different equipment?

[zonker]

hello, all.

haven't been here in a very long time. several months ago, i asked if keeping my ahi under 5 was the best i could hope for. i was sleeping tolerably well, with occasional wake ups throughout the night. and i mention that higher pressure caused too much gas which led me to very light sleeping.

pugsy suggested that i raise my epr. d'oh! not something i'd thought of because i had used that feature when i was brand new to cpap and not only did i not find it helpful, it seemed to cause even more wake ups. but i decided to give it a try.

it worked. i could actually raise my pressure to the point where i am now, at 11 for lower pressure and 14 for the higher pressure. the result was my ahi came down from 4-5 to more in the 1-2 range.

alas, it didn't stay that way. the ahi started to creep up until now i'm back in the 4-5 range. and turning the bottom pressure up past 11 will result in gas.

so, what i'm wondering at this point is, would a change in equipment help me to lower the ahi? would changing to a different type of mask improve the ahi? would changing to either asv or bi level help?

it's not that i'm not sleeping well. and i'm certainly being treated during my sleep.

still, i want to get the best results that i can.

thanks!

[Pugsy]

What is that higher than you want AHI composed of? How much in each event category?

Have you considered adding soft cervical collar?

Are you unhappy with the way you feel or just the numbers? Meaning do you think you need to feel better or is it that you just want better "numbers"?

I am assuming the increase in AHI is from and increase in obstructive in nature events....Obstructive Apneas and hyponeas. The way to reduce those is more pressure and your only real option due to the belly situation is maybe a 1 cm drop in EPR to bring your exhale pressure up just a little and hope it holds the airway open better and doesn't make the aerophagia issues worse in the process.

If the increase in AHI is Central/Clear Airway apnea events...you have to ignore them because we can't fix them (assuming they are real) with more pressure.

Changing masks is unlikely to help.

Going to a different machine...like a regular bilevel machine where you could maybe expand your pressures making use of PS greater than the 3 you get with EPR...might work. It's usually the first thought of thing to try when someone has serious aerophagia issues.

ASV.....it's a bilevel but some special capabilities and it might offer some help because it goes up faster and back down faster and thus less chance of spending as much time at the higher pressures which mess with the belly. It's a pretty expensive experiment though and it's doubtful that insurance would help you out with it.
Now a regular bilevel...yeah, insurance would likely help if you can get the doctor on board saying you need more pressure but more pressure causes significant belly issues.

Or you could do like me...buy whatever machine you want if you can find one in a price range you and afford.

I use an ASV and I use it mainly because it's more rapid response means that I can use lower pressures for the bulk of the night and when I need more it goes up quickly and comes down quickly.
Responds much faster than apap or auto bipap...and I start the night at about 4 cm lower than I would start with if using apap or auto bipap.

So...what is your primary goal? How important is it to have "better" numbers even if you are sleeping great and feeling decent and it's only the "numbers" thing that bugs you.
Or do you feel like something could still be improved upon in terms of how you feel regardless of the numbers?

And do you have funds available to go the DIY route and pay for something yourself if that's what you end up having to do?

[zonker]

pugsy! i am so happy that your eyes fell upon my post. i'm sure that with your help, i'll get to the bottom of this.

so, let's get started-

you-"What is that higher than you want AHI composed of? How much in each event category?"

most recent ahi is 4.31 and consists of-
csr 12 events
ca 3 events
fl 3 events
h 5 events
o 30 events

ahi 3.47 consists of
csr 12
ca 4
fl 2
h 10
o 18

ahi 4.35 consists of
csr 14
ca 7
fl 7
h 10
o 21

ahi 3.84 consists of
csr 4
ca 5
fl 7
h 4
o 25

mind you, these are not 4 nights in a row. my ahi CAN and does get lower.

you-"Have you considered adding soft cervical collar?"

done and dusted as our british friends would say. i currently sleep with a cervical collar, a ruby chinstrap and our friend jay's trick of using the soft hairband across the mouth. the only thing i add to that is a small gauze pad against the lips to catch any drool.

you-"Are you unhappy with the way you feel or just the numbers? Meaning do you think you need to feel better or is it that you just want better "numbers"?"

ha! you get right to the meat of the matter there. it's an important question that you and others often ask. at first, i was just chasing zero. but i really do feel better if i'm in the 1-2 range. and i must admit, it makes me a little nervous that that ahi number is rising.

