What happened here please?

[offlineon]

I had a much lower AHI than normal but I saw I had one obstructive lasting almost 60 sec. I know my BP was up too. Could this be a central? I don't understand how the Bipap treated it. It seemed to raise EPAP?

My first AHI's (on a plain Auto Remstar) averaged 30, but I have got them down to 7-5 on average, but with more hyponeas than anything else. My PSG was a washout, but I'm waiting to get another next year - they estimated 120 events per hour, but it was much more than that. BTW my average apnea duration now seems mostly under 20 seconds; but sometimes totals over 400 seconds in a 4.5 hour period.

http://xpap.servebeer.com/50secahi2.JPG

http://xpap.servebeer.com/50secahi.JPG

I'm also concerned that I might be suffering from the "runaway effect"

http://xpap.servebeer.com/aone.JPG

http://xpap.servebeer.com/atwo.JPG

Could some one look at my XML data and give me an opinion please? I prefer to email it if possible, as it has personal ID info in it.

[rested gal]

I'm no doctor, and not a good judge of "graphs", but it looks to me like the machine is doing what it's supposed to do, offlineon.

To have had an AHI of 120 at your sleep study, you're getting a wonderfully low AHI (2.0) for one of the charts you posted. Actually, that chart is the only one I'm accustomed to looking at, so was the only one I really looked at closely...the "Daily Details" chart for Dec. 15 from Encore Pro:
http://xpap.servebeer.com/50secahi.JPG

Looked good to me. Doesn't look like a runaway scenario. Looks like the machine was raising the IPAP as needed to try to ward off more hypopnea/flow limitations.

I've never been sure of this...perhaps someone knows the answer: Does "Total Time in Apnea" look at only the Obstructive Apneas, or does it also count the time spent in "Hypopneas"? Since it's says "apnea", it seems that it would be only Obstructive Apneas, but I'm not certain. If it's counting both and totaling them as "apnea", then the "Average Apnea Duration" would be using both also, wouldn't it?

[Snoredog]

I agree with RG your report looks good, but the data can say more if you read into it. I do see your lowest AHI being obtained at 13cm IPAP and 11cm EPAP (according to the graphs below), yet the machine has run up to 17.1cm, when checking why it ran to 17cm,

Assuming the data is correct, you only had 1 Obstructive apnea and only 9 Hypopnea.

your EncorePro report, it shows flat-lining at 20cm pressure (the Max limit set) in order to treat Flow Limitation. Flow limitations are ignored on PSG's because they don't cause a drop in oxygen levels.

I would NOT let the machine run to 20cm for treatment of a flow limitation for that reason, you have to weigh the good with the bad and with comfort. If you observe your other reports (James put a name on the top will ya), you will see that your ideal IPAP pressure is 13cm and your ideal EPAP pressure is 11cm.

In therapy hour 2.75 from the EncorePro report the machine seen a FL and increased pressure with a triple-Hypopnea that followed taking machine up to 17.1cm pressure, then it stayed and more FL's continued and machine went to the Max. set pressure of 20cm. This is not runaways or pressure induced centrals, it is the machine being allowed to run where it wants to treat FL's.

Personally, I would limit the machine above your ideal IPAP/EPAP, makes no sense to tolerate the 20cm pressure only to clear Flow Limitations which don't usually result in any kind of arousal or drop in oxygen levels.

http://xpap.servebeer.com/50secahi2.jpg

EncorePro, note the increase at hour 2.75:
http://xpap.servebeer.com/50secahi.jpg

This shows IPAP ideal is 13cm:
http://xpap.servebeer.com/aone.jpg
Then this one shows ideal EPAP at 11cm:
http://xpap.servebeer.com/atwo.jpg

So you have to ask yourself, do you want to tolerate 7cm extra pressure to only treat Flow Limitations?

I would set the limit down lower so maybe you can turn that low 4.5hrs of sleep into a better 8 or 9hrs. But I don't see any pressure induced central apnea runaway taking place in your data to worry about.

[StillAnotherGuest]

Flow limitations are ignored on PSG's because they don't cause a drop in oxygen levels.

If the PSG is employing pressure transducer technology (which everyone should) flow limitations are reviewed. If they are terminated by arousal, the event is termed RERA (Respiratory Effort-Related Arousal). This would be reflected in the RDI (Respiratory Disturbance Index, composed of apneas, hypopneas and RERAs) as opposed to the AHI (Apnea-Hypopnea Index, those two guys only).
SAG

[Snoredog]

Flow limitations are ignored on PSG's because they don't cause a drop in oxygen levels.

