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Pugsy
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Mon Jul 13, 2020 1:12 pm
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Okay...we know the real central index as in asleep is much less than the 3 we see now. The bulk of it obviously was during the known awake time.

It's okay to have a few centrals here and there. Some real and some awake related. We ignore those.
More pressure won't fix centrals with this machine anyway.

When share a detailed report image always include how you slept in general and any known prolonged awake times...because we mentally remove awake data from the evaluation process.

I would like 3 nights total with this minimum of 5 and if the pattern holds in terms of OAs and hyponeas then I would like to see 3 nights with a minimum of 6....and then if not happy with OAs and hyponeas then 7 minimum. You can keep your maximum as it is. It doesn't appear to be wanting to reach it anyway. Will re-evaluate that if we see it hit the max often or prolonged.

Keep Flex off for now.

As for bad sleep quality...sometimes statins can cause problems going to sleep or staying asleep. Fairly common and we are kind caught between a rock and a hard place....gotta take them. Some brands worse than others apparently but none that don't come with some sort of unwanted baggage. Most meds come with some sort of baggage anyway.


I do want you to go look at the videos in the above link and learn how to try to figure out asleep flagged events from awake/arousal flagged events. I know it is talking mainly about central apneas but those arousal related flags can happen with OAs and hyponeas as well. I know that for sure because I see them all the time. I have some sleep quality issues myself because of a lot of tossing and turning from back pain stuff.
On the nights it's real bad...my AHI looks really ugly but 75% of that AHI is false positive flagging from being half awake and tossing and turning to get to a more comfortable position where I don't hurt.

You won't be able to know for sure on some of them but most you will be able to tell if awake or asleep when the flag happened. Enough to ease your mind a bit if the AHI is a bit higher than you might want.

Heck, I had an AHI of 9.4 about a month ago...bad back pain night because I did stuff during the day that I shouldn't have. I paid for it.
Anyway I did go look up close and 90% were so obviously awake related flagging that a blind person could see it. It was just a bad night for sleep in general that was totally unrelated to apnea. When I see those high AHI nights and I know I didn't sleep well....I shrug my shoulders and move on.

We can only fix the bad sleep with a cpap machine when the bad sleep is caused by airway issues WHILE ASLEEP. We can't fix bad sleep with the cpap machine when the bad sleep is caused by something other than airway issues. Wish we could but we just can't.

I can't tell from this image if the OAs we see are airway related or not but if they are they should reduce with the increase in the minimum pressure. If they don't start reducing much with the increases then we start digging deeper.

Again unless something changes with future reports...I don't see any need for ASV at this time.

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DeltaBravo3.8
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Mon Jul 13, 2020 1:43 pm
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I'm just chiming in to say I'm following along, and agree with info/suggestions Pugsy suggests. I do think as well an ASV and you won't play well. Besides, the low level of CA mentioned dismisses the ASV as a need. Waiting to see what the OSCAR reports tell us.

BTW on OSCAR sometimes not reporting machine settings accurately: as I understand it, it's a data building flaw that sometimes crops up. OSCAR doesn't get updated setting data in some circumstances. I'm not techy enough to explain it in detail. Anyway, sometimes OSCAR gets a flawed setting report and reports a prior setting dataset if the new data is of that flawed variety. And the OSCAR team is in the code to fix things of this sort for the next update.

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Respirator99
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Mon Jul 13, 2020 5:09 pm
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Pugsy wrote:
Sometimes OSCAR just screws up reporting the settings. Don't worry about it. It tells me all the time my humidifier isn't attached or on and it's built in and indeed on. It's a known bug. Thought it was fixed with his latest version of OSCAR...guess I was wrong.


Except that in this case it hasn't screwed up. When Jill took her aternoon nap Flex was obviously on. Then later that night the settings were changed, as you can see from the pressure trace. So, which setting should Oscar report - it can't report both. So after some discussion in the Oscar software forum it was decided to use the first settings of the day.

Without knowing the internal details of the data structure I seem to remember also that some machines record the settings in a file which is generated when you first turn it on that day and subsequent changes are not included (I may be wrong on this). In that case Oscar has no option about what to report.

Getting back to Jill's therapy, I think Pugsy is on the right track. The only caution I'd throw in is that central / complex apnea can be very inconsistent. You could have a couple of good nights then a bad one for no apparent reason. If you're prepared for that, then you won't be disappointed when it happens. The main thing is to make the good nights as good as possible and reduce the number of bad nights.

