Complex Sleep Apnea - Hypopneas - Central or Obstructive

[Tonawanda]

The more informed you are, the better you can help your doctor help you.
A higher pressure can certainly cause some discomfort but generally we get used to it.
Have you zoomed in on some of those H to see what they look like?
Examine your data just before you take the mask off. Maybe you will see a trend.

The only thing I've really looked at was the event flags and where they are in relation to the time I'm sleeping and waking up... I haven't been able to pick up anything yet, but since I don't know what I'm looking for, I can't find it. There are 14 graphs and right now most of them are Latin to me... And, I actually took Latin in high school and still don't understand them.

[TedVPAP]

The more informed you are, the better you can help your doctor help you.
A higher pressure can certainly cause some discomfort but generally we get used to it.
Have you zoomed in on some of those H to see what they look like?
Examine your data just before you take the mask off. Maybe you will see a trend.

The only thing I've really looked at was the event flags and where they are in relation to the time I'm sleeping and waking up... I haven't been able to pick up anything yet, but since I don't know what I'm looking for, I can't find it. There are 14 graphs and right now most of them are Latin to me... And, I actually took Latin in high school and still don't understand them.

Sleepyhead allows you to zoom in and see every breath. On the Events Flags chart, left click and drag and you will highlight a region. Use the arrow keys to make the region bigger/smaller (up/down arrow) , or you can move the region left or right. Now you see avery breath during an event and what was happening before you pulled the mask off.

The three links below may help you.

[MichaelGuessford]

Try increasing the pressure a little and see what happens.

[palerider]

The only thing I've really looked at was the event flags and where they are in relation to the time I'm sleeping and waking up... I haven't been able to pick up anything yet, but since I don't know what I'm looking for, I can't find it. There are 14 graphs and right now most of them are Latin to me... And, I actually took Latin in high school and still don't understand them.

Read through "pugsy's pointers' up in the announcements at the top of the main page.

it'll help translate it into something more meaningful

[Tonawanda]

<r><QUOTE author="TedVPAP" post_id="1245334" time="1524345652" user_id="50123"><s>

</s>
The more informed you are, the better you can help your doctor help you. <br/>
A higher pressure can certainly cause some discomfort but generally we get used to it.<br/>
Have you zoomed in on some of those H to see what they look like?<br/>
Examine your data just before you take the mask off. Maybe you will see a trend.
<e>

</e></QUOTE>

Ted, for the most part, I did the reviews. I moved the graphs in the suggested order. There was no FLOW LIMIT graph on my report. I created a screenshot highlighting the FLOW rate of the last, or last grouping of events before waking up for the last days. The examples are obviously zoomed in differently.

Flow Rate.PNG (183.85 KiB) Viewed 14203 times

[TedVPAP]

<r><QUOTE author="TedVPAP" post_id="1245334" time="1524345652" user_id="50123"><s>

</s>
The more informed you are, the better you can help your doctor help you. <br/>
A higher pressure can certainly cause some discomfort but generally we get used to it.<br/>
Have you zoomed in on some of those H to see what they look like?<br/>
Examine your data just before you take the mask off. Maybe you will see a trend.
<e>

</e></QUOTE>

Ted, for the most part, I did the reviews. I moved the graphs in the suggested order. There was no FLOW LIMIT graph on my report. I created a screenshot highlighting the FLOW rate of the last, or last grouping of events before waking up for the last days. The examples are obviously zoomed in differently.
Flow Rate.PNG

Thanks for the charts.
I think I confused you as I had two separate thoughts. The first thought is about what your events look like when zoomed in. The second thought is about what is going on just before you ripped of the mask.
Regarding the first thought, the zoomed in flow forms shown in chart 1 is unclear but chart 2, 3, 4 clearly show obstruction. Chart 5 is labeled obstructive which is most likely correct but without seeing it zoomed in I don't want to guess.

So what do your charts look like just prior to ripping off the mask? Not zoomed in, just trying to see if cluster of events are happening. If they look like chart 5 then it is likely that a cluster of events are happening and that is why you are ripping off the mask. If so, better treatment may help you keep the mask on.

