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+--- Thread: [Treatment] Lowenstein Prisma OSCAR data: FL, RERA galore + extremely tired? (/Thread-Treatment-Lowenstein-Prisma-OSCAR-data-FL-RERA-galore-extremely-tired)
RE: Lowenstein Prisma OSCAR data: FL, RERA galore + extremely tired? - Phaleronic - 05-24-2024
Hi Anorthlow
You do have a mix of class2/3 waveforms flow limited it appears to be to me.. I personally do not have that issue but mine are also not 100 percent perfect
Here's a snapshot from one of my charts to compare:
RE: Lowenstein Prisma OSCAR data: FL, RERA galore + extremely tired? - WisNaeMe - 05-25-2024
As PL&P said earlier, give any changes you’ve made a chance to settle before you contemplate switching to Dynamic mode …and maybe post a further screen shot to let us see where that’s left you. Dynamic mode could / should help manage your FLs and RERAs a fair bit, but it’s not a panacea.
From the initial chart you posted it looks like there’s also a positional component to your FL’s and RERAs (banding of the FL & RERA flags), so trying a Soft Cervical Collar and a lower pillow might help thin these out a bit. The banding might also reflect periods of REM sleep (they usually show up as clumps too) as REM can be quite disrupted sleep. If you have a wearable health device (e.g. a watch or ring), then you might want to compare any sleep data from there with your OSCAR chart to check for REM sleep stages.
Turn on the Deep Sleep (DS) Flag, as it will give you a reasonable indication of your sleep (or at least your more settled breathing) throughout the night. Just now, you don’t seem to be getting much (12.47%), but it will at least give you an indication of when and where it’s happening and perhaps how fragmented or otherwise it is.
Also check ApneaBoard’s WIKI Lowenstein pages (see link), to get a better understanding of Lowenstein machines and how SoftPAP works.
https://www.apneaboard.com/wiki/index.php?title=Lowenstein_PrismaLine_optimization
SoftPAP is more dynamic than ResMed’s EPR, in that within each SoftPAP level (i.e Slight & Normal), EPR / PS will change depending on the pressure being delivered at that time. So it might not be delivering quite what you’re expecting as there are some bands of pressure that don’t increase EPR / PS. This is better explained in the above link, where there’s a table indicating what EPR / PS is being delivered for a given IPAP.
But, if you find yourself needing more EPR / PS to manage your FLs, then you’ll generally need to raise your minimum pressure or step up to the next higher SoftPAP level, which I think you have. But bear in mind that pressure increases carry the usual risks of inducing breathing discomfort, aerophagia, etc., and this varies from person to person - best to increase pressure gradually in order to acclimate to the change.
RE: Lowenstein Prisma OSCAR data: FL, RERA galore + extremely tired? - anorthlow - 05-25-2024
Thank's for all of the info, so much to learn!
Hi Phaleronic - interesting, your's look like class 6 and mine 2/3.
WisNaeMe I've ordered a cervical collar now, and better chinstraps to tolerate higher pressure, will sleep on a thin pillow from now on.
And yes im already at max softpap, level 2 - tinkered with the pressure and 12 seems to be the max for me before i feel like i wake up in a hurricane from the release valves in my nasal mask, and my cheeks expand with air. As you say one thing at a time, and i will wait with dynamic mode until i've read up some more and tested various solutions.
Currently i've raised min pressure to 8, seems to be way better and gives less of a suffocating feeling, the initial 4 my doc set was very unpleasant. So min 8 max 11.5, seems to be it for me atm.
Also i found the deep sleep event and will report back in a few days with new data!
RE: Lowenstein Prisma OSCAR data: FL, RERA galore + extremely tired? - jlsmithseven - 05-26-2024
Please keep this thread going as I am also having some similar issues as you. I came from an airsense 11, and I just finally got my full nights rest after a few days of not being able to use it. I’m trying to dial in my pressures from EPR of 3 and softpap is just way different.