If the PSG is employing pressure transducer technology (which everyone should) flow limitations are reviewed. If they are terminated by arousal, the event is termed RERA (Respiratory Effort-Related Arousal). This would be reflected in the RDI (Respiratory Disturbance Index, composed of apneas, hypopneas and RERAs) as opposed to the AHI (Apnea-Hypopnea Index, those two guys only).
SAG

[HP]

I cannot help but wonder if you might have intermittent mask leaks, such as a mask seal compromise due to a "tossing and turning" event.

A short term significant leak could result in loss of therapy. What I do not know is whether the sensing of an apnea or hypopnea is also lost during this same event or not.

Your daily does indicate an 85 leak rate, I believe. It would be nice to know when that occured. It's probably less than the leak rate it would show if you start the PAP before your mask is in place.

I'm no health care professional. Just a crazy engineer.

Just a thought.

[Goofproof]

I too am only used to Encore Pro Reports, and not BiPAP, but it looks to me like the leak numbers are a little high. Jim

[rested gal]

I would NOT let the machine run to 20cm for treatment of a flow limitation for that reason, you have to weigh the good with the bad and with comfort.

----snipped----

makes no sense to tolerate the 20cm pressure only to clear Flow Limitations

I agree with weighing the good with the bad and with comfort.

I do wonder, though... how do you know the machine going up to 20 was not necessary? Perhaps the higher pressures were needed in order to prevent limited flow situations from getting worse?

At any rate, a person could tweak some ranges to see how it goes. If changes are made, it's a good idea to keep it the same for a week to get a good look at the results.

[Snoredog]

RG wrote:

how do you know the machine going up to 20 was not necessary? Perhaps the higher pressures were needed in order to prevent limited flow situations from getting worse?

How do I know? you observe the event right before the pressure increase on the graph and it will show you what triggered the pressure increase, there was a double/triple Hypopnea before which triggered the machine to go to 17cm, then only flow limitations taking it on up to 20cm.

While the machine would respond to FL's it seen lower pressure(s) there is no reason why it wouldn't also respond to them at 17cm as you suggest. They have to be short events because if they were lasting longer than >10-seconds the machine would be logging them as Hypopnea not FL's.

I am also missing the legend data at the bottom of the page which would confirm what event triggered the machine up to 20cm, I don't have that data but I can still tell by observing the tics in front of the pressure increase.

FL's being logged by the machine don't show up as Hypopnea or Apnea so they don't roll up in adding too/subtracting from your overall AHI indices.

So if the FL's are lasting less than 10seconds in duration and there are only a hand full total to deal with, does that warrant 7cm more pressure?

I know I wouldn't want to unless my sleep greatly deteriorated. Higher pressure = greater machine noise, greater mask leak and noise, more interruptions during sleep a higher degree of discomfort.

While the AHI score remains very low, 5 is still considered normal, it would be interesting to see what would happen if pressures were limited to say 15cm maximum, the goal would be for obtaining longer sleep sessions instead of the 4.5hrs seen.

[sthnreb]

According to the 4-1/2 hrs or so sleep and it topping out at 20 (high) and staying there for awhile, I would probably try the limit at 25 cm. My pressure is not that high, set at 8 Epap and 18 Ipap. I never reach the 18 but the pressure is available to me if needed. I need the 8 Epap as a low, hence the auto starts at 8-10 pressure. My graph seems the more leak, the higher the pressure to accommodate the leak. This keeps my AHI usually 2 or lower.

[offlineon]

Thank you all.

I've uploaded the main data for two nights.

The original night posted with Encore tabled data:

http://xpap.servebeer.com/ep15.pdf [200k]

..and last night (which was also better than "normal")

http://xpap.servebeer.com/ep16.pdf [200k]

@ Snoredog

How is this for new settings?

ABFLE - same as before
18 IPAP - new 2cm lower
10 EPAP - new 1cm lower (tried last night)
6 PS - same as before
3 FLEX - same as before

I'd rather have discomfort (although I'm not conscious of discomfort really) than risk any unnecessary destats. But some REM would be nice.
I have not been told but its obvious to me I have OHS. To sum up:

- under 40yrs
- OHS is a given
- Hypertension (16mg ACE Inhibitor / 40mg loop diuretic)
- D. Septum / L. Tonsils / L. Epi / L. Adenoids
- heavy smoker (gave up not so long ago)

..almost a tick in every box I guess.

