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+--- Thread: BoxcarPete: An Adventure in Fine-Tuning (/Thread-BoxcarPete-An-Adventure-in-Fine-Tuning)
BoxcarPete: An Adventure in Fine-Tuning - BoxcarPete - 11-26-2023
Hey, all! Got two nights in under my belt with the shiny new AirSense 10 unit. I have to say, it is an instant improvement over benching the old REMstar and trying to deal with the tiredness, or limping along with MAD and cervical collar alone.
Couple things:
1. It's weird that my mask leaks are almost like an on/off switch at 24L/min or nothing. There are a few that are bigger or smaller, but most of the time it's just long chunks of time at effectively two different flow rates. Never really felt leaks against my face, but I'll check all the fittings tonight. Anything else jump out at y'all as a cause, or is it just a curiosity?
2. The system flags are a bit weird sometimes. Look at this event, and these two non-events. In the first I have no idea why it didn't flag anything at all during this two minute span. Then in the next one, I was awake for this. I take my mask off my face for a few seconds to pick my nose and put it back on, breathe a couple dozen perfect breaths, and get dinged for a hypopnea. Anyone have any idea why?
In the full night there is a false CA at the end, I was awake for that one as well. I took such a deep, steady breath that the machine claimed my mask was leaking and I wasn't breathing at all. Interesting how the sensors in the machine have to guess what is going on all the time.
[attachment=56488][attachment=56489][attachment=56490]
Anyway, I'm thinking about upping my minimum pressure again. Started at 5 standard response, but was awoken several times throughout the night by the pressure spikes. Second night I changed the response from standard to soft, upped the min to 6, gave myself a flat 30min ramp as well. I'm not sure if I really need it, I thought ResMed was mad at my manual breathing pattern and spiking my pressure while I was trying to fall asleep, but it might have been reacting to the change in pattern as I fell asleep and the pressure spike kept shaking me out of it. Hard to say. Slept through the night with much fewer wake-ups.
The AHI is worse, but there are several chunks of 40min-1hr+ that are nice and clean* with sections of gnarly disordered breathing of 20 minutes or less separating them. 0455-0543 if you look closely is 14 minutes disordered, 9 minutes squeaky clean, then 25 minutes nasty. Fits my original diagnosis of 0 AHI in nREM and 25+ within REM. It's amazing to see, even without event flags the REM sections stick out like sore thumbs. There is a 12 minute section just before the cluster of events around 0540 that looks worse than any other section in the whole night, even with no events officially flagged, no more than a dozen breaths are the same before they spike and/or stop for a few seconds over and over.
I'll keep the settings as is tonight now that I'm back in my own bed at home, then we'll see what to do next. Probably raise the minimum again tomorrow.
*in particular 0133-0218 (CA notwithstanding) and 0330-0450. 0550-0635 is quite nice if you ignore the two centrals, and 0225-0325 isn't horrible either.
RE: BoxcarPete: An Adventure in Fine-Tuning - Sleeprider - 11-26-2023
Turn on PR full-time at 3 and maybe increase minimum pressure to 9.0. You'll be surprised to see a more normal inspiratory curve without the high flow limits. It's okay to work into EPR gradually if that better suits you. Just keep the same settings with EPR Full Time at 1 or 2.
RE: BoxcarPete: An Adventure in Fine-Tuning - BoxcarPete - 11-27-2023
Another night with the same settings, and we have what looks a little better, but with a caveat or two.
The first thing I notice is that my two mask off events (for getting young children back to bed) put me in the penalty box for 30 minutes due to my ramp settings. The first looks completely clean, but the second shows what looks like flow limits leading to a hypopnea and one apnea which the machine ignored due to the ramp setting, leaving me on 6cm through both events.
The other thing is mask leaks. I never felt leaks on my face, and on one of my mask off events it's showing a significant leak right up to 30s before I took my mask off, which I should have been awake for. Maybe waking up just instantly stopped the leaking, or there's something else going on. Almost looks like my mask has a bi-level bypass rate, what the machine zeroes off at, and that much +22-30 L/min where it will sit for long periods of time. I also am attaching a shot of a portion of the night which appears like it might be periodic breathing until you look at the mask leak chart, where peaks in tidal volume correspond to dips in mask leak, and vice versa. My median tidal volume is listed as 440mL which is suspiciously low for being a bigger guy as well.
Any thoughts are appreciated besides EPR, I want to go a few more nights before going down that road. I'll consider it if we can resolve the other issues first and not get where we need to be.