RE: Lowenstein Prisma OSCAR data: FL, RERA galore + extremely tired? - anorthlow - 05-28-2024
hi jlsmithseven, i'll definitely keep the thread going until i've figured out what's going on with both flow limitations, breathing patterns and tiredness.
Just got my cervical collar and slept with it tonight, - i'll give an update after tonight with new data.
I've concluded i have more or less constant type 2/3 flow limitation breathing despite collar, low pillow and the highest pressure i can tolerate for now.
Since Loewenstein apparently has no "flow limit" graph, but instead events i guess you'll have to look at the flow rates around various events to get an idea what's going on, but i don't know if that is easily comparable to people with Resmed - do they also have FL events, if so how many generally?
What's your Flow Limitation number in OSCAR (left side - not sure what it indicates as there is no % symbol?) , mine is between 40-60 every night.
RE: Lowenstein Prisma OSCAR data: FL, RERA galore + extremely tired? - Narcil - 05-28-2024
no there is no FL events with resmed just shows a graph. and statistics. like
Flow Limit.
min 0.00
med 0.00
95% 0.10
99.5% 0.25
RE: Lowenstein Prisma OSCAR data: FL, RERA galore + extremely tired? - anorthlow - 05-29-2024
So here's a new nights sleep with the recommendations. (thanks everyone!)
I now sleep with a 3m cervical collar, and on a very thin pillow.
Still what looks like large amounts of flow limitation and class 2 / class 3 breathing. (https://www.apneaboard.com/wiki/images/f/fd/Flowlimitations_Classes.png)
I've added a daily screenshot of the last night and 2 of zoomed in shots of waveforms that are present all night.
I have a few questions:
1) I've settled on min pressure 8, max pressure 10 for now. Otherwise i have difficulties with air in my mouth even with the collar, i also feel like it's "breathing too fast" or the algorithm hyperventilates for me at higher pressures. Is that normal? Is there any way to increase this or do i just have to settle?
2) The tidal pressure also seems quite low, much lower than when awake, it hovers around 200ml when my ideal weight is 70kg so it should be 490 from my calculations (7*ideal weight in kg = tidal pressure in ml). This makes sense as i've seen flow limitation linked to less breaths, and less volume ie less tidal pressure? http://ars.els-cdn.com/content/image/1-s2.0-S1984006315000516-gr5.jpg - i'm mostly between 90% -97% oxygenation from my wellue though so not catastrophic but i still feel tired so could be higher hematocrit levels to compensate?
3) Does this mean BIPAP is an option? User Sleeprider describes a case which in my eyes looks similar to mine, though with more FL as "pure torture" and recommends bipap https://www.apneaboard.com/forums/Thread-CPAP-Newby-trying-to-understand-what-i-am-seeing?pid=504010
4) Lastly i've come to the conclusion i also have some form of UARS, ie. my airway is just narrow from birth because sports have always made me incredibly winded - also i often gasp for air while awake, and kind of like to "pack air into my lungs", almost as a tick. This is despite trying to workout 3+ times a week. Has anyone treated a case similar to mine well?
5) To the well treated people here, how much flow limitation do you have, are your waveforms stable and pretty, and if not do you suspect non OSA is at play, ie. restricted airway, im trying to figure out if my case of FL is severe, moderate or comparable to many others?
Thank you so much in advance, this forum is a godsend!
RE: Lowenstein Prisma OSCAR data: FL, RERA galore + extremely tired? - jlsmithseven - 05-29-2024
I had the almost exact same issues as you and moved back to my airsense 11. I am on very similar pressures and use epr 3 otherwise I have way too many flow Limits. I think I need bipap as well I like the inhale but hate the exhale. I need like 10 ipap ideally and 5-6 epap, and the lowenstein can’t truly provide that. Sorry.
RE: Lowenstein Prisma OSCAR data: FL, RERA galore + extremely tired? - WisNaeMe - 05-29-2024
At your current setting of 10 cmH20, your Pmax is too low to allow the full 3 cmH20 of pressure relief that your machine is capable of - the maximum it can achieve on your present settings is 2.5 cmH2O. Your Pmax needs to be nearer 13 (a full 3 cmH2O of relief only kicks in at 12 cmH2O in pressure or above).