you-"I am assuming the increase in AHI is from and increase in obstructive in nature events....Obstructive Apneas and hyponeas. "
that certainly seems to be the case. looking at all my sleepyhead charts, obstructive rears it's head when the ahi is about 3 or more. i know i'm stating that backwards. i'm hoping you know what i mean.

you-"The way to reduce those is more pressure and your only real option due to the belly situation is maybe a 1 cm drop in EPR to bring your exhale pressure up just a little and hope it holds the airway open better and doesn't make the aerophagia issues worse in the process."

hold on! i want to make sure i understand you correctly. my epr is currently set at a max of 3. are you suggesting i lower that to 2?

you-"If the increase in AHI is Central/Clear Airway apnea events...you have to ignore them because we can't fix them (assuming they are real) with more pressure. "

fortunately, that doesn't seem to be the case, so at least i've got that going for me!

<SNIP!> cut a lot of your text out so i can get to this-

you-"So...what is your primary goal? How important is it to have "better" numbers even if you are sleeping great and feeling decent and it's only the "numbers" thing that bugs you.
Or do you feel like something could still be improved upon in terms of how you feel regardless of the numbers?

And do you have funds available to go the DIY route and pay for something yourself if that's what you end up having to do?"

i'm in a good place financially, thank goodness. i can afford to buy what may be best for me. HOWEVER, as a baby boomer, i was raised by a mother that was a child in the great depression. the value of a dollar is strong in me.

so i will ponder this carefully and investigate the price of an asv machine.

when all is said and done, i may just be satisfied where i am!

[Pugsy]

Where are you located?

hold on! i want to make sure i understand you correctly. my epr is currently set at a max of 3. are you suggesting i lower that to 2?

Yep. Lowering EPR a bit will effectively increase your baseline average pressure just a little and it might be enough to better reduce the obstructive stuff and still not cause too much of a problem with the belly.
If you lower EPR to 2 and keep everything else the same....it might work but if you can't handle just that tiny little overall average increase in the baseline then if it were me I would proceed with evaluation as to whether or not I wanted to move up to a bilevel machine or not.

Chasing 0.0 AHI...an unrealistic goal. Some of your AHI is clear airway/centrals and it's normal to have an occasional central (remember we can't fix centrals with your machine and you aren't having enough of the (even if they were all real) for doctors to get all that concerned about them especially since you aren't reporting sleeping horribly and feeling horribly. Some of those clear airway flagged events might be sleep stage transition centrals or what we call sleep onset centrals. These are normal and unless someone has so many of them that can't stay asleep or they create problems doctors won't usually want to do much. Also some of them might not be "real"...some might be awake/semi awake breathing getting flagged or maybe you turn over in bed and hold your breath and not realize it and the machine flags a central. They aren't real though and if they aren't real they have to be mentally removed from the evaluation process.

So attaining the elusive 0.0...might not happen simply because of an occasional normal central getting flagged or some awake/semi awake breathing events getting flagged. The machine doesn't know if you are awake or asleep. All it knows to measure is air flow and our awake/semi awake breathing is often very irregular and we don't realize it and it hurts nothing but the machine doesn't know that and you get a flag. If you look at your software reports and see some event flags in very close proximity to known awake times then there's a good chance those flagged events are what we call SWJ or Sleep/Wake/Junk.

Now if you can tell a difference in how you feel physically with an AHI less than 2.0 when compared to an AHI of 4.0 (with at least 75% of it being obstructive) then it might be worth trying to bring down that AHI a little as long as we don't create a bigger problem with the return of the aerophagia monster.

Besides....AHI of 0.0 doesn't guarantee you anything except a nice math score. It doesn't guarantee that you will feel great at all. A person can have a horrible nights sleep for any number of reasons and still have a nice low AHI but feel like total crap.
I speak from first hand experience. My AHI's are always really low but I have other issues that sometimes make it so I don't sleep so great and have lots of wake ups and the end result is my reports look spectacularly good with low AHI and I still feel like crap because I slept like crap.

Quit chasing numbers. It will drive you crazy and doesn't guarantee a thing.
Now if you want to see if reducing the obstructive stuff will help in how you feel...that's a good enough reason to try something else if you want to but don't do it just to be chasing numbers.