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Pugsy
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Mon Jul 13, 2020 5:30 pm
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Respirator99 wrote:
Except that in this case it hasn't screwed up. When Jill took her aternoon nap Flex was obviously on. Then later that night the settings were changed, as you can see from the pressure trace. So, which setting should Oscar report - it can't report both. So after some discussion in the Oscar software forum it was decided to use the first settings of the day.


Ahhhh...so it reports the first session within that day's reporting. I think I understand now.
I won't guarantee that I will remember it but I will try. :lol:
I haven't kept up with all the bugs in SleepyHead or OSCAR or which ones got fixed or didn't get fixed. Just not enough hours in the day...you know how it goes.
Plus as far as checking for bugs...I rarely do more than glance at my software reports. After 11 years they are fairly predictable. I wouldn't notice a bug unless it slapped me in the face.
Now if something is way off like the AHI of 9.4 night...I will look out of curiosity more than anything else. I always figured I don't get a redo on a bad night anyway so why worry about it unless I saw something off consistently on a night by night basis. I have learned that no matter what my AHI is...low or high...the bulk of it is going to be SWJ false positives because of the nights that sometimes I just sleep so poorly due to the pain issues. That's a war I know I won't ever totally win but I continue to try to fight the battles when I can.

I figure we need a least a week (maybe 2 weeks) worth of data with Flex off to get a feel for if Flex was the central trigger. See how many times there ends up being a bad central night or not. All the while I am crossing my fingers it was that simple of a fix.

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jillkam
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Tue Jul 14, 2020 5:14 am

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Good morning! AHI of 8 last night, with just 4 centrals. The AHI number itself is typical, but it is not typical for me that the centrals are this much lower than the obstructives, so that's a good indicator that flex off is good for me. Lots of hypopneas though. Please see attached.

I got up once last night and it probably took me 30-45 mins to get back to sleep. Just lots going on right now, lots of thoughts churning in my mind, but I wasn't awake that long.

I have a habit that when I wake up (even if I don't get up/disconnect the machine), I look at the pressure number and if it's over 9 or so, I reset it. From the pressure graph, this happened 3 times last night (00:15, 02:50-ish, 04:30). It is a data-driven habit and the graphs sort of support this -- there are often few events after the pressure starts over. But not always. Please let me know if you'd like me to NOT do this tonight.

Thanks and have a great day!
Jill


Attachments:
File comment: APAP Mon night 7/13
screenshot-20200714-apap.png
screenshot-20200714-apap.png [ 110.24 KiB | Viewed 359 times ]
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jillkam
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Tue Jul 14, 2020 5:18 am

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PS, thanks Respirator, and I know that my numbers vary from 5-13 or so on APAP over the last year, and I mostly can never figure out why. Amen to more good nights than bad! Typical for me is 7-9.5, and 8 is pretty darned average. As I've said, if that's as good as it gets, it's a lot better than 30 (pre-APAP) or 15 (APAP with my doctor's best attempt settings)

And thanks, Pugsy for all the insight. I will look more carefully at the graphs, and I can learn to recognize the arousals and re-calculate the "actual" AHI. I'm assuming that any events in arousal time, including hypopnea's, can be disregarded. The little burst of hyponea's at 23:45 looks a little suspicious to me -- your thoughts?

Something else I forgot to mention, for the evaluation mix. Last summer, somewhere I read that using an oxygen concentrator can help with centrals, so I've been using one. After watching the video last night with the CO2 explanation of CPAP-induced centrals, my husband and I debated if we should turn it off. As a compromise we knocked it down to 1 liter/min. We live at high altitude, 6700 feet or so. Sleep studies without oxygen haven't been terrible, but there are pockets of time during the night with O2 sat in 88% range or so. Just another data point, I'll certainly turn it off if you'd like to see the data with that. Not that the numbers will be absolutely indicative as we know and as has been said much just on this thread: sometimes it goes up for a known reason (e.g., Pugsy's back pain), and sometimes for unknown reasons (could just be stress or whatever). I know it's been hot here lately, and that's one reason why I'm awake during the night lately.

Thanks again!!


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Pugsy
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Tue Jul 14, 2020 8:45 am
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That cluster of hyponeas at 23:45 looks suspicious to me as well...
Overall I really suspect we need more baseline minimum pressure.
Now that I know you live at altitude....again another explanation for the centrals. So it might be a combination of things.
At altitude some people can have centrals and it simply be the altitude that is the cause and have nothing to do with a bilevel situation.
So for you it might be a combination thing. There are other things that end up causing the CO2 imbalance besides just bilevel settings. My suggestion is play with the adding of O2 like you are doing and even turn it off and see what happens.

