High Clear Airways during sleep

[Jay Aitchsee]

I'd be more inclined to try ~9.6 or 10 as an experiment

Hi Sirc, here's my thinking: Jim's AHI now is comprised mostly of CA. Increasing the pressure will not prevent them and, in fact, may make them worse. His AHI net of CA is quite satisfactory. He had no hypopneas and the few OA's he had (4) could have been caused by arousals and breath holding, so I see no reason to increase the pressure unless we start to see OA and hypopneas creep in. I think his CA's are being caused by disturbances, most likely the leaks, but it could simply be the pressure as well. Maybe, after a couple days, we'll have a better idea.
Generally speaking, and within reason, I think the lower the pressure the better, assuming OA's and hypopneas are controlled. A lower pressure is more comfortable, not as likely to cause leaks and not as likely to cause CA's.
EPR has the net effect of lowering the pressure, theoretically, it provides exhale relief, but, if the pressure is reduced too far by EPR, it could allow OA's to occur prior to inhale. So, if the pressure is reduced to provide comfort, prevent leaks or reduce CA's, one may have to reduce or eliminate EPR to prevent OA's and/or Hypopneas. (I think Palerider did a bit on this a while back. Maybe he'll give us a link.)
Anyway, they goal is to obtain restful, restorative, sleep with a low AHI (less than 5), but not necessarily an AHI of 0.0. Sometimes, a little AHI has to be traded for rest.

[jimnlacy]

Good to see the 9 working out for you and like you say, leaving it for a few days gives you a better idea of how you'll adjust to this setting. I don't think you can go lower than 9 but that is only because the auto migrated to 9 in short order and looked like it wanted to stay up there. I'd be more inclined to try ~9.6 or 10 as an experiment (down the road somewhere). I'm used to my 11cm pressure and don't find it uncomfortable, get to sleep in short order. Try Jay's advice first tho as he has much more experience . I wound down my EPR from 3 level and slowly to 'off'. Wish I had kept better notes, i'm experimenting with level 2 again and getting good results but it's only been 2 nights.

Experiment lots and keep notes, you'll be glad you did if your planning on optimizing. Enjoying your ongoing results, as I too learn from your experience, this is like a small hobby for me.

... g'luck Sirc

Sirc,

Thanks. Keeping notes on my daily charts.

Jim

[Sircadian]

Hi Sirc, here's my thinking: Jim's AHI now is comprised mostly of CA. Increasing the pressure will not prevent them and, in fact, may make them worse..

Hi Jay, agree with all, especially about the CA's, in fact many are only at the 'going to sleep' and 'wakening' period (for his second report and in the second section of that night). Don't know if it's correct but think I've read that those can be ignored, for the most part. Like your idea about the EPR testing, in fact, like the idea of all testing. I'd use the lower pressure for the solid reasons you mentioned. I still would want to test the high end at some future date just to see where my limits fall, and exactly when the higher pressure gets totally ineffective. Comfort, as you mentioned, is important but comfort can be attained by many at higher pressures.

Pressure wanted to climb to the upper limit in the first image, looked like it was trying to get the airway open and was limited. Still curious, like to see where that pressure would have gone, in the first image, with the Autoset mode opened up a bit. I'm another one of those guys that has to take everything apart, that may explain it best

[jimnlacy]

I'd be more inclined to try ~9.6 or 10 as an experiment

Hi Sirc, here's my thinking: Jim's AHI now is comprised mostly of CA. Increasing the pressure will not prevent them and, in fact, may make them worse. His AHI net of CA is quite satisfactory. He had no hypopneas and the few OA's he had (4) could have been caused by arousals and breath holding, so I see no reason to increase the pressure unless we start to see OA and hypopneas creep in. I think his CA's are being caused by disturbances, most likely the leaks, but it could simply be the pressure as well. Maybe, after a couple days, we'll have a better idea.
Generally speaking, and within reason, I think the lower the pressure the better, assuming OA's and hypopneas are controlled. A lower pressure is more comfortable, not as likely to cause leaks and not as likely to cause CA's.
EPR has the net effect of lowering the pressure, theoretically, it provides exhale relief, but, if the pressure is reduced too far by EPR, it could allow OA's to occur prior to inhale. So, if the pressure is reduced to provide comfort, prevent leaks or reduce CA's, one may have to reduce or eliminate EPR to prevent OA's and/or Hypopneas. (I think Palerider did a bit on this a while back. Maybe he'll give us a link.)
Anyway, they goal is to obtain restful, restorative, sleep with a low AHI (less than 5), but not necessarily an AHI of 0.0. Sometimes, a little AHI has to be traded for rest.

