Just don't feel any better

[The Tired Vet]

Do those leaks bother you? You have a lot of leaking going on and they could be causing arousals that you don't remember.

I forget....what mask are you using?

I don't know what Rubicon might suggest but if it were me I would suggest working on leak management for one thing just in case the leaks are causing arousals and I would give auto mode a try and add in EPR and see what happens to the FL graph.
I wouldn't go increasing the pressure at this point and I would put UARS thinking on the back burner for now and instead work on known documented problems first.

I don't know that you need 14 cm fixed without any EPR to deal with your OSA anyway. The biggest part of your AHI is SWJ flagging anyway.
I don't like making a lot of changes at one time either because with multiple changes at one time if we see a change in something we don't know which change brought about the new result.

I think auto mode instead of fixed....keep the 14 cm pressure as the minimum....set max to 20 cm just to see where the machine wants to go to fight the FLs but add in 3 EPR full time.
At least that is what I would suggest if you were my hubby in this situation.
See what happens and how you feel and go from there.

Okay, I'm going to try this out tonight, but I thought I would ease into it a little (trying 14-18) as I've been on 12-15 again for around a week now with EPR set to 3. I still feel pretty tired and I'm posting a few more of my recent days' SleepHQ results. One thing that changed quite a bit with turning on EPR is that the leaks are down. If anyone can explain how that works I'd be interested in understanding--considering I am going to try moving the pressure up, if the EPR lowered the leaks then I suspect the leaks were somehow due to expiratory pressure, but if I move the pressure up am I going to get the leaks back? We'll find out.

August 25th: https://sleephq.com/public/0be3d491-8c6 ... 902db08274
August 26th: https://sleephq.com/public/b1b1829e-1ce ... daee653c4d
August 27th: https://sleephq.com/public/4dfbb98f-726 ... fce46fb5a1

I'll give this 14-18 a shot for a few days and see what changes. I'd like to have some time to get used to changes lest the change itself wakes me up.

Also, it seems odd to me that I need/am using such high pressures. If UARS is a culprit of my poor sleep is UARS usually treated with much higher pressures than OSA?

[Pugsy]

If UARS is a culprit of my poor sleep is UARS usually treated with much higher pressures than OSA?

That does seem to be the case at least from the people here with documented UARS.
I remember one woman whose apap machine only wanted to give her around 8 cm pressure but when she had a titration sleep study done with the Pes device and her cpap machine it was determined that she needed 13 cm pressure to resolve the UARS problem.

[GumbyCT]

If UARS is a culprit of my poor sleep

My sleep doc said anyone with sleep apnea has UARS.

[Rubicon]

Check out this on the 26th:



There's a little that on those 3 days. Probably from the EPR. Looks CSRy but undoubtedly CompSASy.

[Rubicon]

On the 25th:

[ozij]

There's a little that on those 3 days. Probably from the EPR. Looks CSRy but undoubtedly CompSASy.

Ok, so it looks like a waxing and waning of the respiratory drive.
And to - explain the acronym to those who don't know it - you're saying it looks like something with a "Complex Sleep Apnea Syndrome" whiff to it --

Does that explain why he's still tired?
Does it mean he should try the same pressure range without EPR - since EPR helps him blow off CO2, and too little CO2 makes for that cyclical breathing?
Does it mean he should maybe try a somewhat lower pressure - fixed or range?
Does it qualify him for an ASV machine?
Inquiring minds etc....

[The Tired Vet]

There's a little that on those 3 days. Probably from the EPR. Looks CSRy but undoubtedly CompSASy.

Ok, so it looks like a waxing and waning of the respiratory drive.
And to - explain the acronym to those who don't know it - you're saying it looks like something with a "Complex Sleep Apnea Syndrome" whiff to it --

Does that explain why he's still tired?
Does it mean he should try the same pressure range without EPR - since EPR helps him blow off CO2, and too little CO2 makes for that cyclical breathing?
Does it mean he should maybe try a somewhat lower pressure - fixed or range?
Does it qualify him for an ASV machine?
Inquiring minds etc....

Just an FYI: I only started using the EPR around a week ago, and that cyclical breathing has been part in my reports every night going back to April when I first started collecting the data.