Can you get me one screen shot of one of those nights with the AHI a little over 4...like the 4.35 AHI?
The detailed report. I would like to see somethings and see if they correlate with some other things and it's just easier if I can see the report straight away.
Plus I would also like to see the CSR flagged stuff but I want you to zoom in and need to see the overall graphs to get an idea of which one to have you zoom in on.

Do you have any history of cardiac function issues at all?
Do you take any medications and if so, what?

I could maybe point you in the direction of a bilevel device...either the regular bilevel auto or the ASV bilevel that will likely be more attractive than online pricing. Get with me privately about that plus I can share more how I come to use ASV and why...and why you might also like it. I don't think you need it for centrals and the treatment for centrals is a big high rapid burst of pressure...so be glad of that but there are ways to make use of the fast response on the ASV to keep OSA treating pressures on the lower side and thus keep the aerophagia monster away. It would be overkill in terms of machine vs the OSA treatment but sometimes it doesn't hurt a thing to do the over kill...heck, I do it with mine.

But for now maybe try EPR at 2 and see what happens. Might get lucky and that's all you need to get the numbers back to where you want them to be and you feel better and the belly stays happy.

[zonker]

[quote="Pugsy"]Where are you located?

after 37 years in the seattle area, we moved to flagstaff az december 2016.


Yep. Lowering EPR a bit will effectively increase your baseline average pressure just a little and it might be enough to better reduce the obstructive stuff and still not cause too much of a problem with the belly.
If you lower EPR to 2 and keep everything else the same....it might work but if you can't handle just that tiny little overall average increase in the baseline then if it were me I would proceed with evaluation as to whether or not I wanted to move up to a bilevel machine or not.

thanks for the explanation. it didn't make sense to me. i figured i would have to go even higher on epr in order to have higher pressure. of course, if i'm at 3, that plainly wouldn't work!


Now if you can tell a difference in how you feel physically with an AHI less than 2.0 when compared to an AHI of 4.0 (with at least 75% of it being obstructive) then it might be worth trying to bring down that AHI a little as long as we don't create a bigger problem with the return of the aerophagia monster.

not chasing zero; chasing 1-2! does that make me less obsessive? what i did last night was set epr to 2 and bumped my bottom pressure from 11 to 11.5. no aerophagia but didn't sleep well. that could be from the crazy day i had though. will try again tonight.


Can you get me one screen shot of one of those nights with the AHI a little over 4...like the 4.35 AHI?

will TRY. it's been a long time since i've posted. let's see...


Do you have any history of cardiac function issues at all?
Do you take any medications and if so, what?

no and no.

hope the chart turns out to be posted correctly!

and as always, thanks....

[Pugsy]

Is there a possibility that you were awake from 7:20 to around 8 AM...give or take a few minutes either side?

Can you zoom in on something for me please?

Go to the events tab...then go to the CSR category...and click on it to open it up for all the CSR flagged events and there should be some times associated with them.
Look for a CSR cluster around 7:45...hard to say for sure from looking at this report but I would like to see a zoomed in section of CSR that includes other event flags at around the same time.
Click on one of the CSR flagged events that is sort of in the middle time wise of a little group of CSR flagged events and see if you can catch an OA or CA at the same zoom level.

When you click on the single event in that category the graphs will automatically zoom in and change to the scale I want to see.
Get me another screen shot just like this one but with those graphs zoomed in from clicking on the one event.

I am wondering if some of those flagged events are SWJ getting flagged by mistake. I can maybe have an idea if that's the case if I can see the zoomed in flow rate pattern.
If they are indeed awake events getting flagged (and you admit not a great night of sleep last night) then maybe the AHI isn't really as high as you think if we remove the SWJ (if you have SWJ flagged events).
If it wasn't for that 40 minutes after 7:20 your AHI would have been significantly lower.

[Doublev]

I have upgraded machines to where I have two 2 bipaps now... what improves my AHI and sleep is the mask. I agree in that I feel much better with an AHI below 1 than a 3 or 4. AHI seems to properly reflect how my sleep went...

But I can only do so much with a nasal or pillows... i do well with full face only. The point is the mask is important and in my opinion probably more important than the machine unless you have something very specific going on.

[zonker]

Is there a possibility that you were awake from 7:20 to around 8 AM...give or take a few minutes either side?

Can you zoom in on something for me please?