That would also stop it hitting the top of your pressure range at night and clipping the breaths (might also explain your low tidal volumes) - though I don’t think that it would necessarily impact on the underlying FLs. The downside to this change is the potential for mask leaks, arousals and discomfort as the pressure ranges closer to the upper limit of 13. Only trying Pmax=13 (with possibly Pmin=9, if you could manage it) would confirm.
I think I might also be inclined to try dynamic mode now. If nothing else, it might remove or reduce the RERAs.
As to drawing FL comparisons with ResMed. I don’t think there is enough data (or knowledge) out there to do this with any degree of accuracy or certainty. Lowenstein might have different FL thresholds and so be throwing up more flags. It may be worth turning on the eFL flag (epoch Flow Limitations), as this would indicate the spread of what Lowenstein regards as ‘peak’ FLs (and so the bits it acts upon).
But comparing your FLs to mine (when I was using the same machine) - yours are significantly higher (mine were about 10% of yours). I cut my losses with the Lowenstein at that lower level and moved to bi-level (ResMed AirCurve 10 Vauto). This change seems to be addressing my FL issues. It might be that you need to consider a similar change. An AirSense 10 might achieve the same results, if you are able to bring your FLs under control with EPR=3), but that is a bit of an unknown.
To get more pressure support / EPR on a Lowenstein, you would need to move to a Prisma 20A with SoftPAP 3, which can deliver pressure relief of up to 4 cmH2O. Beyond that, and should you find that you have more ‘complex’ SDB, then you might need to consider Lowenstein’s PrismaLine 25 or 30 series' Bi & Tri-level machines - but these are costly and not as widely supported. AB member Macka has both of them and might be able to advise on your situation. While the Prisma Smart machine seems to be adequate for managing the more straightforward OAs or Hs, it does seem to be stretched by the greyer area of UARS, FLs and RERAs.
More generally -
Check that you don’t have your Soft Cervical Collar on too tight - It’s there to stop your chin dropping down towards your chest, rather than immobilise your neck - you need to be able to comfortably insert a couple of fingers behind it - it should simply prop up your chin, whilst not restricting your airway.
The continued banded nature of your FLs, might also indicate more ‘conventional’ positional apnea (i.e. left, right, prone or supine body position). It might be worth ruling this out by using a sleep position (phone) app such as SomnoPose (Apple) or Torena (Android).
RE: Lowenstein Prisma OSCAR data: FL, RERA galore + extremely tired? - anorthlow - 05-30-2024
Thanks for the answers!
WisNaeMe cery interesting with the "clipping" you mention - is that a general rule, that you should increase pressure until there's no clipping/headrooom above pmax?
I'm asking because my doc started at pmax 20 (just a guess from her, no titration), and the machine would hit 17-20 max pressure every night, almost always after at least 3-4 hours, unfortunately waking me up, giving me aerophagia and blowing air into my mouth. I wonder why it did that? Maybe to compensate the flow limitation? Weirdly it didn't help, as my FL numbers were exactly the same ~50, so i turned it down to 10 as that keeps me sleeping, but maybe higher pressure is better even if i wake up a few times. I've attached a screenshot from OSCAR of such a night before i turned down to pmax 10.
Regarding the point with "pmax >12 gives you softpap 2 which equates to 3 cmh2o equivalent of EPR 3", so weird that this is not referenced anywhere just rather hidden here in the wiki here (also quite confusing naming): https://www.apneaboard.com/wiki/index.php?title=Lowenstein_PrismaLine_optimization, "The example below shows a PS of 3cmH2o. This is the maximum PS available on a Prisma Smart", thank you for the info. I guess it kicks in already at 12 so i'll try with 9/12 pressures tonight, then dynamic mode soon!
Also thank you for the pointers on position.
20a or bilevel may be the answer in the end but lets see, i've only had this machine for 3 weeks now, hope in can make it work
