Can't get AHI below 38

[Pugsy]

Would further reduction in AFlex stand much chance of helping stabilize things?
It had been at 2 and changed it to 1 the other night.
My gut says it probably wouldn't make much difference since Flex is flow based and already causing the machine to be confused.

[Morbius]

From the 7th. Leaks don't appear to help:

[Morbius]

Would further reduction in AFlex stand much chance of helping stabilize things?
It had been at 2 and changed it to 1 the other night.
My gut says it probably wouldn't make much difference since Flex is flow based and already causing the machine to be confused.

Yeah, EPR is more of a culprit in that instance, but hey, can't hurt.

[Morbius]

Don't forget to tell the doc that CSA and APAP don't mix!

[Morbius]

So you got what you're going to say tomorrow all set?

"I was finally able to get a download of my machine after a year, and look what I found! He's been having Cheyne Stokes Respiration for a year! Why are they using APAP? Would ASV be safe for him? Is it ever going to rain in California?"

[kaiasgram]

So you got what you're going to say tomorrow all set?

"I was finally able to get a download of my machine after a year, and look what I found! He's been having Cheyne Stokes Respiration for a year! Why are they using APAP? Would ASV be safe for him? Is it ever going to rain in California?"

Yep. Short and sweet. It's the docs who need to do all the splainin' and not clearyt -- she just needs to ask the right questions.

[clearyt]

Thanks to you great folks at cpaptalk I have some idea of what I need to say to get the ball rolling. I've copy/pasted comments onto a page that I will review to try to have the names of things straight. I hope the doc will take it and go with it. Morbius, does any of the info this evening matter in terms of my visit tomorrow. I'm quite lost on that new info.
Thanks once again to all of you who have taken your time to help!!

[Pugsy]

No, this recent discussion doesn't really change anything that you need to talk to the doctor about tomorrow.
I was speculating about the role that Flex might be playing...remember I talked briefly about it the other night when we changed AFlex from 2 to 1 and I originally wanted to turn it off but you were locked out of that choice.

Changing Flex would be a very minor change that I was comfortable with suggesting in this situation.
Changing anything else at this time wasn't something I was comfortable suggesting. When situations are complicated like we have here AND there is an opportunity to see a doctor and get the ball rolling on that end, I prefer to let the professionals earn their big bucks.

APAP mode and CSR don't play nice together and if the doctor appointment was way far off then maybe look at using an extremely tight apap range or just do a fixed pressure but with the doctor appointment so soon I really hesitate to start playing around with the settings other than the very minor Flex setting.

When we have complicated cases here we often toss about ideas and thoughts for educational purposes.

So your script tomorrow is unchanged...you might also include the new reports I sent you today that have last night's results on them and make sure that you document that those results are with the FitLife mask...I think the mask did help the unstable breathing to some extent and that could be important to know later.
That's one leaky mask though. I tried it just for fun once and I couldn't get it to stay sealed for 15 seconds...the fact he got it to work for a good chunk of the night is something to be really proud of.

[Morbius]

Changing anything else at this time wasn't something I was comfortable suggesting.

I mean, it is so tempting to say "Y'know, things look good at 5.0 cmH2O, let's try that, or even better, why use CPAP at all?"

But you still have that AHI 53 from the HST, and you don't know where that came from. Is that all/mostly central too? Is he now better (CSR should be looked at as a symptom - treat the underlying cause and it disappears. So maybe he is better and there isn't any underlying CSR anymore, and APAP just exposes reaction to insult). Was the HST a bunch of hypopneas? Were there bad desats? Is there positional stuff?

[Pugsy]

But you still have that AHI 53 from the HST, and you don't know where that came from. Is that all/mostly central too? Is he now better (CSR should be looked at as a symptom - treat the underlying cause and it disappears. So maybe he is better and there isn't any underlying CSR anymore, and APAP just exposes reaction to insult). Was the HST a bunch of hypopneas? Were there bad desats? Is there positional stuff?

I hear you loud and clear and all those unknowns was why I didn't feel comfortable suggesting anything other than AFlex change.
In fact my first words to OP the other night when we chatted were "you need to have a doctor who knows about this stuff evaluate the situation and if the pulmo thinks that this is okay then you need to find a different doctor" and this was before I ever saw the wave form graphs. Once I got the SD card contents and saw the wave form I knew that no way would I want to go down the dialawingin road here with this patient. Too scary and not in the patient's best interest at all because there was so much that we didn't know...like the stuff you mentioned.

I really hope that those people who jumped on the "let's increase the minimum pressure" bandwagon before they even saw a report will pause and think the next time this sort of thing happens with someone posting here for help. I know that is the knee jerk reaction when AHI is high using APAP starting at a low range and probably in most situations it would be indicated but it's better to wait and see the data (since it was available easily) before climbing on that bandwagon.

[OkyDoky]

I thought it was interesting that the doctor recently increased the pressure. "The pressure was 5-15, but recently upped the max to 18." You could tell by looking at the graphs or even the summary that the pressure wasn't going to the max. I wasn't aware of NRAH until Moribus answered my question but it looks to be a protective algorithm especially in this case.

[Pugsy]

I thought it was interesting that the doctor recently increased the pressure. "The pressure was 5-15, but recently upped the max to 18." You could tell by looking at the graphs or even the summary that the pressure wasn't going to the max. I wasn't aware of NRAH until Moribus answered my question but it looks to be a protective algorithm especially in this case.

It does make me wonder what the doc was looking at (if he was looking) when he would take the SD card and generate the reports. I am still scratching my head over that one. This isn't rocket science and I would think anyone with half a brain would understand that increasing the max wouldn't do a thing if the machine never went close to the previous max in the first place.

At any rate the ball is at least rolling in another direction with the cardiologist at this time and we will see what comes from that visit.
I probably won't be around Friday through Monday (taking the grandson back to Las Vegas and if we go to the mountains there's no internet) and OP is aware that if I don't respond it isn't because I abandoned her.

I don't expect a miracle fix from today's visit...what I do hope/expect is at least "let's get this figured out" and at least some sort of starting point effort. It's a complicated situation and there's a lot to be considered here in terms of what to do.

[OSAHell]

Hi clearyt,

How did your appointment with your cardiologist go?

I didn't add more comment because Morbius explained (a lot better) some of my thought.

PS Thanks Morbius for the "CSA salvo" link, it was pretty good and well explained infos for my personal case.

[clearyt]

Hi all. The visit to the cardiologist resulted in, "You need to get with the pulmonologist and show him these records". So that's what we will do. Thanks to you all, I feel comfortable showing him and explaining what I think we need to do (visit a board certified sleep doctor) to sort out all of this and to get to the bottom of the problem. Here is something interesting. Began using a really full face mask (FitLife) last week, about Tuesday, and the AHI has been in the teens. Any ideas on that? When Pugsy gets back I'll send the records to see if anything is really better. I know that this is complicated, and I don't really think the pulmo has a real handle on it. The cardio did agree that this can be very dangerous if not treated correctly.

[Morbius]

Here is something interesting. Began using a really full face mask (FitLife) last week, about Tuesday, and the AHI has been in the teens. Any ideas on that?

FitLife has a ton of deadspace:

Deadspace Volume

• Small 375 mL
• Large 550 mL

Amara View:

Deadspace

• Small 150.4 mL
• Medium 148.8 mL
• Large 167.8 mL