pulmonologist, Respiratory Therapist and numerous threads and posts that I have read here at ApneaBoard.  And even some wiki articles.

[PreparedGalaxy]

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[mtueckcr]

I slept until 7:30am with the mask on and woke up feeling very fatigued. Whenever I use the mask it takes me a lot longer to fall asleep and I feel like my sleep is very light. After waking I could not go back to sleep with the mask on so I took it off and slept until 10:30am. My sleep was not restful at all and I have had pressure on my head and fatigue throughout the whole day. I took a 1,5hr nap around 15:30 to 17:00.

I had an MRI scan to exclude any irregularities in the brain and everything is healthy and normal. The measurement of my airway shows the same obstruction as my CBCT scans from earlier this year. The area of my throat behind my tongue is about 3-4mm wide.

I have attached my OSCAR data and a picture of the MRI scan.

[Jay51]

Thank you again for posting that.  What jumps out at me in this OSCAR chart is the flow rate chart.  Lots of large spikes for most of the night.  You do have some leaks lining up with these spikes though.  The time from 4:20am to 5:20am though looks good and smooth, like some quality sleep.  

I am not an expert on the Prisma line, but here is an article about optimizing Lowenstein Prismas:  

Lowenstein PrismaLine optimization