WaveForm analysis Please explain how this works

[pudellvr]

I am having some difficulty understanding how all of this works. I had lots of arousals last night in spite of the fact that I took clonazepam to settle my legs down. I assume they came with the arrousals. I also had difficulty with the umffm due to spit collection. The big leaks are when I was trying to wipe my face. I feel a little draggy this morning.

These are my settings
Mode : APAP+FL
Min pressure : 8.0 cmH2O
Max pressure : 20.0 cmH2O
Ramp latency : 15 min (15 min)
Pressure decrease : fast
Command on Flow Limitation Run : enable
Max pressure for command on Apnea : 14.0 cmH2O
Comfort pressure : 10.0 cmH2O

Here is a link to my waveform analysis
http://picasaweb.google.com/lh/photo/IL ... 57kpD6nVjg

Session 5 was my Sunday afternoon nap!

Thanks,
Tricia

[ScottyT]

I'm new at this as well, but isn't a 12cm gap from your minimum to your max rather extreme? I thought the goal for APAP was to have a range of about 5cm or so.

[echo]

Tricia, can you maybe make the graph a tad larger? I know it's just a bunch of lines, but it is really hard for me to read .. Go for something around 1200x750 of maybe slightly larger. Thanks!

From what I can make out, that last session looks pretty OK. Still a few centrals hanging about though. Any reason why you have the command on apnea set to 14cm?

Have you set the initial and the minimum pressures differently, or are they the same value? Is comfort value the same as initial, i wonder, or does it have something to do with the ramp? Sorry i am not yet familiar with the sandman. Also, do you have the IFL1 and IFL2 settings like in the 420E, and if so what are they set to?

Do you do/have shallow breathing?

ScottyT - when people talk about tightening up the APAP range they are usually referring to setting the minimum pressure higher. Here's a nice post from restedgal explaining her opinions on the issue: viewtopic/p309863/viewtopic.php?p=307265#p307265

[pudellvr]

http://picasaweb.google.com/lh/photo/ZH ... Z5syJshNhg
Try this one

Any reason why you have the command on apnea set to 14cm?
It came that way. What would be a good setting? I don't understand what some of these terms mean. I am a RN but this is stuff that they don't cover in school. I don't even think that your run of the mill RT's know what these terms mean.


Also, do you have the IFL1 and IFL2 settings like in the 420E, and if so what are they set to?
No, I don't think so. Aren't those settings for BiPap? this is APAP

Do you do/have shallow breathing
Yes, I am pretty sure that I do.

[echo]

Edit: Here's the link from rested gal on setting the APAP range:
viewtopic/p309863/viewtopic.php?p=307265#p307265

http://picasaweb.google.com/lh/photo/ZH ... Z5syJshNhg
Try this one
Thanks! That's already much better. I have to do some work now so I won't be able to look at it in detail just at the moment, but I will answer some questions below quickly.

Any reason why you have the command on apnea set to 14cm?
It came that way. What would be a good setting? I don't understand what some of these terms mean. I am a RN but this is stuff that they don't cover in school. I don't even think that your run of the mill RT's know what these terms mean.
Command on apnea settings limits the pressure at which the APAP will respond to apneas. The thinking is that obstructive apnea's can turn into central apnea's if the pressure is too high. 10cm is the a slightly arbitrary but documented pressure above which many people tend to get those pressure induced centrals. On most machines, 10cm is the pre-programmed pressure, above which you will NOT get a pressure increase if the detected event is an apnea - but it wll increase pressure for snores, hypopneas, etc.

Also, do you have the IFL1 and IFL2 settings like in the 420E, and if so what are they set to?
No, I don't think so. Aren't those settings for BiPap? this is APAP
No, you're thinking of IPAP (inhale pressure) and EPAP (exhale pressure) on the Bipap. IFL1 and IFL2 on the 420E (also an APAP, and the predecessor of the Sandman Auto) are settings which refer to reductions in breathing that are not so severe as to be classified as a hypopnea. IFL1 , if set to "ON" will also increase pressure when it detects flow limitations - also called "Runs" on your graph. Tehcnically a run is 3 or more flow limitations in successive order. If IFL1 "OFF", it wont respond to those events. Some people turn it off because they are a shallow breather, so the machine thinks they are having a flow limitations, and attempts to increase the pressure - this can cause arousals and thus poor sleep. Since you say you are a shallow breather, turning off IFL1 may actually help you. But as I said I don't nkow if the Sandman has that option (I'm guessing it should?). Do a search on IFL1 and you will find plenty of reading (check posts from Ozij, Snoredog, -SWS, SAG, Restedgal).

Do you do/have shallow breathing
Yes, I am pretty sure that I do.