Hey Jay,

This is some great stuff. Being new to this everything is something to take in for consideration.

Thanks,

Jim

[coolbranch]

This thread is as "heady" as I have stumbled across. This is real help to us all. Sincere thanks!

[palerider]

So, if the pressure is reduced to provide comfort, prevent leaks or reduce CA's, one may have to reduce or eliminate EPR to prevent OA's and/or Hypopneas. (I think Palerider did a bit on this a while back. Maybe he'll give us a link.)

probably just another of my vague rants *lol* I do have something that *shows* the issue thanks to my new toy.

EPR reduces pressure when you're not inhaling, so if you tend to have apneas at, for example. 9cm or below, and you have your pressure at 10, and crank in 1, or 2 epr, your pressure, except when inhaling, is 9, or 8... and that could let your airway close, and then you can't inhale to get EPR to raise the pressure back up. visually:
this example starts out with pressure of 13, then adds epr 3.

[Jay Aitchsee]

So, if the pressure is reduced to provide comfort, prevent leaks or reduce CA's, one may have to reduce or eliminate EPR to prevent OA's and/or Hypopneas. (I think Palerider did a bit on this a while back. Maybe he'll give us a link.)

probably just another of my vague rants *lol* I do have something that *shows* the issue thanks to my new toy.

EPR reduces pressure when you're not inhaling, so if you tend to have apneas at, for example. 9cm or below, and you have your pressure at 10, and crank in 1, or 2 epr, your pressure, except when inhaling, is 9, or 8... and that could let your airway close, and then you can't inhale to get EPR to raise the pressure back up. visually:
this example starts out with pressure of 13, then adds epr 3.

Thanks for that, PR. At least ResMed provides a fail-safe if you stop breathing for more than 10 seconds. I can just hear the engineers saying, "Oh, shit!" when they figured that out.

To ensure comfort without compromising therapy, EPR has an automatic 'time out' feature. The device determines the baseline breathing average. If a patient's breathing drops 75% below the baseline for 10 seconds or more, pressure relief is suspended. After the event is over, EPR will start again.

[palerider]

Thanks for that, PR. At least ResMed provides a fail-safe if you stop breathing for more than 10 seconds. I can just hear the engineers saying, "Oh, shit!" when they figured that out.

To ensure comfort without compromising therapy, EPR has an automatic 'time out' feature. The device determines the baseline breathing average. If a patient's breathing drops 75% below the baseline for 10 seconds or more, pressure relief is suspended. After the event is over, EPR will start again.

I'll have to try it on a different machine.... as you can see in the above trace, the pressure DIDN'T come back up.

[Jay Aitchsee]

Thanks for that, PR. At least ResMed provides a fail-safe if you stop breathing for more than 10 seconds. I can just hear the engineers saying, "Oh, shit!" when they figured that out.

To ensure comfort without compromising therapy, EPR has an automatic 'time out' feature. The device determines the baseline breathing average. If a patient's breathing drops 75% below the baseline for 10 seconds or more, pressure relief is suspended. After the event is over, EPR will start again.

I'll have to try it on a different machine.... as you can see in the above trace, the pressure DIDN'T come back up.

Well, it's possible the algorithm has changed or it's different for VPAP machines, the quote above came from material that applied to the S8 II line of about 5 years ago describing ResMed's Easy-Breathe EPR. I really didn't look for anything newer.
I think the point remains though, as your graphic points out, that EPR could reduce pressure low enough to allow airway collapse which could possibly result in an arousal to correct - fail-safe or no.

[palerider]

I'll have to try it on a different machine.... as you can see in the above trace, the pressure DIDN'T come back up.

Well, it's possible the algorithm has changed or it's different for VPAP machines, the quote above came from material that applied to the S8 II line of about 5 years ago describing ResMed's Easy-Breathe EPR. I really didn't look for anything newer.
I think the point remains though, as your graphic points out, that EPR could reduce pressure low enough to allow airway collapse which could possibly result in an arousal to correct - fail-safe or no.

it also could be that I had the machine set to cpap mode, not one of the vpap modes. more experimentation is required

but, yes, it does show the effect of EPR on mask pressure, and how it's really not exhale pressure relief exactly, because if it were, it'd raise the pressure back up after the exhale ended, instead of when an inhale started.