[Tonawanda]

<r><QUOTE author="TedVPAP" post_id="1245334" time="1524345652" user_id="50123"><s>

</s>
The more informed you are, the better you can help your doctor help you. <br/>
A higher pressure can certainly cause some discomfort but generally we get used to it.<br/>
Have you zoomed in on some of those H to see what they look like?<br/>
Examine your data just before you take the mask off. Maybe you will see a trend.
<e>

</e></QUOTE>

Ted, for the most part, I did the reviews. I moved the graphs in the suggested order. There was no FLOW LIMIT graph on my report. I created a screenshot highlighting the FLOW rate of the last, or last grouping of events before waking up for the last days. The examples are obviously zoomed in differently.
Flow Rate.PNG

Thanks for the charts.
I think I confused you as I had two separate thoughts. The first thought is about what your events look like when zoomed in. The second thought is about what is going on just before you ripped of the mask.
Regarding the first thought, the zoomed in flow forms shown in chart 1 is unclear but chart 2, 3, 4 clearly show obstruction. Chart 5 is labeled obstructive which is most likely correct but without seeing it zoomed in I don't want to guess.

So what do your charts look like just prior to ripping off the mask? Not zoomed in, just trying to see if cluster of events are happening. If they look like chart 5 then it is likely that a cluster of events are happening and that is why you are ripping off the mask. If so, better treatment may help you keep the mask on.

First, thank you for your interpretation of the charts! As I mentioned earlier, my understanding of my condition, the machine's recording limitations, and now what I now consider somewhat of a confirmation will be invaluable to me.

Actually, I kind of understood what you were asking. The charts mostly represented events that occurred just prior to wake up time. There has only been 3 or 4 nights in the last couple of months that resulted in a cluster of events just prior to wake up time. Most of the daily flow rate charts show a pretty even distribution of events with small clusters occurring during the course of sleep.

For clarification, I don't actually spontaneously rip off the mask when a significant leak occurs (I use the term mask blast off facetiously). I sometimes spend up to 15 minutes trying to re-acclimate my breathing to the bipap to get back to sleep. The longer it takes, the more awake I become until I find it next to impossible to get back to sleep. Having said that, I completely agree that better treatment, and with time, I will find the correct pressure and comfort level to keep the AHI low, and hopefully get more hours of sleep. BTW, At the lower pressure of 15.2 - 10, I am sleeping well, feeling better with no mask issues, and hoping that the incremental pressure increases help me get used to the pressure required.

[Tonawanda]

It's not so much the machine couldn't determine OA or central but the fact that this particular model of machine simply doesn't distinguish between central vs obstructive apnea. One of the things I don't like about these high end ResMed machines.
We assume obstructive but can't prove it. Even in cpap mode it doesn't use FOT to decide open vs closed airway. You get UA flags.
I know because I had this machine to try and tried cpap mode.
Central apneas and obstructive apneas all get tossed in the generic "Apnea Basket"...so you get AI without any sub categories.
AHI is composed of AI plus the hyponea index and not the usual 3 categories.

If using ResScan it would be called "unclassified".

The hyponeas...most likely obstructive but would not be totally impossible for them to be central in nature.

And if obstructive most usually IPAP is what we look at but there's more than one way to obtain more IPAP than just increasing IPAP all by itself.
If we increase IPAP alone that increases PS and more PS might cause too much carbon dioxide blow off which could potentially make centrals worse.
If it were my report I would be increasing IPAP but I would do it by increasing EPAP so that it pushes IPAP up and not mess with PS.
All this after I zoomed in on the hyponeas to try to make sure they looked obstructive in nature and not central.

If new to therapy...and I assume has a follow up visit with the sleep doctor scheduled sometime soon...I would make sure that these results are brought to the attention of the sleep doctor.
If no follow up appointment is on the books for anytime soon...I would call them up and make one.

These settings aren't optimal and some adjustment is necessary. Ideally the sleep doctor should have his thumb on things and not let this slide.

UPDATE I increased the EPAP from 10 to 10.2, and continued the IPAP at 15.2.

The average AHI for the previous pressure of 10 and 15.2 was 8.92. The average AHI for the pressure 10.2 and 15.2 for the last 37 days was 5.52. The improvement of of about 3.4 per night with no mask or pressure discomfort was welcomed .

Attached is a AHI summary for the last 30 days, and a event detail for 2 very different days. I've been trying to find a reason for the wide range of the AHI. I'm looking at timing of meds, naps taken, fatigue level, meals, or anything else that could improve it. (50% of days below 5 and 33% below 6 with some high numbers mixed in) Is a range for 30 days between .9 and 12.5 considered normal?

I do have an appointment with my sleep doctor in 5 weeks. I was hoping that I could tweak the pressure one more time to establish a better AHI record before I see him. I was thinking increasing EPAP to 10.3 and continuing the IPAP at 15.2?
And finally, although it should be obvious , what is the abbreviation PS? Thanks for your patience and help.