[lynninnj]

There's a little that on those 3 days. Probably from the EPR. Looks CSRy but undoubtedly CompSASy.

Ok, so it looks like a waxing and waning of the respiratory drive.
And to - explain the acronym to those who don't know it - you're saying it looks like something with a "Complex Sleep Apnea Syndrome" whiff to it --

Does that explain why he's still tired?
Does it mean he should try the same pressure range without EPR - since EPR helps him blow off CO2, and too little CO2 makes for that cyclical breathing?
Does it mean he should maybe try a somewhat lower pressure - fixed or range?
Does it qualify him for an ASV machine?
Inquiring minds etc....

I mentioned Cheyne-Stokes a week or 2ago, associated with the Complex sleep apnea syndrome you mention above, but it didn’t seem to go over well even though it was just a question.

This inquiring mind wants to know also. But if it is a complex type that’s something for the pulmonologist or the cardiologist I would imagine.

[Rubicon]

I mentioned Cheyne-Stokes a week or 2ago, associated with the Complex sleep apnea syndrome you mention above, but it didn’t seem to go over well even though it was just a question.

What, you mean this?

as a part of my learning let me ask outright from one of them- is that Cheyne Stokes?

IDK what you're referring to, but he don't have any CSR.

I think it went over fine.

Some things:

1. I think you have to be careful tossing around CSR. It can open up a serious can of worms.

2. If you do want to consider CSR you need to follow Da Rules:

In adults Cheyne-Stokes breathing is scored when both of the following are met: (1) there are episodes of ≥ 3 consecutive central apneas and/or central hypopneas separated by a crescendo and decrescendo change in breathing amplitude with a cycle length of at least 40 seconds (typically 45 to 90 seconds), and (2) there are five or more central apneas and/or central hypopneas per hour associated with the crescendo/decrescendo breathing pattern recorded over a minimum of 2 hours of monitoring.

and in the previous submissions I did not see anything that met either criteria, much less both. About all you say is there was waxing and waning.

3. Some of those events were SWJ and should be discarded anyway. This is obviously easier when you have NPSG to do that with.

4. The current submissions show a more pronounced waxing and waning. Yes they do look CSR-y, but given the settings change (max EPR) one might (should) consider CompSASy stuff.

5. If the OP has a tendency to CompSAS, we need to return to one of my original questions:

How'd you end up on 14 cmH2O?

Is some of this from unnecessarily aggressive pressures? If so the answer isn't ASV, it's stop arbitrary dial wingin'.

[Pugsy]

5. If the OP has a tendency to CompSAS, we need to return to one of my original questions:

How'd you end up on 14 cmH2O?

Is some of this from unnecessarily aggressive pressures? If so the answer isn't ASV, it's stop arbitrary dial wingin'.

I asked this question quite a while back and the impression I got was that it sort of magically appeared after being drawn out of someone's butt.
I did notice the CSRish waxing and waning on pre EPR flow rate but didn't see the needed centrals with it and a lot of it looked more like SWJish stuff anyway....so while I wasn't going to totally ignore it with the idea to add in EPR...I was going to keep an eye on it from the back burner.

My sole goal with the idea of a lower minimum and add in EPR was to see if any OAs grew in number and see if sleep quality improved at all with the main goal of just improving sleep quality itself. See if the train wreck of sleep quality could be lessened at all. Instead I get UARS idea thrown in and the decision to increase the pressures and not reduce them and we have zero idea if UARS is even a factor here.
I have seen no proof that 14 cm is anywhere near being needed or for that matter 10 cm.

[Rubicon]

My sole goal with the idea of a lower minimum and add in EPR was to see if any OAs grew in number and see if sleep quality improved at all with the main goal of just improving sleep quality itself. See if the train wreck of sleep quality could be lessened at all.

I think that's a superior idea.

[The Tired Vet]

5. If the OP has a tendency to CompSAS, we need to return to one of my original questions:

How'd you end up on 14 cmH2O?

Is some of this from unnecessarily aggressive pressures? If so the answer isn't ASV, it's stop arbitrary dial wingin'.

