what is the significance of respiratory rate

Goofproof wrote:As far as Respiratory Rate, Doctors seem to be for it, but Morticians are against it. Jim

rick blaine wrote:"The one time he tried auto ... " With the EPR switched on? And set to 3?

Am I the only one who sees the problem? EPR and its Respironics counterpart, A-Flex, are algorithms, which - as I understand it - take their cues from the beginning of the slight change in breathing which heralds expiration.

So what will the algorithms do when they 'see' the saw-tooth pattern?

It'd be easy to tell on the resmed side by zooming in on the mask pressure trace.

Normally the machine does nothing. It doesn't do a pressure change and why the rise in min pressure or fixed pressure helps,

ajack wrote:Normally the machine does nothing. It doesn't do a pressure change and why the rise in min pressure or fixed pressure helps,

Not following. I am pretty sure that even in Australia sentence don't end in commas.

Wrong button and I was going to finish with.... on the auto it was still messy.

It doesn't sound like this, but it's worth looking at. Just check the air out of the hose, make sure there is enough flow

ajack wrote:Normally the machine does nothing. It doesn't do a pressure change and why the rise in min pressure or fixed pressure helps,

You're not making much sense lately... You might want to start reviewing your posts the next morning, and see if they make sense to you then.. or get someone to help.

Rick, I understand your concern about EPR. I think, in this case, it would be better to not use it, too, just to remove one of the variables. However, in the example posted from 10/17, EPR was off and the Flow Rate waveform was still "messy" leading to an erroneous, in my opinion, RR count.

Ajack, I agree Steve's "messy" results look as though a they could be influenced by a physical problem such as a leaking hose, mask, anti-asphyxiation valve, etc, and should definitely be checked as well as the machine itself. I think it likely, though, the physical problem is Steve's anatomy and method of breathing. If he is a dedicated mouth breather, perhaps a hybrid or oral only mask would help.

Somebody needs to be "hands on" with Steve. He hasn't adapted to the therapy for whatever reason and he doesn't appear to want to engage directly with the forum. His latest results (that we have) are from last October. If he wants help, I think he should return to his doctor for a proper polysomnogram which should resolve any question regarding abnormal breathing. Keep in mind, ResMed didn't intend for ventilation variables such as Respiration Rate, Inspiration Time, Expiration Time, I:E, etc. to be analyzed via ResScan from non-ventilation machines such as CPAP and Steve's Autoset. The only such variable supplied via ResScan for non ventilators is Minute Ventilation (and we haven't looked at Steve's). Since ResMed doesn't intend these variables to be analyzed through its proprietary software, ResScan, I wonder, sometimes, about the presentation and validity via SleepyHead.

I spoke with Steve briefly today. He has tried two FFM. Takes them off after a few hours. Says he feels like he has been running; not sure if it is panting or heart racing. If the small cycles reflect the heart rate then it looks like his heart is racing (150-200 BPM). He has been trying for 1-2 years. He will look for his reports so hopefully I can get some better information. He has had two titrations. The second titration concluded a very low pressure was needed. He said he could not breath so they turned it up to ~9. He doesn't remember the specifics so hopefully he will find his reports. His last appointment was in last Fall and he complained about the panting and showed his sleepyhead charts and the doctor said he doesn't believe the data and has never heard of the software. Since his AHI is good, he is fine. Steve lost all confidence and stopped over at the sleep clinic (attached to the office) to see if he could get a detailed report of his last titration and was told that they don't record breathing rate. At my request, he turned EPR off which didn't help so he quit.

He asked me if I know of a better doctor but mine is no better.
Another friend's (Andy) doctor has been telling him for 1.5 year that his AHI ~9 is good since it is under 10. I have been helping him raise his minimum pressure on his autopap up from 6. At 15 his 1 week average AHI is 2.6 and feeling much better. He is now trying 16 which I think is close to where he needs to be.

So another question I have is how to find a truly competent sleep doctor and clinic? When I was dealing with A-Fib, I was able to find forums that tract true experts.
Thanks for everyone's help.

Here is a zoomed look at IPAP of 12 and EPAP of 11. This is just before he rips the mask off.
Looking at this data makes me think he is struggling with moving air.
Maybe his messy flow curves is also caused by struggling to move air.
Until he can find a better doctor, I am going to encourage him to try again but at much higher pressure and PRS=0. Makes sense?

TedVPAP wrote:Here is a zoomed look at IPAP of 12 and EPAP of 11. This is just before he rips the mask off.Looking at this data makes me think he is struggling with moving air. Maybe his messy flow curves is also caused by struggling to move air.Until he can find a better doctor, I am going to encourage him to try again but at much higher pressure and PRS=0. Makes sense?

Worth a try on the pressure.

Just a couple of things. You have the Y scale set pretty wide at +-180. Some of the Flow Rate Swings are greater than +-60. Now, I don't know what is normal, but my wake Flow Rate swings are sometimes around 60 while my asleep Flow Rate amplitudes are usually around 30 or less. How about setting the scale @ +- 80 and see how things look.

See the flat line around 22:02:27. Trying to imitate that, it seems it could be a paused inhale followed by breath holding and then a sigh. Which could be typical of awake breathing. That set is followed by another and then a transition to what looks like more normal asleep breathing.

Steve has a constant leak. Not huge, around 5, but increasing with some breaths as we can see in the above example. This could be influencing the shape of the Flow Wave somewhat, but I continue to believe the abnormal look of the Flow Wave is caused primarily by mouth breathing. Has Steve ever experienced his chin falling from the mask, uncovering his lower lip?

