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+--- Thread: Struggling to become compliant - Suggestions needed (/Thread-Struggling-to-become-compliant-Suggestions-needed)
Struggling to become compliant - Suggestions needed - dpl788 - 01-30-2019
I apologize in advance for the length of this post. This has been a 12 year journey and I hope a bit of the background may be helpful.
I’m a 51 year old male, 5’6”, 150 lbs. My weight has been near the same since first diagnosed with sleep apnea. I’m fairly active, with a daytime job that requires a fair bit of walking. The only medication I take is for high blood pressure – which has been the same dosage for the past 7+ years and very well controlled. I do not drink alcohol regularly or excessively.
In January 2007 (then 39 years old) I had a sleep study done, was diagnosed with mild OSA and was prescribed a CPAP machine set to 8 cm of H20 and a full face mask. (Note: I have summary reports of my initial sleep study and PAP-NAP, but not the detailed report). The machine was a ResMed S8 Escape that did not have EPR, nor any data recording. I tried to become compliant with the setup for several months, but gave up since the machine usage made my sleep worse than without it. My complaints were: too much pressure on exhale, mask made me feel claustrophobic and leaked if I slept in any position other than on my back.
In late 2014 I revisited the sleep doctor. He suggested a PAP-NAP to find a new mask. Out of the PAP-NAP, I settled on ResMed AirFit P10 (nasal pillow) and a chin strap (since I’m a mouth breather). During the PAP-NAP, they used a ResMed S9 in Auto Mode with a heated hose. I tried my new equipment (mask, chin strap and Hybernite heated hose) on my original S8 Escape, but continued to have compliance issues. I tried adjusting my pressure down (in the 5-7 cmH20 range), but without data collection, I didn’t know what the therapy results were …. Just that I still couldn’t stand the setup. Complaints were that I still seemed to have to work to exhale, never felt rested after using.
Based on my PAP-NAP experience, I started to look for used ResMed S9 machines on the “grey” market (since my health insurance is more like “catastrophic coverage”, where most everything is out of pocket until you reach a max deductible). I wanted a machine that had full data recording capability, so I could import into SleepHead, and an integrated heated hose.
In early 2017, I found a ResMed S9 VPAP Auto that was virtually unused. With my very limited knowledge of the difference in therapy of the machine models, I assumed I could get similar operation from the VPAP Auto as an AutoSet with EPR….this may have been a bad assumption.
I have always used the new machine in VAuto mode. Ti Max, Ti Min, Trigger and cycle are default values (2 sec/ 0.3 sec/Med/Med respectively). Ramp is off. I have kept the Min EPAP + PS set to around my original 8 cm H20 prescription (4+4, 5+3, 6+2) and a couple of times to around 7. Results all seem to be about the same. I consistently awake about 1 hour after going to bed/falling asleep. I’m not sure if this is a natural occurrence for most people. However, when this happens, I struggle to fall back asleep with the mask and generally remove it. Out of my 30+ days total usage of the new machine (over the course of 3 years), SleepHead has only shown 4 OSA occurrences and 1 Hypopnea occurrence. Every other occurrence has been a Central. I have tried to keep the PS at 2 (or occasionally 3) based on Sleeprider’s comment that a larger PS can cause central apnea due to wash-out of CO2.
I estimate that I get 3-4 hours of sleep a night without using the machine, however, I don’t believe that it is restful/restorative/deep sleep. I have many awakenings throughout the night. My spouse indicates that I snore, stop breathing and generally thrash about the bed. I believe I have “learned” to live with the lack of good sleep, but I know that it impairs my cognitive skills, it definitely affects my mood. I only have a handful of really “bad” days during the year, where I feel completely “whacked out”… like I haven’t slept at all during the night. During the last year, I’ve noticed that when I get out of bed in the morning my calves are very tight.
OK….so here are my questions:
Is the arousal/wake up after one hour normal? Is there anything I can try to break this cycle? (I would like to get more than 1 hour of machine data)
Why mostly Centrals? Do I have the wrong settings or possibly the wrong machine? BTW, I have no knowledge of experiencing a Central while awake. Also, it seems the machine usage is causing the centrals. I start to fall asleep, then realize I’m not breathing and wake up (this doesn’t happen when not using the machine). I also notice when the machine starts cycling pressure (Forced Oscillation) to determine airway patency – this sometimes wakes me up.