Go to the events tab...then go to the CSR category...and click on it to open it up for all the CSR flagged events and there should be some times associated with them.
Look for a CSR cluster around 7:45...hard to say for sure from looking at this report but I would like to see a zoomed in section of CSR that includes other event flags at around the same time.
Click on one of the CSR flagged events that is sort of in the middle time wise of a little group of CSR flagged events and see if you can catch an OA or CA at the same zoom level.

When you click on the single event in that category the graphs will automatically zoom in and change to the scale I want to see.
Get me another screen shot just like this one but with those graphs zoomed in from clicking on the one event.

I am wondering if some of those flagged events are SWJ getting flagged by mistake. I can maybe have an idea if that's the case if I can see the zoomed in flow rate pattern.
If they are indeed awake events getting flagged (and you admit not a great night of sleep last night) then maybe the AHI isn't really as high as you think if we remove the SWJ (if you have SWJ flagged events).
If it wasn't for that 40 minutes after 7:20 your AHI would have been significantly lower.

it's very likely that i was awake at that time. it's my sleep pattern that i can be awake between 7 and 8:15 or whenever i decide to give up and greet the day.

here's the additional info you requested-



please tell me if i haven't followed your instructions. i look forward to reading what you interpret!

[Pugsy]

Yes, thank you, you followed my instructions just fine.
Only caught the one OA in that segment.

I am not the best as analyzing flow rate at this level to come up with sleep or awake status unless it's so obvious a blind person could see it. I am leaning towards SWJ though.
See this thread along with the ones inside it.
viewtopic.php?f=1&t=114600&p=1110933#p1110933

What you might do to help sort out if you were actually asleep or not is just reach over and turn the machine off and back on again.
That way there is a small break in the therapy lines (pressure, flow rate, leak,etc) and we will know that it's very possible that the flagged stuff in close proximity to a known awake time stands a real good chance of being SWJ and can be ignored.

In the case of the normal hour or so right before you finally get up...maybe do it multiple times or each time you wake up enough to be clear headed enough to reach over and turn the machine off and back on again.
Do this in the middle of the night also.

Your CSR flagged breathing doesn't look like classic CSR that we start worrying about heart issues if we see it.
Your CSR looks more like some ordinary Periodic Breathing. CSR is just one of many forms of Periodic Breathing.
I don't think there is anything to be concerned with here but next time you see your doctor you might alert him about it and at least get his input.
While Cheyne Stokes Respiration can be a sign of heart issues (though yours doesn't look classic CSR) people can also have true CSR without any known reason why. Usually associated with centrals when it is particularly worrisome but not impossible to be associated with OA or hyponea right smack dab in the middle of the flagged green time. Yours doesn't do that either...no real events during your flagged CSR time of any significant number.

When I was using a machine that flagged Periodic Breathing/CSR I would often see some sort segments like yours when I was awake.
It's very possible that our awake breathing irregularities can mimic the irregularities of Periodic Breathing and thus the machine will flag it.

Classic CSR breathing example is shown in the manual. Page 8
https://sleep.tnet.com/home/files/resme ... -guide.pdf

Or on a SleepyHead report it looks like this

or this

[Jay Aitchsee]

Hi Zonker,

Good advice from Pugsy. It does look like you could use a little more pressure. Maybe lowering the EPR will help.

You wearing quite a bit of stuff to bed, mask, chin strap, hairband, neck collar, maybe this is a little disturbing, contributing to the SWJ periods. Maybe not.

I suggest you ditch the chin strap. In my experience, they do little to stop mouth breathing and you still have the hair band and collar which should slow the amount of mouth exhalation and keep your chin up and airway open. A big problem with chin straps is that they tend to pull the chin backwards which exacerbates the conditions leading to obstructive apnea, working exactly the opposite of mandibular devices designed to move the jaw forward to treat OA.

[Pugsy]

I would also ditch the chin strap.
Unless mouth breathing causes wake ups sometimes it's less sleep disturbing sometimes to just let a few mouth breathing leaks happen (and they don't always mean massive therapy pressure loss anyway).
My leak lines aren't real pretty what with an occasional mouth breathing or mask movement leak ...but I sleep through it all and for me to use something like a chin strap would actually cause more poor sleep quality than the leaks might be a problem.

Primary goal has to be good solid sleep as much as possible. Without good sleep it doesn't mean squat if our AHI is nice and low with even 0.0 and a perfectly flat leak line.
And the position that chin straps will force the jaw into could maybe be causing the need for more pressure and more pressure is a problem for you with the aerophagia monster looming on the side lines.