[jimnlacy]

Hi All,

Here's my data from Sat and Sun.

Sat:


Sun:


The results are better looking. Sunday night was not as restful as Saturday. I worked 10 1/2 hours Sunday on a project with a deadline and I think the subconscious stress leaked into my sleep.

Also on Sunday I woke a few times feeling air starved. Perhaps I need to tweak the pressure up a tad.

Thoughts?

Jim

[Pugsy]

Can you try the next size up in the nasal pillows to see if it helps with the "air starved" feeling?

Also you might play with EPR and see if that helps.

[Jay Aitchsee]

Jim, I still think most, if not all, of your events are caused by disturbances linked either to the pressure or leaks or both. Saturday looks pretty good. Nearly all the events are CA with a cluster of CA in the early morning. This is not uncommon as we are sleeping lightly, drifting in and out of sleep in the early hours. This is often referred to as Sleep Wake Junk (SWJ) and would not be counted in a lab study. Other events on Saturday seem to be aligned with leaks, again making me think they are a result of disturbances caused by your leaks (which appear to be mouth breathing).

Increasing the pressure would not have fixed these CA's. Otherwise, your Flow limitations, OA and Hypopnoeas look good. Once again, increasing the pressure will help with FL, OA, Hypopneas, but not CA. Increasing the pressure could increase your CA's. The Goal of CPAP is to prevent Obstructive events without inducing Central events. See page 7, Titration Protocol.

Sunday has more events, could be stress related, but look at the leak line. Again, it looks like mouth breathing and most events occur during those periods - could be the reason you feel air starved. Still on Sunday, Flow limitations are reasonable with a couple OA's and Hypopneas. Again, most of the events are CA and increasing the pressure will not help. I suggest lowering the pressure to 8.6 and reducing EPR to 1 or off.

Even though your leaks are not "bad" in terms of liters per min - generally less than the "red line" of 24 L/min - I suggest you think about working on them, choices might include different pillow size, tape, chin strap, or full face mask. But, before doing anything drastic there, I think a trial at a lower pressure is in order.
J
(I see Pugsy has suggested a different pillow size. If you have them, that could be an easy try and leaks around the pillows could account for your disturbances and leak line )

[jimnlacy]

Can you try the next size up in the nasal pillows to see if it helps with the "air starved" feeling?

Also you might play with EPR and see if that helps.

Hi Pugsy,

I will see how the larger size feels. And I plan to adjust the EPR.

Jim

[jimnlacy]

Jim, I still think most, if not all, of your events are caused by disturbances linked either to the pressure or leaks or both. Saturday looks pretty good. Nearly all the events are CA with a cluster of CA in the early morning. This is not uncommon as we are sleeping lightly, drifting in and out of sleep in the early hours. This is often referred to as Sleep Wake Junk (SWJ) and would not be counted in a lab study. Other events on Saturday seem to be aligned with leaks, again making me think they are a result of disturbances caused by your leaks (which appear to be mouth breathing).

Increasing the pressure would not have fixed these CA's. Otherwise, your Flow limitations, OA and Hypopnoeas look good. Once again, increasing the pressure will help with FL, OA, Hypopneas, but not CA. Increasing the pressure could increase your CA's. The Goal of CPAP is to prevent Obstructive events without inducing Central events. See page 7, Titration Protocol.

Sunday has more events, could be stress related, but look at the leak line. Again, it looks like mouth breathing and most events occur during those periods - could be the reason you feel air starved. Still on Sunday, Flow limitations are reasonable with a couple OA's and Hypopneas. Again, most of the events are CA and increasing the pressure will not help. I suggest lowering the pressure to 8.6 and reducing EPR to 1 or off.

Even though your leaks are not "bad" in terms of liters per min - generally less than the "red line" of 24 L/min - I suggest you think about working on them, choices might include different pillow size, tape, chin strap, or full face mask. But, before doing anything drastic there, I think a trial at a lower pressure is in order.
J
(I see Pugsy has suggested a different pillow size. If you have them, that could be an easy try and leaks around the pillows could account for your disturbances and leak line )

Hi Jay,

I will make the adjustments to the pressure and EPR. I will also try out a larger size pillow per Pugsy's suggestion.

Thanks,

Jim