[attachment=56495]
[attachment=56496]
Edit to add: and now look at this! A curiously positioned OA just happens to coincide with a drop in mask leak rate, with nice looking breaths on either side, but maybe some position changing shortly after. Breaths before are listing a suspiciously low tidal volume in the low-mid 300s, but after the OA, leaks are reported as zero, and some good looking breaths later tidal volume is a much more reasonable 550-600.
[attachment=56499]
RE: BoxcarPete: An Adventure in Fine-Tuning - Sleeprider - 11-27-2023
I don't think the CA events are anything to be concerned about, if they are real at all. Would need to look closer. I think you should raise minimum pressure to 7.0 and consider turning off ramp if you don't need it. Mask fit and mostly controlling air pressure in your mouth is going to be worth doing some training to mitigate. Try speaking under pressure and maybe sip some water from a glass using a straw. I have a thermal cup with a straw I can use to drink from and by learning to control air pressure as you sip, swallow and speak can translate to better control of the pressure. I remain certain you will benefit from EPR.
RE: BoxcarPete: An Adventure in Fine-Tuning - BoxcarPete - 11-27-2023
I have done that to some extent. If (while awake) I try to mouth breathe with the mask and air on, the breath comes right through my nose instead. Humming is easy and comes out normal. Speaking is a little difficult, but possible with the mask going. The sound comes out distorted. I would think 23 years of playing a brass instrument counts as training the pressure control within my mouth, so I don't know how much more of that would help me in this regard. Do you mean trying those exercises with the machine going?
Would it be worth considering tape instead?
RE: BoxcarPete: An Adventure in Fine-Tuning - BoxcarPete - 11-27-2023
Regarding EPR, my flow limits invariably look like this, with downward sloping flat tops:
[attachment=56507]
This, according to our very own wiki, is a dead ringer for "inspiratory flow limit with normal expiratory flow morphology" which I think only needs a bit more IPAP, and no need for EPR if I find the higher pressures tolerable. You agree, or still think I need EPR?
RE: BoxcarPete: An Adventure in Fine-Tuning - Sleeprider - 11-27-2023
I do mean to practice the air/pressure control exercises with the machine on. I used to play brass as well and while I'm sure it helps, the sensation of controlling pressure applied from the nasal interface is different. My wife and I can converse with the mask and pressure on, take a drink of water if we want, open mouth and still control pressure. The more you are able to do these things while awake, the more likely you can avoid or stop pressure loss from the mouth.
I know you are skeptical about EPR, but it is bilevel pressure support. If you require a minimum pressure of 6.0 to control obstructive events, then you need to set the minimum pressure to 6.0 plus the EPR setting. So for EPR 3, pressure is 9.0/6.0 (inhale/exhale, minimum pressure 9.0), and that can range as high as needed. From what I have seen you will need pressure from 9 to 12 with EPR 3, or 8 to 11 with EPR 2, 7 to 10 with EPR 3.
RE: BoxcarPete: An Adventure in Fine-Tuning - BoxcarPete - 11-27-2023
My primary goal needs to be eliminating the mouth leaks.
I'm going back and forth in my head between two options for tonight:
7-11 EPR off, to try and limit the damage caused by mouth leaks on the higher end, though I don't think it's directly correlated to pressures, it seemed to happen at any point and any pressure. There's also the possibility of tape to go along with either this setting or a 7-12.
9-12 EPR 3, this strikes me as perhaps too big of a change, and perhaps a hail mary to see if something happens like the lowered exhale pressure resets my mouth/nose flap or something. I am also concerned about increasing CAs which are not out of control at my current setting, but may be amplified by EPR.
RE: BoxcarPete: An Adventure in Fine-Tuning - Sleeprider - 11-27-2023
Ya know, anything you do can be undone at anytime. It's like buying from Amazon.
RE: BoxcarPete: An Adventure in Fine-Tuning - BoxcarPete - 11-27-2023
Of course, you are correct. But there are only so many times a man can try some new kind of treatment for a struggle he's faced for years, finding that it works amazingly, and can't believe he ever did anything different, only to find that over the next few nights, everything keeps getting worse. I fully acknowledge that my response isn't completely rational, but I feel like every night is precious, and I feel like I can't risk having another night as bad or worse than last night. I went from tearing apart at the seams to on top of the world and back to the breaking point over the course of the last year, and then now somehow I've done it three times in the last month (old CPAP, SCC/positional, new CPAP). I have no idea why my first night was the best and these others are worse, but I'm dragging hard right now.
I've even considered popping in the MAD and cinching down my cervical collar with the CPAP going, for a belt-and-suspenders-up-to-11 method. Once I get to a more stable place, I'm willing to be analytical and methodical, but right now I'm feeling a little desperate. Hope that puts my responses into perspective for you.