[Snoredog]

http://picasaweb.google.com/lh/photo/ZH ... Z5syJshNhg
Try this one

Any reason why you have the command on apnea set to 14cm?
It came that way. What would be a good setting? I don't understand what some of these terms mean. I am a RN but this is stuff that they don't cover in school. I don't even think that your run of the mill RT's know what these terms mean.


Also, do you have the IFL1 and IFL2 settings like in the 420E, and if so what are they set to?
No, I don't think so. Aren't those settings for BiPap? this is APAP

Do you do/have shallow breathing
Yes, I am pretty sure that I do.

I would:

Increase Initial pressure to 9.0cm, from current 8.0 cm.
I would set Command on Apnea back down to 10 cm (from current 14 cm).

You need to go back to your 11/01 settings (first 2 days) those results look a lot better.

[rested gal]

Q. Any reason why you have the command on apnea set to 14cm?
A. It came that way. What would be a good setting?
That's really odd that it would come that way. The setting for "command on apnea" setting when Puritan Bennett autopaps (420E and Sandman) leave the factory is 10 cm.

Leaving it at the default of 10 cm is usually a "good" setting for that special advanced setting ("Maximum pressure for command on apnea.")

I don't understand what some of these terms mean. I am a RN but this is stuff that they don't cover in school. I don't even think that your run of the mill RT's know what these terms mean.

I think you're right. I'd even go so far as to say I doubt if most board certified "sleep doctors" know what the advanced settings in the Puritan Bennett machines mean...or do...or how they should be set for certain circumstances.

Q. Also, do you have the IFL1 and IFL2 settings like in the 420E, and if so what are they set to?
A. No, I don't think so. Aren't those settings for BiPap? this is APAP
IFL1 and IFL2 are not settings for BiPAP machines. You may be thinking of "IPAP/EPAP", which BiPAP machines have. IFL1 and IFL2 are the names of special settings in the Puritan Bennett 420E autopap, for inspiratory flow of air that the machine senses as becoming reduced ("limited".)

Some people using a 420E have found they need to turn off IFL1 (called just "FL" in the 420E's window) to prevent the machine from misinterpreting slightly restricted airflow breathing that is normal for them, as a flow limitation that needs more pressure. Giving the person more and more pressure unnecessarily.

In the 420E auto (dunno about the Sandman Auto) IFL1 and IFL2 can be turned on or off, independently of each other...in the "advanced settings."

[Snoredog]

you NEED to go to the Settlings Panel in Sandman software, and click on "Default Settings" button, this will restore things back to your settings of the first few days.

Next, click on AutoCPAP button,

Below in that same Panel, move the slider bar for Minimum Pressure from default 3 cm to 7 or 8 cm.
Leave Maximum Pressure set to 20 cm.

to the right,

Set Comfort Pressure to 6.0 cm.
Set Ramp timer to 30 minutes.

Under Auto-CPAP Parameters:

Leave Speed of Pressure Decrease radio button Fast
Leave Command on Flow Inspiration box checked.
Leave Max. Pressure for Command on apnea at 10 cm.

Hit the SAVE button.

This will set you up with a pressure range of 7/8 cm to 20 cm.
A comfort Ramp of 6.0 cm for 30 minutes.

When you first turn on your machine it will go to 7/8 cm pressure, if you hit the Ramp button it will drop to 6.0 cm
so you can fall asleep. You need to compare your 11/01 report to todays, it was much better before, the above
should put you back there.

[pudellvr]

Thanks,
I never use ramp, btw. It has never bothered me to go full blast! I just wish I could get my thinking and energy there too!

I am going to reset the machine now. Thanks for all of your help.

Trish

[Snoredog]

Thanks,
I never use ramp, btw. It has never bothered me to go full blast! I just wish I could get my thinking and energy there too!

I am going to reset the machine now. Thanks for all of your help.

Trish

You want to see fewer of those central events on line 2 of that Waveform report. See an increase in those and
your quality of sleep will go down in a hurry. The only thing you need to adjust on that machine is the Minimum pressure,
you should start where it is comfortable and you are not starving for air.

Because you have centrals showing up on your report at all, you should set the Minimum pressure down as low as possible
and let the machine do its thing. It won't respond to those centrals, but many times increasing the Minimum pressure
up to get rid of the obstructive events makes it worse. Let the machine decide if it needs to respond. Those centrals
may reduce after several days use of the machine. The reason is the machine retrains your breathing the more you use it, so
once that happens those centrals should reduce in frequency on their own. With your Max up at 20, the machine will avoid any response
to centrals but if it sees a frank apnea it will still respond. Same for snore, same for FL.

You don't have that many FL's showing up on your reports so just leave that enabled for the time being.

[pudellvr]

When I tried to set the Comfort Pressure it wouldn't let me go below 8. Due to minimum pressure setting at 8. Should I decrease the minimum now or wait a week or two to see how it goes? Thanks for the explanations.

