Bad sleep study titration? SpO2 drops...

[raisedfist]

please replace the top picture with a proper one.

very deep, very brief drops in the spo2 are almost certainly movement artifacts.

I'm not sure what my next step would be: bump the EPAP up by 1 more? Or maybe lower the IPAP to 18? Or go the vauto route?

already made my recommendation.

Thanks - will use your recommendation tonight.

[raisedfist]

With vauto suggested settings, I woke up with an AHI of 0.0 and never had the sensation of my mouth popping open. Only 1 recorded event "Large Leak." I did notice that even while awake, like 10-15 minutes after turning the machine on, for whatever reason the machine ramped up to 25 IPAP / 15 EPAP for a while. The IPAP/EPAP pressures seem to settle down and stay rather constant after a short period of time though.

I woke up with my chest feeling tighter. I noticed that by enabling vauto mode, it seems to disable the "rise time" feature and instead uses the "Easy Breathe" waveform - which totally changes the sensation on how you feel the delivery of the air. I felt the sensation of getting less air. My SpO2 chart looks worse than the night before.

[Sleeprider]

Very interesting the difference between VPAP-S mode and Vauto, and the auto mode seems to have cleared up the issues we saw in the earlier graphs. I think Palerider and Pugsy have been very helpful, so I only have a question. Have you ever discussed the use of the Aircurve ST machine with your doctor? Your restrictive pulmonary problems and periodic hypopnea would seem to fit the intention of that device, however I'm impressed with this last posted result using Vauto with the large pressure support.

[raisedfist]

Very interesting the difference between VPAP-S mode and Vauto, and the auto mode seems to have cleared up the issues we saw in the earlier graphs. I think Palerider and Pugsy have been very helpful, so I only have a question. Have you ever discussed the use of the Aircurve ST machine with your doctor? Your restrictive pulmonary problems and periodic hypopnea would seem to fit the intention of that device, however I'm impressed with this last posted result using Vauto with the large pressure support.

I've only seen my new sleep doctor the once, when he ordered the bi-level titration. He reviewed the report and he said I did very well. When I went home and examined the report, I noticed when you look at the graphs it appears the "therapeutic settings" appear to only have been applied/titrated for the last hour of sleep or so. It did say I had REM sleep during these pressures though, and that I only had transient drops to 88-89% SpO2 and otherwise remained > 92%. Clearly there is a problem since my SpO2 charts show otherwise. Plus after about 40 days of 100% compliance at 13/8, I didn't really feel better at all and still woke up with headaches. I will have to ask about the ST capable machines.

What's interesting is that at IPAP 13/EPAP 8 I also have an AHI 0.0 and nothing weird shows up in the graphs, but at 13/8 I have sustained desaturations (lasting several minutes at a time) - presumably due to hypoventilation. The higher pressure support here seems to help reduce the length of the desaturations by a lot, as evidenced by the previous charts at 20/4 where the desats recover quickly, and also here with the Vauto settings. I will say that the Vauto mode was not as comfortable, I much prefer the "rise time" setting of 3, as opposed to the "Easy Breathe" waveform that is applied with Vauto - the Easy Breathe seems to, for lack of better explanation, to impede the flow of air.

IPAP 20/EPAP 4 seemed to induce some type of apneas - perhaps pressure induced centrals? IPAP 20/8 did reduce those by about half (of the AHI at least).

I always used a full face mask before, so I would have never noticed my mouth "popping open" though.

I am set for a first follow up next Thursday 9/29 - which is six weeks after my first day of using the machine. I will have to bring a print out of several oximetry reports at 13/8 showing the sustained desaturations that are still occurring. I will need to be more forceful and makes sure he addresses all my concerns (I had to leave my last Sleep Dr. because he appeared not interested in helping me) because struggling long-term like this is taking a toll on my QOL.

[palerider]

Have you ever discussed the use of the Aircurve ST machine with your doctor? Your restrictive pulmonary problems and periodic hypopnea would seem to fit the intention of that device.

where do you come up with THAT?

[palerider]

I did notice that even while awake, like 10-15 minutes after turning the machine on, for whatever reason the machine ramped up to 25 IPAP / 15 EPAP for a while. The IPAP/EPAP pressures seem to settle down and stay rather constant after a short period of time though.

the pressure and mask pressure charts duplicate the same info at that zoom level, the flow limitation chart may show why your pressure went up. pressure would go up either due to flow limitation or snores.

I'd also like to see the inspiration time strip.

[palerider]

I will have to ask about the ST capable machines.

probably best to ignore sleeprider, I think he means well, but he mostly just muddles the waters. the ST machine is for people with central apnea, who need the machine to force them to breath. (the T in ST, for Timed Breath, ie, if you don't trigger a breath, it'll do it for you).

I will say that the Vauto mode was not as comfortable, I much prefer the "rise time" setting of 3, as opposed to the "Easy Breathe" waveform that is applied with Vauto - the Easy Breathe seems to, for lack of better explanation, to impede the flow of air.

if you zoom in on the mask pressure line, and compare the s mode pressure trace to the vauto pressure trace, you can see the difference with easybreath on and off. I find the gentle increase in pressure with easybreath to be vastly more comfortable, of course, that is what I'm used to, and you're used to the other situation.

