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+--- Thread: Lorrubdb Therapy Thread: Fine-tuning therapy with Oscar (/Thread-Lorrubdb-Therapy-Thread-Fine-tuning-therapy-with-Oscar)
RE: AHI CA/UA still high, EPR changes - Lorrubdb - 02-06-2022
Here is last night's oximetry
[attachment=39667]
RE: AHI CA/UA still high, EPR changes - Lorrubdb - 02-06-2022
Can someone please answer me, waiting impatiently to find out what to do tonite.
Should I try tha nasal thing again, maybe breathing too much carbon dioxide in the face mask.
Thank you
RE: AHI CA/UA still high, EPR changes - Sleeprider - 02-07-2022
i have not followed your thread as you seemed to be getting good help, so apologies if I missed something from the history here. When you don't see replies to your new posts, it is nothing personal, the individuals involved with the thread are just not on sometimes. Bumping the thread, or sending a PM to let us know you have been awaiting a response is fine. Your SpO2 chart does not seem to align with the times in your chart from 2/5/22, so perhaps the time is offset by about -1 hour.
Your interpretation of the results seems correct. On 2/3/22 your 9.6 - 15.2, EPR 3 resulted in a higher central event rate. Reducing EPR to 2 on 2/4/22 seemed to resolve that, and on 2/5/22, AHI was elevated with lower minimum pressure of 8.6-15.2, EPR 2 due to two clusters of obstructive apnea and a cluster of CA. There is nothing in your results that suggests the SpO2 fluctuations between 90% and 96% at about 12:30 to 1:45, so that may have been a poor connection or other interference. The most recent results do not establish much of a trend. Your central events have tended to be higher with EPR 3 and the clusters of OA on 2/5 seem to be a first-time occurrence of obstructive clusters. I think you should return the minimum pressure to 9.6, even though EPR was cut. Your AHI has trended downward since you used to use a minimum pressure of 8.0 and maximum 14.0, and the higher pressure looks more promising.
It might be helpful to look at some zoomed images of your normal respiratory flow-rate. We don't need to see what it looks like during events, the objective is just to see some detail that might explain why your inspiratory side of the flow curve seems flat compared to the expiratory side which is more uneven or variable. Also, I'm curious if you have always used a full face mask or if you have ever tried a nasal interface?
RE: Need Help! AHI increasing, can't decipher Oscar - Lorrubdb - 02-07-2022
Thanks so much for your reply and suggestions. I didn’t realize the same people follow certain threads and maybe just aren’t around that day. I just thought if there’s a new post whoever is on answers. Makes sense since and good to know! And you’re right- I have been getting great help-so won’t take it personal
I will keep on min pressure of 9.6 and post some zooms of my regular breathing. I always wondered why my inspiration and expiration is so unequal.
I did try the nasal mask a couple of times but immediately felt like I couldn’t get enough air -so panicked and put on the face mask. I think I might try it again with a chin strap and try to control my anxiety and settle in before I rip it off! The face masks never really fit right and sooner or later have leaking problems.
RE: Need Help! AHI increasing, can't decipher Oscar - Sleeprider - 02-07-2022
I'm trying to get to the bottom of your relatively long inspiration time vs short expiration time by having you post a zoomed view of your normal flow rate graph. A 3-4 minute view of the flow rate tells us a lot of whether the statistics reported in Oscar are believable, or if something is actually going on. Please don't ignore the last paragraph of my last post, I want to see your respiratory wave because flow limitation is often under-reported in statistics.
RE: Need Help! AHI increasing, can't decipher Oscar - Lorrubdb - 02-07-2022
Hi Sleeprider,
Here are some zoomed posts of regular uneventful breathing but I just read your last post and sounds like these are too short
I will post more with longer periods of 3-4 minutes and won't stretch it out. I understand now what you want to see, although I have no clue how you can tell how the respiratory waves effects my inspiration/respiration rate. Thanks for looking into this- I did have very high flow limits, would be great to know what's going on.
[attachment=39707][attachment=39708][attachment=39709]
RE: Need Help! AHI increasing, can't decipher Oscar - Lorrubdb - 02-07-2022
is this more what you need?
[attachment=39719][attachment=39720][attachment=39721]
RE: Need Help! AHI increasing, can't decipher Oscar - Sleeprider - 02-07-2022
That is what I was looking for. Your breathing is chronically flow-limited with flattened or downward sloping inspiratory peaks. Oscar is not properly identifying the start of inspiration, but is including a significant part of your exhale as your inspiration time. Your results suggest normal breath morphology with flow limitation, and and you can ignore the inspiration and expiration times. If I could put you on a Resmed Aircurve 10 Vauto, I'm pretty sure we would clear this up very quickly with a combination of pressure support and trigger sensitivity. If you're happy with therapy as-is, then we can optimize as best as possible with the CPAP. If you're looking to take it to the next level, then you're going to need a bilevel Aircurve Vauto. Another option may be to increase EPR to resolve the flow limits, and either let you adapt to the higher ventilation rate, or help you reserve some expiratory CO2 to avoid the centrals. Probably the first question in that regard is, do you find higher central apnea event rates to be a problem in how you feel? Many people do not.