Trish

[pudellvr]

I woke up feeling pretty good this morning. Not as fuzzy. Did not take clonazempam last night. My legs feel like they worked all night but the sheets aren't torn up.

Here is my data from last night

• Pressure, events and leaks Report
  Analysis period
  Start date : 11/02/2008 - 12:00
  End date : 11/03/2008 - 11:59
  Period : 1 days
  Last settings of the period
  Mode : APAP+FL
  Min pressure : 8.0 cmH2O Snoredog, I did change these but it didn't show the changes today
  Max pressure : 20.0 cmH2O
  Ramp latency : 15 min (15 min)
  Pressure decrease : fast
  Command on Flow Limitation Run : enable
  Max pressure for command on Apnea : 14.0 cmH2O
  Comfort pressure : 10.0 cmH2O
  Pressure
  Min. Max. Aver.
  0.0 cmH2O 11.0 cmH2O 8.7 cmH2O
  Pressure efficient more than 90 % of time : 10.0 cmH2O
  Apnea/Hypopnea Index Number Index/h
  AH obs 16 1.8
  AH cnt 27 3.1
  Detected events Number Index/h
  Apneas : 3 0.3
  Apneas/CA : 8 0.9
  Hypopneas : 13 1.5
  Hypopneas CNT : 19 2.2
  Snorings : 16 1.8
  Runs : 80 9.2

http://picasaweb.google.com/randtyork/CPAP# This is a link to my waveform reports cumulative.

Thanks
Trish

[echo]

Tricia - I would recheck your settings and/or the info you exported for the previous post. Your command on apnea still appears to be at 14cm as well.

Do you have the Sandman clinician's manual? Can you check what "comfort pressure" means? If it won't let you set it below the minimum, then it has nothing to do with ramp. Sounds more like the "initial pressure" from the 420E.

Your leaks are looking good, but you've still got a high AHI and still too many central's. I wonder how many of the "AH obs" are actually Hypopnea's. Is there no way to separate those out on the charts?

[Snoredog]

Your 11/03/08 report looks better.

Look at your 11/03 report at the activity, it starts at 1:15AM (Probably your first REM period). It starts off with Flow Limitation then Snore, then Central Apnea and mix of Obstructive Apnea. Machine does a good job at "dancing around the issue", it seen the Central apnea and if you look carefully at what pressure did there are two periods where it "held" pressure steady in that hill climb of pressure.

Normally you'd ask why didn't it drop pressure when it seen those CA's? Because there was a mix of central and obstructive apnea at the same time, if current pressure was below the Command on Apnea setting it continues to increase pressure and only holds that if it sees Cardiac Oscillations. So the machine did a good job in that situation in my opinion.

However, you have to go back to the beginning of that sequence of events, you were at 8.0 cm pressure and a Flow Limitation started the train wreck. What would have happened if pressure was higher at 8.5 or 9.0 cm? It may have eliminated the Flow limitation that started things off you don't know unless you try. Then if you look at your Minimum pressure across the whole session observe "how much pressure" was needed to eliminate the events above. You will notice that if the Minimum floor pressure was a bit higher it may eliminate a lot of those FL's, snores, and possibly preemptively eliminated some of the obstructive apnea seen. Ideal is no events seen during the session. Since the floor or Minimum pressure is steady like CPAP it usually doesn't cause problems with Central Apnea unless you are disposed to traits found with CSDB, but I think they had that diagnosis out way too much. You don't want that disorder anyway and you certainly have the right machine to avoid any adverse response to the Centrals. But your centrals are related to the Obstructive events seen. There were a couple rouge centrals seen 2 from the Large 20-minute Leak seen starting at 2:30AM. That is either a dislodged mask or mouth breathing.

I would continue on for a while with current settings, if you must wing dials, I would increase that Minimum pressure from 8.0 to 9.0 cm, sorta ignore the Centrals seen for the time being, reduce the obstructive events and maybe those will go away on their own. Those centrals could be just from transitioning from deep sleep to REM and vice versa.

[pudellvr]

Snoredog,
Around 0230 I had ripped my mask of to deal with some major nose itches! I think the 2 centrals there can be ignored due to my disturbing the piece. What do you think?

What came first? The runs seem to preceed the obs then ca. I am unclear as to what runs mean. I thought at first they were runs of ah but they proceed the marks on the upper line. I am also curious about the cycle states.

I did notice this morning that I felt a little airless. Not SOB but that the breeze was less and woke me up. I guess after being used to 10--8 just feels light.

Echo,
The clinicians manual seems to be a ditto of the patient manual. I am going to scrounge around on the PB site and see what I can come up with. Of all of the neat features of the Sandman, I am most disappointed about the poor documentation and no "auto on" when I put on my mask. Also, if you have a major leak, it turns itself off. No audible alerts are available.