As for as to why some nights people do well and some nights they have pockets of centrals....we don't know why. I have chatted with Jason about this very thing and he says that sometimes they don't know why it is so intermittent even when nothing is changed. They just know it happens and can't explain why in some people.
Add in altitude...greater chance for unexplained respiratory imbalance happening.

I think you need to proceed with addressing the hyponeas with a little more minimum. I would go slow and small though. Hyponeas are usually fairly easily killed off but I want to be careful that more baseline pressure doesn't trigger that imbalance that causes centrals.

Be careful and try to avoid making more than one change in anything at the same time as pressure changes so that we can best evaluate the change.
So don't turn off the O2 and increase the minimum at the same time.

In fact I would put the changing or turning off of the O2 on the back burner for now. Keep it at the 1 L/min you did last night for a while and once we figure out a good minimum for you then proceed with playing with the O2 settings.

When we change 2 things at once...and we get a different result (good or bad) we don't know which change caused the different result. Science 101...keep your variables to a minimum whenever possible.

You may need a little more than 1 cm more minimum but I want to go slow with you.
If you have a night where you just don't sleep well because of something like pain or the dog or whatever...we will probably have to toss that night of data. That's okay...it happens to us all from time to time.

So for tonight...keep the O2 at 1 and just increase that minimum from 5 to 6.

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DeltaBravo3.8
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Tue Jul 14, 2020 1:18 pm
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FWIW as I have a CA issue on anything other than an ASV, I take notice of CA and have done my best to learn all about these as pertaining to my therapy. On another apnea forum I frequent, the phrase "Consistently Inconsistent" is a way we describe most if not all CA events. They are hard to pin down due to their inconsistent nature.

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optimalsleep
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Tue Jul 14, 2020 2:08 pm

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OSCAR or Polysomnograph will show a true Central Apnea during normal breathing oscillations. Anything spiking or erratic is awaking/arousal.


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jillkam
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Wed Jul 15, 2020 5:12 am

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Good morning! We kept O2 at 1 liter/min last night (forgot to mention, before that it's been around 3.5), and raised min pressure to 6. See attached. OH and I also resisted the temptation and did NOT hit the reset button when I'd wake and see that I was at a high pressure. :)

Overall I didn't sleep GREAT. I know I was awake during the cluster of events just after I disconnected to use the restroom. If I take those 11 out of the calculation, I get an AHI of 8.5 if I keep the # of hours the same, or 11.8 if I subtract the 1/2 hour or so. I see a lot of suspicious events but don't have time to weed them all out right now.

I also see the Cheyne-Stokes respiration a bit; not uncommon for me to see a few periods of this in a night.

I feel tired but I also think I'm still recovering from last week's ASV experimentation.
It's definitely significant that centrals are so low. That's not been my pattern for over a year -- centrals have nearly always been higher than obstructives and often twice as high. I'm confident that with your help, we'll dial back the OA's and hypop's.
Let me know what you think!!

And again again again: I'm so grateful for all of you: optimalsleep, DeltaBravo, Pugsy, Respirator -- for coming along side me this week to help!!
Have a great day,
Jill


Attachments:
File comment: APAP Tues night 7/14
screenshot-20200715-apap.png
screenshot-20200715-apap.png [ 95.28 KiB | Viewed 323 times ]
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Pugsy
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Wed Jul 15, 2020 5:58 am
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I know you have experimented with a lot of minimums.

Did you ever get to a minimum pressure where the hyponeas and OAs were reduced to an acceptable level? How high of a minimum did you go to?
How high of a minimum can you handle without Flex being added do your think you might be comfortable with?

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Respirator99
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Wed Jul 15, 2020 6:25 am
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There is a rule of thumb that to thoroughly control obstructive apnea you should raise the minimum pressure to the machine's median. I understand that higher pressures cause you discomfort, but eventually you'll probably need a minimum around 9.0. It's probably best to edge up to it a centimetre (or less) at a time, hold for a few days to a week then go again. The idea is to let your body acclimatise gradually to the increased pressure.

