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+--- Thread: BoxcarPete: An Adventure in Fine-Tuning (/Thread-BoxcarPete-An-Adventure-in-Fine-Tuning)
RE: BoxcarPete: An Adventure in Fine-Tuning - Sleeprider - 11-27-2023
It's your therapy and always your decision. You've come a long way from the Respironics RemStar.
RE: BoxcarPete: An Adventure in Fine-Tuning - BoxcarPete - 11-28-2023
A much better night last night, with some really good chunks of smooth nREM. Shorter duration because of a late night hockey game, but I think overall I'm starting to figure out how to improve things. I found that CAs tended to happen shortly after pressure increases, or shortly after starting or resolving a mouth leak. Cutting the pressure range seems to have helped with that, with just one such event triggered by it. Mouth leaks remain a problem.
Three things I think really helped last night:
1. Tighter pressure range. The machine hit its cap a few times, but the flow limits went away anyway, so there really may not be much need for me to go above 11 here. When I woke up, I was at 8.5 and that pressure was pretty much indistinguishable to breathing atmospheric air for me. I might tighten it down to 8-11 or even boost to 9-12 and see what we get.
2. Exercise. I was in a pretty rough mental state yesterday with a less restful night compounded with worry about the CAs and mouth leaks. Nothing helps blow off all that steam like a good workout, and I have to imagine that helped.
3. Cervical collar? This is my first night ever recorded with ZERO obstructive events. Wearing it certainly doesn't bother me, so I'll count it as a possible contributor and keep it in the mix.
On another note, should we count RERAs if the flow limitation is resolved completely by the machine's pressure response? This event doesn't appear to have disturbed me in the least.
[attachment=56536]
[attachment=56537]
RE: BoxcarPete: An Adventure in Fine-Tuning - Sleeprider - 11-28-2023
RERA enters into the arousal index. The arousal may not be full awakening, but rather a shift in sleep stage sufficient to cause in increase in breathing rate or volume. That is a pretty classic view of a RERA which is an increasingly severe flow limitation leading to arousal as indicated by a change in respiration.
RE: BoxcarPete: An Adventure in Fine-Tuning - MrIvanDrago - 11-28-2023
(11-28-2023, 03:26 PM)Sleeprider Wrote: RERA enters into the arousal index. The arousal may not be full awakening, but rather a shift in sleep stage sufficient to cause in increase in breathing rate or volume. That is a pretty classic view of a RERA which is an increasingly severe flow limitation leading to arousal as indicated by a change in respiration.
Why doesn't the Aircurve 10 mark RERA's? Or does it and I am missing something?
RE: BoxcarPete: An Adventure in Fine-Tuning - BoxcarPete - 11-28-2023
The reason I'm asking about that is because I see patterns like that all over my charts, pretty much every time I see flow limitations in (what I suspect to be) nREM sleep it looks just like that, and this is the only one that got a flag for some reason. I had a couple RERAs that appear as you describe, with breathing following the flag that looks like a change in pattern, but this one looks too steady for that. Look closer at the breath preceding the flag. It's the already showing a little roundness on top instead of the flat tops preceding it, and this is occurring right when my machine has decided my pressure needs to be higher. The flagged breath looks like it was plucked right out of a perfect sequence, not compensatory at all like a true arousal might indicate. Breathing rate stays quite steady, with a small dip followed by a surge in tidal volume and minute vent together.
Just curious to me to note the algorithm's decision to flag this one compared to all the other times something similar has happened each night I've used it. I'm willing to look right past it and call it a triumph of the APAP having my back. I want to balance keeping this kind of feature available to me against the increase in comfort and reduction of CA events I've noticed from keeping the pressure range higher and tighter. This pattern has re-occurred later in the night with higher starting pressures in some of my other nights, so I expect it may not be simply resolvable with a higher pressure CPAP.
RE: BoxcarPete: An Adventure in Fine-Tuning - Sleeprider - 11-28-2023
The Aircurve 10 does not flag RERA at all and the Airsense 10 is inconsistent. The best way to avoid RERA is to treat the flow limits. With the Aircurve Vauto, we do it with pressure support. I hate to sound like a broken record, and you have consistently dismissed my advice that with the Airsense 10, we can do it with EPR.