Should I be concerned with the shape of the Flow Rate?…..specifically the exhale. It seems to be shallow for a long time.
Should I be concerned with my Respiratory Rate? It seems low. Is there a “normal” range?
Older data from last year. Largest PS (4) tried.
[attachment=10072]
More recent data. PS set to 2
[attachment=10073]
Abnormal data. A slew of Centrals
[attachment=10074]
Last nights data. Changed from VAuto to CPAP. Pressure set to 8, EPR set to 2
[attachment=10075]
RE: Struggling to become compliant - Suggestions needed - Sleeprider - 01-30-2019
You have put a lot of effort into this and your pressure and pressure support are all in a reasonable range. Results in terms of every measured parameter is good: AHI, tidal volume, breaths/minute, minute vent, I:E ratio etc. Respiration rate is on the slow side, and exhale is very long. The really bizarre thing is where you have clusters of CA that normalize but leaks increase, then leaks decrease and CA starts again. This is not the pattern we usually see. All of these sessions are less than 2-hours.
I think we need to take a closer look at respiration (2-minute segments). I really don't have a clue what is going on at this point.
Hopefully Fred has my back here.
RE: Struggling to become compliant - Suggestions needed - Gideon - 01-30-2019
SR you are on the right track to look at 2 minute segments. In the one I have just given up on I think I found the problem in a 2 min segment but he won't expand on them besides won't set values to complete the experiments. sorry, frustrated. Set UF1 in Preferences to 60% and 10 seconds then let Sleepyhead reset and use UF1 locations to ID where to look at 2 min segments. I would love to be able to look at 2 min segments in real time.
RE: Struggling to become compliant - Suggestions needed - dpl788 - 01-30-2019
Sleeprider. Thank-you for the quick feedback.
I have found the UF1 settings that Fred referred to and reprocessed my data. Is there a specific night(s) of data you would like to see the 2 minute plots for?BTW: The 3rd screenshot that I titled "Abnormal - A Slew of Centrals" is the only one I have like that. I had never experienced that behavior before or after.
RE: Struggling to become compliant - Suggestions needed - Gideon - 01-30-2019
OK DPL where are you? I'm in Troy
I want you to in Sleepyhead to define a User Flag as flooows
Click "File"
Clik "Preferences"
Click "CPAP"
toward the bottom click "Custom CPAP User Eveb=nt Flagging"
on #1 set to 60% and 10 Seconds
Click "OK" (lower right corner and wait a few minutes
Open up last nights chart and Post a Screen Shot,
in several areas where the UF1 shows an event post a 2 minute segment and we can look at it tomorrow.
Fred
RE: Struggling to become compliant - Suggestions needed - Sleeprider - 01-31-2019
(01-30-2019, 11:38 PM)dpl788 Wrote: Sleeprider. Thank-you for the quick feedback.
BTW: The 3rd screenshot that I titled "Abnormal - A Slew of Centrals" is the only one I have like that. I had never experienced that behavior before or after.
When you have an unusual night like the "slew of centrals", the best thing to do is to just move on. There is no point in examining something that is not repeatable. That they have not occurred before or again is a good thing. Other than that commentary, we are looking to improve the things that might disturb sleep on a routine basis. Looking forward to seeing the charts Fred suggests.
RE: Struggling to become compliant - Suggestions needed - dpl788 - 01-31-2019
Hey Fred, I'm in Hartland.
I grabbed several screen shots.
[attachment=10079][attachment=10080][attachment=10081][attachment=10082][attachment=10083]
Thanks!
RE: Struggling to become compliant - Suggestions needed - dpl788 - 02-02-2019
Any additional feedback is appreciated. Thanks
RE: Struggling to become compliant - Suggestions needed - Gideon - 02-02-2019
Dan, I see nothing that needs adjusting from a therapy point of view.
I would like to set you up for comfort so with the S9 VPAP Auto
Mode: VAuto
EPAP Min: 4 (min pressure possible to exhale with)
IPAP Max: 12 (Not too high, just want to give a little room increase)
PS: 4 (to put you at 8, a pressure you have used many times)
Other than the Odd day CA has never been a problem
I also want you to use at these setting before you go to sleep, watch TV, read a book, play games on your phone, anything that you enjoy. Why, just to help your body get used to the machine.
Fred