RE: Need Help! AHI increasing, can't decipher Oscar - Lorrubdb - 02-08-2022
Sleeprider, thank you, amazing how you figured out my whole problem (and solutions) so fast, you're very knowledgeable. Didn't know the breathing pattern and shape could show so much and in my case chronic limited breathing. Wonder why my doctor doesn't know that! Sounds so right on, I've struggled with restricted breathing (during the day) for around a year pre-cpap and now if I have a lot of events the prior night. If AHI is low which it was for awhile, have no breathing problems while awake. Glad to hear my breathing is somewhat normal though..
So had another bad night with a relatively high AHI of 4.16, lots of centrals-to answer your question-yes they do bother me a lot-I wish I was one of those people who they don't-but right away when I got up like felt like I can't breathe. I know most people feel tired but mostly I just get the dyspnea from high central apneas. I think there may be something wrong with my machine or the sd card-as the recording is off-I went to sleep more like around midnight-not 2 AM and it's missing some time later on. Had EPR on 2 and looks like I did ok until around 4:30 and then flow limits went up along with centrals and some obstructives. Leaks again, I know. Weird its fine, then air just starts pouring out the sides. Maybe from moving around a lot. Will definitely try the nasal cushions again tonight.
I wish I could get the machine you recommend but doubt if I could get the doc to order it or if insurance would even cover it. Also doubt if I could afford it on my own with supplies and everything, but will look into the pricing-a lot I'm sure. So what do you suggest I do for now? Higher ventilation (you mean min. pressure right?) doesn't bother me, I like a lot of air so are you talking about raising the min pressure and EPR? To what numbers? Not sure what you mean about reserving some expiratory CO2 or how you do it. Thanks, Lorie
[attachment=39730]
RE: Need Help! AHI increasing, can't decipher Oscar - Sleeprider - 02-08-2022
Doctors do not normally deal with flow limitation or respiratory flow unless they are otolaryngology or pulmonary specialists, and even then, they rarely associate flow limitation with the sleep disordered breathing portion of their practice. Upper airway inspiratory flow limit may be nasal, pharyngeal or esophageal. If you are aware of nasal congestion or air restriction, or if you feel your throat closes, those are potential hints on how to proceed. For example, you are using a full face mask which can impose pressure on the sinuses at the side of your nose or pull your jaw back. I have seen nasal flow limitation eliminated with nasal pillows masks.
Flow limitation responds well to pressure support which is the difference between inspiratory and expiratory pressure (IPAP-EPAP=PS). Higher difference in the pressure support higher volume airflow during inspiration and makes expiration easier. Your Autoset uses EPR for a similar effect but higher EPR has resulted is somewhat higher CA events for you. The reason increased pressure support or EPR causes some people to have more central events is that the improved ventilation actually reduces the CO2 levels in your blood stream. Carbon dioxide is a natural and important component in your body that is a key in regulating respiration and respiratory drive. If a person is poorly ventilated or in a confined area, carbon dioxide can build up (hypercapnia) which results in a hyperventilation response as the body tries to equalize the carbon dioxide by removing. Similarly, a person that has hyperventilated or received more air exchange than usual, as sometimes happens with CPAP/BPAP, may experience a low carboin dioxide level in the blood (hypocapnia) which often results in suppressed respiratory drive or a central apnea. This is the physiological mechanism you are experiencing with higher EPR. Because respiratory needs are usually exceeded when hypocapnia occurs, many people are unaware of a central apnea event. They are brief, the body is not trying to breathe and breathing naturally resumes when carbon dioxide normalizes. I want you to understand the mechanisms at play, because we can use your therapy to alter them.
I think you need more EPR/PS to help you overcome the flow limitation that is present throughout the night on your chart. Your inspiration is flow limited much of the night. I think you should use EPR 3 and let it run several nights. You will likely have higher CA event rate, but any sleep disruption from that should be offset by easier (less effort) breathing. This may reduce respiratory effort relate arousals (RERA) which are happening, but not visible at this zoom resolution. In the chart below, I think the CA are an artifact of sleep disruption and the large leak around 06:45. We often refer to this as sleep-wake-junk because you are not really fully asleep but are shifting in and out of light sleep. Higher EPR is going to enable better sleep, and for a few nights we are going to just observe and ignore the CA events. If we need to control CA, we can consider using enhanced expiratory rebreathing space, but let's not get too far into this unconventional approach for now. http://www.apneaboard.com/wiki/index.php/Enhanced_Expiratory_Rebreathing_Space_(EERS) . Let's start with 9.0 minimum, 13.0 maximum and EPR 3.