5-30-18.PNG (92.11 KiB) Viewed 14105 times

[Pugsy]

Don't forget sleeping position as a potential variable in things.
It's common for the obstructive apnea to worsen and/or need more pressure when we are on our back.

[Jas_williams]

Is there any reason why large leaks graph is turned off ? If your experiencing large leaks as well that can also affect therapy effectiveness and can cause the machine to flag Hypopnea. But Hypopnea need to be treated with more pressure.

[Mogy]

Hi Tonawanda,
PS stands for pressure support. It means the difference between IPAP and EPAP.
15.2 - 10.2 = 5 PS
Increasing your EPAP slightly seems like a reasonable adjustment and may help. You would be reducing the PS.

Another thread discussing PS.
viewtopic.php?f=1&t=166776&hilit=pressure+support

[jnk...]

According to my understanding, I am unaware of any home-treatment machine of any brand or vintage that attempts in its reports to differentiate between obstructive hypopneas and central hypopneas. Therefore, any reported hypopnea by any brand of any year is simply a report of a reduction in flow for a particular duration, in context, which may be either (1) an indication of a partial obstruction or (2) an indication of shallow breathing. In other words, a certain amount of reduction in flow will get you a report of a hypopnea from a home machine, whether the primary cause of the reduction is narrowing of the airway or is a breath that is shallow. That is, for example, why ResMed's APAP algorithm does not use hypopneas when it comes to its pressure decisions--it watches instead for changes in the shape of the flow curve that indicate actual impending obstruction, independent of its hypopnea reporting, which reporting is done merely for purposes of providing trending information.

Any flattening of the inspiratory flow curve, even when it doesn't lead to a report of a hypopnea from a home machine, may indicate a possible benefit of increasing IPAP. On the other hand, any changes in pressure that exacerbate the central aspects of complex sleep apnea should be avoided, if the central issues disturb sleep. That balancing act can be difficult if the line changes night-to-night. Thus the beauty of ASV for a certain subset of patients.

[Tonawanda]

Don't forget sleeping position as a potential variable in things.
It's common for the obstructive apnea to worsen and/or need more pressure when we are on our back.

Thanks for the reminder. I do work at sleeping on my side. I have to be creative because I still wake up on my back some of the time. I actually sleep at the side of the bed (no where to go except down ) with a wall of very large heavy pillows behind me. It isn't totally effective, RLS(controlled with pramipexole) sometimes wins the fight.

[Tonawanda]

Hi Tonawanda,
PS stands for pressure support. It means the difference between IPAP and EPAP.
15.2 - 10.2 = 5 PS
Increasing your EPAP slightly seems like a reasonable adjustment and may help. You would be reducing the PS.

Another thread discussing PS.
viewtopic.php?f=1&t=166776&hilit=pressure+support

Thanks for your response and link Mogy. I'll have to do some more reading to completely understand how PS effects my treatment settings. My Aircurve 10 is in the ST mode. If this helps helps clarify the PS on my machine, Under pressure units, the cm h2o is "ON". The other option, HPA is turned "OFF".

[Tonawanda]

According to my understanding, I am unaware of any home-treatment machine of any brand or vintage that attempts in its reports to differentiate between obstructive hypopneas and central hypopneas. Therefore, any reported hypopnea by any brand of any year is simply a report of a reduction in flow for a particular duration, in context, which may be either (1) an indication of a partial obstruction or (2) an indication of shallow breathing. In other words, a certain amount of reduction in flow will get you a report of a hypopnea from a home machine, whether the primary cause of the reduction is narrowing of the airway or is a breath that is shallow. That is, for example, why ResMed's APAP algorithm does not use hypopneas when it comes to its pressure decisions--it watches instead for changes in the shape of the flow curve that indicate actual impending obstruction, independent of its hypopnea reporting, which reporting is done merely for purposes of providing trending information.

Any flattening of the inspiratory flow curve, even when it doesn't lead to a report of a hypopnea from a home machine, may indicate a possible benefit of increasing IPAP. On the other hand, any changes in pressure that exacerbate the central aspects of complex sleep apnea should be avoided, if the central issues disturb sleep. That balancing act can be difficult if the line changes night-to-night. Thus the beauty of ASV for a certain subset of patients.

Thanks for the info jnk, I will be very cautious, and compare detailed Sleepyhead reports after making any changes on my settings!