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Pugsy
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Wed Jul 15, 2020 6:56 am
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To add to what Respirator99 has said...what we want to do (ideally) is use a minimum pressure that optimally stents the airway open enough to prevent those OAs and hyponeas from trying to occur in the first place. Things work so much better when the collapse is prevented in the first place as opposed to trying to fix things after the fact.
The machine won't do anything at all when the collapse/event is actually happening. Instead it waits until the airway is open and re-evaluates things to try to see what it can do to better prevent the next collapse from happening. It's a complicated algorithm for the auto adjusting and takes into account snores, flow limitations, how many OAs and hyponeas a person had, etc. It doesn't do anything quickly though and while it is thinking about what to do events keep happening. Obviously we don't want that happening.

The key is prevention...hence the need for a higher minimum pressure to start with.

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DeltaBravo3.8
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Wed Jul 15, 2020 8:42 am
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I agree with the others. I think what needs to happen for best outcome regarding comfort with the required therapy pressure is slowly raising it over time to get to where the reported 90% indicates. Since you're not doing this in a lab where you have to pay for time, you can take as long as needed at each pressure increase as you want/need. Basically this is akin to a long drawn out titration. Bump the pressure up, view results, let yourself get used to it, and repeat until you get to the 90% number. Best wishes that you will soon be very successful.

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jillkam
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Wed Jul 15, 2020 10:09 am

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I am not sure I ever played around with the minimum. It was the maximum that I played around with, and landed on 12.5 to stay below 10 AHI most of the time.

I get that this is a long drawn out titration for sure, and that's why I appreciate the continued interest from all of YOU!! :-) It will be worth it in the end if I don't need the ASV (which seems very very likely thanks to you all) and if I can get them OA's/hypo's down a bit and ignore the turd events.

Maybe I should keep it at 6 for a couple more nights, and then bump to 7 -- if you agree no need to reply, as I value your time. I'll post more results Friday or Saturday from the nights at 6 and then bump it up. Thanks!

PS -- for Pugsy's comment -- I'll do what it takes and I won't go back to flex. I really was fine last night and the pressure was high for quite some time. I didn't lower the max pressure so much for comfort, but because that's where I saw a sweet spot of improved AHI. Do you think I should bump it up to 7 tonight? I can, no problem!!


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LSAT
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Wed Jul 15, 2020 10:15 am

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The max pressure will do little to decrease your AHI and eliminate events. It's the minimum that needs to be increased and by locking the max at 12.5 you are preventing the machine from doing it's job. You can tell from your data that it wanted to go higher but was blocked. You should be at 8 minimum and 20 maximum...Try that for a night and watch your AHI go down.


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jillkam
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Wed Jul 15, 2020 12:18 pm

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Thanks, LSAT -- I do realize that I'm limiting the machine by limiting the max pressure.

The reason I did this was, as I think I mentioned in an earlier post... it seems like once the pressure got much higher, I'd have a leak. Then I'd have an endless loop of leak leading to more pressure leading to more leak leading to more pressure.... and that's when I'd finally wake up and hit the reset button and make it start over with a lower pressure.

I can definitely adjust the max and see if this keeps happening.


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DeltaBravo3.8
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Wed Jul 15, 2020 2:37 pm
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If it is a leak rate issue, then I would say it's going to be necessary to find an answer besides a pressure limit. First is to be certain the mask is the right size. Then that it's adjusted properly to enhance comfort while minimizing leaks, which is not being tight enough to be painful. If low leaks and best comfort can't be found with the mask, it is likely either the wrong size or it's just wrong entirely for you. And to make it worse, there's the mask categories to consider, from nasal pillows, nasal, full face, and hybrid that's somewhat like nasal pillows grafted onto the bottom 2/3 of a full face.

Or we can try full headed mask! just kidding...

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jillkam
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Wed Jul 15, 2020 2:45 pm

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Ha ha, thanks DB!

My current mask was ok last night with lots of time at 12.5. I can see what happens as we raise the max pressure. It's possible that last year when I was figuring this out, I was in a different mask anyway. I have 3 others here and can certainly try others.

Do you mind peeking at my leak numbers from last night and see what you think? I'm not sure how to read these... I just notice that the leak graph and the pressure graph do move up and down together. I'm not sure what Oscar means by the stuff on the left under Total Leaks. What is a Max Total Leak? A Min Total Leak?


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DeltaBravo3.8
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Wed Jul 15, 2020 3:23 pm
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If you've posted OSCAR charts, it's fairly easy to decipher the leak rate. Someone will likely answer before I get back to the PC later on this eve and likely with better answers.
So yeah post it and we'll take a stab at the data. Respironics lists what I call expected and then one that's overall. I typically look briefly at the chart and see what large leak number shows on the left data FWIW.

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