IPAP 20/EPAP 4 seemed to induce some type of apneas - perhaps pressure induced centrals? IPAP 20/8 did reduce those by about half (of the AHI at least).

a PS of 16 could very well put you in a hyperventilation scenario where you're having centrals due to excess co2 blowoff.

[raisedfist]

Thanks guys. Palerider, I will get you those requested charts when I get home from work. I will get anyone the information they need to make a suggestion for further improvement. We are obviously getting somewhere which is wonderful.

[raisedfist]

...the ST machine is for people with central apnea, who need the machine to force them to breath. (the T in ST, for Timed Breath, ie, if you don't trigger a breath, it'll do it for you).

Like those with neuromuscular disease?

[palerider]

...the ST machine is for people with central apnea, who need the machine to force them to breath. (the T in ST, for Timed Breath, ie, if you don't trigger a breath, it'll do it for you).

Like those with neuromuscular disease?

do you have central apnea? are you not breathing on your own? do you need a machine that waits and then pushes a breath to you when you don't take one on your own?

you can upload a zip of your full SD card if you'd prefer:
https://www.dropbox.com/request/0LalWvEsijRIgX8sdM7H

[raisedfist]

...the ST machine is for people with central apnea, who need the machine to force them to breath. (the T in ST, for Timed Breath, ie, if you don't trigger a breath, it'll do it for you).

Like those with neuromuscular disease?

do you have central apnea? are you not breathing on your own? do you need a machine that waits and then pushes a breath to you when you don't take one on your own?

you can upload a zip of your full SD card if you'd prefer:
https://www.dropbox.com/request/0LalWvEsijRIgX8sdM7H

i uploaded a .zip of my SD card. let me know if you didn't receive/can't open.

[palerider]

[quote="raisedfist"i uploaded a .zip of my SD card. let me know if you didn't receive/can't open.[/quote]
how 'bout I say "got it, and poked around some".
some thoughts:

there are times you're hitting timax and the machine is cutting off air before you're finished, you might consider increasing that.

you might consider increasing timin, though you're usually over that time, there are times you're hitting it, and possibly a bit more air would help, though I don't know for certain.

even though you said you didn't like the vauto, your respiration rate and tidal volume were much more even throughout the night than when you were on 13/8 or 20/8 or 20/4. might just be a fluke though, since it's only one night's worth of data.

your respirations on the easybreath were more 'normal' looking, more rounded inhale, less abrupt exhale

[Sleeprider]

Have you ever discussed the use of the Aircurve ST machine with your doctor? Your restrictive pulmonary problems and periodic hypopnea would seem to fit the intention of that device.

where do you come up with THAT?

The ST machines are intended not for CA patients that are treated with ASV, but for restrictive and obstructive patients that do not move volume, or who need pressure support on a timed basis, which meets this profile. Next cheap shot please?

By sustaining IPAP pressure, especially with ST auto mode in the Aircurve ST-S machines I think the therapy is tailor made for what we are seeing in the flow / event charts posted by the O.P.

[raisedfist]

there are times you're hitting timax and the machine is cutting off air before you're finished, you might consider increasing that.

you might consider increasing timin, though you're usually over that time, there are times you're hitting it, and possibly a bit more air would help, though I don't know for certain.

even though you said you didn't like the vauto, your respiration rate and tidal volume were much more even throughout the night than when you were on 13/8 or 20/8 or 20/4. might just be a fluke though, since it's only one night's worth of data.

your respirations on the easybreath were more 'normal' looking, more rounded inhale, less abrupt exhale

i think you are spot on with the ti min and max. especially since getting more air in is my exact problem. i actually notice sometimes that I wish I could breathe in for longer, and I'm sure that's even more important when I'm actually sleeping. it actually reminded me of a post i read back in the day on another forum. guy has the same extrapulmonary condition that i do (kyphoscoliosis): http://www.scoliosis.org/forum/showthre ... -headaches

the vauto sensation could just be that i got a workout after breathing "normal" for the first time in who knows how long. i also went to sleep with a sore throat so i could already have not been feeling well regardless when i woke up.

[palerider]

Have you ever discussed the use of the Aircurve ST machine with your doctor? Your restrictive pulmonary problems and periodic hypopnea would seem to fit the intention of that device.

where do you come up with THAT?

The ST machines are intended not for CA patients that are treated with ASV, but for restrictive and obstructive patients that do not move volume, or who need pressure support on a timed basis, which meets this profile. Next cheap shot please?

you apparently don't know what a ST machine *is*.

a the Aircurve ST machine is a machine that offers *Spontaneous* modes, (ie, S) and Timed, ST, and cpap mode.

there is *nothing* in there that would do raisedfist *any* more good than the machine he has, which he can put on S mode. he does not need timed mode, since he has no central apneas when he's not hyperventilating himself with extreme amounts of pressure support.

pointing out your lack of understanding about something you're trying to offer faulty advice on is not a cheap shot.

if you're trying to get a clue by reading through the titration manual and looking for 'restrictive' you'll also see that it mentions the ivaps machine aka ST-A, which might be where your confusion lies.

also, in case you've been asleep for many months, you might have heard of a reluctance of doctors to prescribe ASV machines for certain sufferers of central apnea, those people end up on a ST machine.

By sustaining IPAP pressure, especially with ST auto mode in the Aircurve ST-S machines I think the therapy is tailor made for what we are seeing in the flow / event charts posted by the O.P.

there is no "ST auto mode" there is no "aircurve ST-S" machine.