Has Steve worn a pulse oximeter or heart monitor overnight? I thought his heart rate looked more like 60 than 150-200, but, in any case, it should be checked.

Good luck on a doctor. In my experience, it's been trial and error. Is he seeing a pulmonologist now?

That could be just a bad 30 sec. If it went on for a while would be a concern. Do you have a recording o2 meter you could lend him, if it did?

I would raise the min up to the 95% number and see if it helps. woops, he's of fixed, if the reducing the pressure made the apnea worse (means that he's not over titrated with pressure) then I would increase the pressure to see if the breath sorts out. Going by the charts you have put up, I think they are real and the machine isn't miscounting.

I'm more concerned with the rapid breath. It has to be wearing him out, waking up more tired than when he went to bed. what's his insurance like? I think it's time for at least a sleep doctor and a titration if he doesn't have to sell his house to get it.

I thought you might find this interesting: These are various examples of mouth breathing. I was trying to mimic Steve's but I couldn't quite do it. They are not definitive as they were done quickly without much control. All are FFM except the next to the last which is a nasal pillow mask.
The top is open mouth breathing - note the cardio artifacts and maybe a sharper inhale peak, but the time line scale is a little different from the others.
The second is nasal inhale mouth exhale FFM, looks pretty normal.
The third is FFM with a leak introduced on exhale.
The fourth is Nasal pillow, nasal inhale, mouth exhale. Note the rapid return to flat on exhale.
The bottom is FFM with asphyxiation vent covered mouth open and closed.
Again, these are not definitive because some different types of breathing are intermingled. It needs to be done again with more control, but I haven't the time right now. Also, I noticed my FFM kept my lips fairly closed so that mouth exhales weren't as rapid as they might have been with a different mask and they were all done with an EPR of 3. BTW, compare Steve's to emree's viewtopic/p1219649/Can-someone-help-me- ... l#p1219470


Of the above, I would say Steve's (below) most closely resembles the 4th example above, A nasal mask with mouth exhale.



Of note in the above statistics is that Steve's Tidal Volume at 280 is only about 3/5ths of normal (~500). Since I question the RR, I also question this statistic, but it does go along with the theory he is not getting enough air. However, using the med RR of 32.6 from the above, his Minute Ventilation would be "normal" at 9.1L/m (280ml/b*32.6bpm).

Thanks Jay for taking the time to produce the various waveform. It is interesting. Steve has only used a FFM as nasal breathing is extremely limited.

I spoke with Steve today and examined his sleep study results which was helpful. There are only letters, not the detailed data.

In-lab diagnosis was on 3/2015 concluding AHI=12.1, arousal index=64.2.

Titration on 4/2015 concluded: "IMPRESSION: Obstructive sleep apnea syndrome, significantly improved with the application of CPAP, titration on room air to a pressure of 16-cm of water resulting in sleep consolidation, decrease in apnea-hypopnea index with elimination of obstructive events, recruitment of REM sleep, resolution of hypoxemia, and near-ablation of snoring. RECOMMENDATION: CPAP should be administered nightly on room air a pressure of 16-cm of water with a ramp ......"

Re-Titration on 3/2016 concluded "IMPRESSION: Obstructive sleep apnea with a nasal CPAP re-titration. Possible periodic limb movement disorder, clinical correlation suggested. RECOMMENDATION: The patient should begin a trial of nasal CPAP at 6-cm of water pressure with a ramping device and humidification"

I don't know why he was re-titrated and since the machine data has been over written, I can't look at the old data using sleepyhead. The data I have seen has all been since the re-titration. IMHO, the re-titration appears to be worse than worthless. He told me that he could not breath at 6 so they increased it to 9 which is what the sleepyhead data shows.

He is going to try again (last try was 10/2017) using pressure closer to 16 so hopefully we will see the results via sleepyhead.

Thanks to all for the help.

Yes, let's see what happens. Getting Steve's concurrent impression of what is happening might be useful.
The pillow example above represents a mouth leak on exhale which could happen with a FFM if the chin has dropped out of the mask.
I've seen examples similar to Steve's before, but I'm not sure of the mechanism. It seems to occur among mouth breathers wearing a FFM. Emreee's are similar
viewtopic/t158435/Can-someone-help-me-w ... l#p1219470
I've tried to recreate Steve's, but haven't been successful. I have managed to create a pattern which artificially raised the RR, but it didn't really match Steve's. I think you could have been correct above when you suggested Steve's pattern may have to do with transitioning from nasal to oral. Steve's exhales are sharp and quick, maybe a nasal inhale followed by a rather forceful oral exhale? In my experiments, I've notice that an oral exhale following a nasal inhale sometimes causes a little "bump" or rebound in the exhale portion of the Flow Wave as the throat opens. You mentioned his deviated septum. Do you know what his awake breathing is like? Are you able to observe him? Does he naturally exhale orally?

Sorry, I have not got back to this thread in a while.

Here is an example of breathing that may shed some light on this subject and similar examples which are often posted by folks asking about their odd looking waveforms.

The below is an example of someone exhaling thru the mouth wearing a full face mask with lips parting on exhale and remaining nearly closed. Someone wearing tape with a leak might look similar.

The sharp dip at the beginning of exhale is the lips parting. The dips prior to inhale is a switch from oral to nasal exhale at the end of the breath. This was done while awake and rather quickly so the breaths aren't consistent, but I think they are representative.