RE: BoxcarPete: An Adventure in Fine-Tuning - BoxcarPete - 11-29-2023
I am not dismissing your advice. I am trying to find ways to avoid taking it, which is different. EPR is officially a comfort feature on the AirSense 10, but it happens to work the same way as a limited bi-level therapy, right? So you are espousing its therapeutic benefit to me, which I understand. However, in my case I find it less comfortable than straight pressure, and I already have some minor CA trouble which is presumably CPAP-emergent because it wasn't on my original sleep study. If my therapy for obstructive events is going well, why should I risk upsetting that apple cart? I have tried it out and find it better than Phillips' Flex, but still not as comfortable as straight pressure.
So, that being said, I am pleased with the results of my changes so far up to yesterday. I didn't get a chance to review my charts this morning, but overall it was a less good night than Monday night was. I fell asleep before putting on the headgear and thankfully my baby woke me up a couple hours later. But even after I got it on, I was several times awoken (don't know how many more times disturbed) by mouth leaks and had the worst dry mouth and congestion since I started on this machine. I didn't have either prior to last night despite the OSCAR evidence of mouth leaks, but the fact that it seems to be getting worse means that mouth leaks need to be my #1 priority for the moment.
Is it worth bothering with tape and training exercises, or should I just bite the bullet and go get a full face mask?
RE: BoxcarPete: An Adventure in Fine-Tuning - Sleeprider - 11-29-2023
I have no personal experience with a full face mask or tape. The exercises are not much of an imposition, and simply help with developing a memory of how to control differential air pressure. Having an airway under pressure is not something that normally happens or that we have a lot of experience with unless we work with it. As with anything else in therapy, it's your decision whether to try it or not.
RE: BoxcarPete: An Adventure in Fine-Tuning - BoxcarPete - 11-30-2023
Last night I did some exercises as Sleeprider recommended, breathing in through my pressurized nose and out through my mouth, the reverse, phonating vowels (certain consonants like "n" crack the valve as of yet) and other nonsense while I was falling asleep. All that is what's shaded out in the grey portion of my chart, including an "OA" where I was actually just breathing through my mouth only for a spell.
Looks like some improvement right away! But I suspect that the dam is breaking open once I fall into REM, which makes me despair a little as to whether or not I'll be able to make the nasal pillows work long-term. I ordered some tape to use as a crutch, will continue practicing pressure control, but I may have no choice here.
I am thinking I need to swap out my sleep center. The MD (whom I still have yet to meet) is an immunologist/allergist/sleep doctor, and since I'm all set on his other specialties, I think I want to go find an ENT sleep specialist instead. I had sleep trouble when I was young, tonsillectomy along with the adenoids was world-changing for me, so I must assume that my issues are related to some form of deviant airway physiology.
I'm going to cool off on daily updates for a time, hoping to just settle in for a few weeks or so. Thanks to everyone here (including those who posted their own threads for me to read and learn from) for making available a huge wealth of knowledge on how to tackle sleep disordered breathing!
[attachment=56641]
RE: BoxcarPete: An Adventure in Fine-Tuning - BoxcarPete - 12-04-2023
Update regarding the relationship between pressure, minute vent, tidal volume, and periodic breathing/CA events.
Look at this section here between 2:20 and 3:15 last night. Respiration rate rock steady at 15, but tidal volume drops over the course of that hour from around 580 (appropriate for a 6'3" male) down below 400 (too low for a big guy). Reported leaks are up a little during this process but before the beginning of the leak section the trend is already well underway and TV has already dropped below 500 so I'm not convinced it's just a leak issue. Pressure is steadily falling the whole time, could this be a factor? Minute vent drops along with tidal volume from over 7 down to 5.53 during this hour, and this apparently triggers an arousal. Then, we have the second chart (green line is approximately the same position in both) where periodic breathing becomes the norm, along with what look to be lots of arousals. This goes on for hours afterwards, and aside from a couple of 10-minute long chunks of reasonably steady breathing, doesn't resolve until 5:45, nearly the end of the night. I slept prone without PAP for an hour after a 6:15 wakeup from the baby, so that's the end of the chart for me.
[attachment=56759]
[attachment=56760]
Any thoughts? Will EERS help with this? I've been waiting until after I have my leaks under control to try something like that, but maybe I need to work in parallel here.