[StillAnotherGuest]

I'm not sure leak is a major issue. It was at first, but I think the Encore Reports above show that the peak max leak is limited.

Right. Also, the leak seems to be quite consistent. Problem leaks tend to be far less so, and affected considerably more by pressure changes.

Plus, SAG has a new theory that "Big Leaks Can Be Good Leaks."

I'm also thinking that my airway is far less relaxed at this beginning stage of sleep, and also that other non AHI events are ramping the pressure, before any apneas or hypopneas have a chance to occur.

I'm not sure what you mean by this, but the airway tends to be more unstable in the lighter stages of sleep (which can occur at any time during the night) and far more "relaxed" (as in "bad relaxed") in REM. Which brings us to

I do agree that what I posted shows 18cm might be a good limit to impose. I also have data that shows 22cm might be needed (if I sleep in a bad position.) At this stage I'm willing to try 18cm with side sleeping.

A very strong point. There's plenty of factors that go into all this, and another is what happens during REM, where pressure requirements are often increased. The first REM period normally occurs at 90 minutes, and then multiples of 90 minutes thereafter, so given the reproducibility of the the pressure response:





those areas of high pressure utilization could very well be REM periods. Course if the higher pressure implied REM, that's a pretty long REM period. But if you're only sleeping 4.5 hours a night, that could be a rebound. Yet a rebound should occur during the beginning of the night rather than the end. Assuming you're asleep then.

Say, what kinda data did you get from your PSG, such that it was? That might prove helpful. Like if you had really bad desats that continued at higher pressures, then certainly restricting pressures might be an issue. Severe architectural problems could also generate all kinds of problems.

How is this for the new settings?
6 PS

There's a couple ways one could go with that, depending if you're chasing OSA or OHS.

16mg ACE Inhibitor

Talking about multiples, I guess that would make it perindopril. That's a lot.
SAG

[Guest]

Sorry. I meant ARB, not ACE.. new rx.

Say, what kinda data did you get from your PSG, such that it was? That might prove helpful. Like if you had really bad desats that continued at higher pressures, then certainly restricting pressures might be an issue. Severe architectural problems could also generate all kinds of problems.

No idea unfortunately as I had it six years ago, and it was not a good experience. The RT estimated 120 AHI. I only started xPAP in October.
I've fairly sure my nocturnal sao2 was/is pretty woeful. Morning headaches = respiratory acidosis right? Well under xpap mine are gone at least. I bothered my doc for a halter ECG Rx ( I could not get an oxi Rx) and maybe that will show something I can then investigate further.

There's a couple ways one could go with that, depending if you're chasing OSA or OHS.

So BFLE mode at a higher PS might be better for me than auto, no matter the AHI?

Cheers for the input SAG.

[StillAnotherGuest]

Sorry. I meant ARB, not ACE.. new rx.

ACE, ARB, whatever, it's still clubbing them little ATs into oblivion.

So BFLE mode at a higher PS might be better for me than auto, no matter the AHI?

Trying to base treatment on an inadequate study that was 6 years ago is gonna be tough. There could be (and probably is) a number of contributing factors.

For instance:

If you're addressing OHS (exclusively), then more of an NIPPV approach (pCO2 control)(right, the PS thing) is warranted.

If you're addressing OSA (exclusively) then more of a BiPAP approach (address apneas with EPAP, hypopneas and flow limitations with IPAP) is warranted.

If there is persistent oxygen desaturation after the above, then supplemental oxygen is employed.

And if you need 40 of lasix to get through the day, however that would interplay (right-sided vs left-sided insufficiency-- I'm guessing right)(Then again, maybe I'm not).

You bet, morning headaches could be associated with elevated pCO2 levels. Now you're talking arterial blood gas.

Nocturnal oximetry is the bare minimum standard of care to look at at least half of these things. WIth what you've noted so far, you gotta at least do that.

Without that and/or PSG, there's really no way of knowing what you're trying to fix, much less how to fix it.
SAG

[offlineon]

Thanks SAG. I'm trying to get a PSG. I'd love one tomorrow, but there is a long waiting period. I first have to find a new RS. I agree about the pulse ox. Right now I can't afford to wait so I'm working in the dark and trying to patch things along the way. Not an ideal situation, but that is the two tier health system in my country. When you don't have full private coverage, treatment is either delayed, inferior or absent. I'm not whining.. just pointing out the reality I am working under.

Cheers for your help! I really do appreciate the time you have taken.