I have been down that road of trying various things to get a nice pretty leak line and I can do it but my sleep quality gets worsened when I do it and I end up feeling worse with the perfect leak line than I do with the not so perfect leak line.

[zonker]

Yes, thank you, you followed my instructions just fine.
Only caught the one OA in that segment.

I am not the best as analyzing flow rate at this level to come up with sleep or awake status unless it's so obvious a blind person could see it. I am leaning towards SWJ though.
See this thread along with the ones inside it.
viewtopic.php?f=1&t=114600&p=1110933#p1110933

What you might do to help sort out if you were actually asleep or not is just reach over and turn the machine off and back on again.
That way there is a small break in the therapy lines (pressure, flow rate, leak,etc) and we will know that it's very possible that the flagged stuff in close proximity to a known awake time stands a real good chance of being SWJ and can be ignored.

In the case of the normal hour or so right before you finally get up...maybe do it multiple times or each time you wake up enough to be clear headed enough to reach over and turn the machine off and back on again.
Do this in the middle of the night also.

Your CSR flagged breathing doesn't look like classic CSR that we start worrying about heart issues if we see it.
Your CSR looks more like some ordinary Periodic Breathing. CSR is just one of many forms of Periodic Breathing.
I don't think there is anything to be concerned with here but next time you see your doctor you might alert him about it and at least get his input.
While Cheyne Stokes Respiration can be a sign of heart issues (though yours doesn't look classic CSR) people can also have true CSR without any known reason why. Usually associated with centrals when it is particularly worrisome but not impossible to be associated with OA or hyponea right smack dab in the middle of the flagged green time. Yours doesn't do that either...no real events during your flagged CSR time of any significant number.

When I was using a machine that flagged Periodic Breathing/CSR I would often see some sort segments like yours when I was awake.
It's very possible that our awake breathing irregularities can mimic the irregularities of Periodic Breathing and thus the machine will flag it.

Classic CSR breathing example is shown in the manual. Page 8
https://sleep.tnet.com/home/files/resme ... -guide.pdf

Or on a SleepyHead report it looks like this

or this

well, without a doubt, you're better at analyzing flow rate data than *I* am! so i'm inclined to go with your "diagnosis". have ready many times in different posts your Sleep/Wake Junk theory. but i will focus in on what you've linked. maybe as it's something that is directed at me, i'll concentrate more on it.

i like the notion of turning off/on the machine to give us visual clues, too. will try to incorporate that into my routine tonight.

personally, the cheyne stokes breathing notations on the graph have never bothered me. so i'll continue to pay it no mind, unless told otherwise.

so, will press on. have already put epr (or a-flex) back to 3 and dropped pressure. slept better for it.

thanks!

[zonker]

Hi Zonker,

Good advice from Pugsy. It does look like you could use a little more pressure. Maybe lowering the EPR will help.

You wearing quite a bit of stuff to bed, mask, chin strap, hairband, neck collar, maybe this is a little disturbing, contributing to the SWJ periods. Maybe not.

I suggest you ditch the chin strap. In my experience, they do little to stop mouth breathing and you still have the hair band and collar which should slow the amount of mouth exhalation and keep your chin up and airway open. A big problem with chin straps is that they tend to pull the chin backwards which exacerbates the conditions leading to obstructive apnea, working exactly the opposite of mandibular devices designed to move the jaw forward to treat OA.

jay! how good to hear from you.

i typically get stuck into doing the same thing over and over and over again. i'm really a belt and suspenders type of guy. but if you feel that maybe the chin strap is doing more harm than good, then i'll ditch it tonight and see how that goes.

thanks for the suggestion.

[zonker]

so, last night, this happened-



jay-thanks for the suggestion! i don't know if my screenshot shows it, but i had NO obstructive apnea last night. will see tonight for sure, but it looks like ridding myself of the chinstrap directly impacted that. but-

i guess mild anxiety over whether going without the chinstrap would work caused me to sleep very lightly indeed. i'm hoping that my mind will begin to trust that i don't need it and will settle down.hope so, because i don't need those constant wake ups!

pugsy-because of the very nature of my sleep last night, i didn't turn off/on my machine last night. didn't think it would really show anything. i can try doing that routine again if you think it would help.

but i'm wondering if it would. i see that i have NO swj on this chart.