I asked this question quite a while back and the impression I got was that it sort of magically appeared after being drawn out of someone's butt.
I did notice the CSRish waxing and waning on pre EPR flow rate but didn't see the needed centrals with it and a lot of it looked more like SWJish stuff anyway....so while I wasn't going to totally ignore it with the idea to add in EPR...I was going to keep an eye on it from the back burner.

My sole goal with the idea of a lower minimum and add in EPR was to see if any OAs grew in number and see if sleep quality improved at all with the main goal of just improving sleep quality itself. See if the train wreck of sleep quality could be lessened at all. Instead I get UARS idea thrown in and the decision to increase the pressures and not reduce them and we have zero idea if UARS is even a factor here.
I have seen no proof that 14 cm is anywhere near being needed or for that matter 10 cm.

Not for nothing, but trying to sort out a single recommendation from everyone's messages is not a simple task... I also don't make changes very often. Aside from EPR, the next paragraph is all of the changes I've made since probably at least April of this year.

14 cmH20 constant was the recommendation from the sleep doctor on 8/11--she picked this because I think she misunderstood what 95% pressure means. Anyway, I did 14 for about a week and then switched back to 12-15 where I had been for a long time. I did move the range up on 8/28 (so two nights at this point) to 14-18, here's 8/27: https://sleephq.com/public/ab4d6560-b4f ... 2918c7d017. For some reason I changed from standard to soft response last night to see what it did and that was crap so I'm not doing that again. I can try 10-20 (you had suggested 14-20 and I was a touch worried about moving the top to 20 all at once but I think I can handle it now). The only thing that worries me is the changes in pressure and that they'll wake me up. I'll give this a shot for a couple of nights and report back.

There were also the three nights of no chin strap from 8/11-8/13 with massive leaks per doctor's orders. I spoke to her again today and she said she believes no matter how high the leak, even the 104 L/min i had one night without the chin strap, could be compensated for by the CPAP machine. Do I believe this...?

[Pugsy]

There were also the three nights of no chin strap from 8/11-8/13 with massive leaks per doctor's orders. I spoke to her again today and she said she believes no matter how high the leak, even the 104 L/min i had one night without the chin strap, could be compensated for by the CPAP machine.

Well I am going to totally disagree on her idea that the machine can compensate for massive leaks like that but how important that 104 L/min leak might be would depend on how much time you spent up there. If you hit 104 for maybe 10 minutes and the rest of the night the leaks were a lot less drastic (like maybe around 30 L/min)...the machine can do a decent job depending on how much less and how long at less.

Edit::: Plus that much leak is very likely going to disturb sleep anyway....the last thing you need to be happening.

I can try 10-20 (you had suggested 14-20 and I was a touch worried about moving the top to 20 all at once but I think I can handle it now)

Adding EPR to the minimum of 14 would mean 11 EPAP (if using 3 cm EPR) and if you needed more EPAP then we would expect to see some obstructive in nature events materialize but I have my doubts that we would see them happen.
Then my next idea would be go even lower assuming the reduction during EPAP during cause a lot of obstructive stuff.

As I mentioned above...just tossing out ideas that might help reduce the train wreck of your sleep quality and not increase the chances of allowing obstructive stuff to happen.

I seriously doubt that your pressure will go anywhere near 20 cm even if it could. I might be wrong but I just don't see it happening but if you are more comfortable with a limited max...then just limit the max. If you hit the limitation then we discuss maybe increasing the max. Heck set the max limit to 16 and see if you even hit it. If you do then we talk about the why and what to do about it.

I don't know that there is any magic setting or combination of settings that is going to help your overall crappy sleep but I figured why not at least give it a try....just in case.
If we don't try....we know the answer is always "no".

[Pugsy]

So your doc came up with fixed of 14 cm based off a 95% number which was probably near 14????

Here's a 90% number of 16.5 cm....artificially elevated by just one hour at the higher pressures.
This is why I don't like using 90/95% numbers of anything as any sort of standard....they are too easily elevated by times at higher numbers.
Going by that logic someone might prescribe 16.5 fixed for me here...when it is blatantly obvious that I do quite well with a lot lower for the bulk of the night as well as other nights.

I have my doubts that you need 14 cm which was why I first wanted to try EPAP at 11 to see what happens and then most likely go even lower.

[lynninnj]

I mentioned Cheyne-Stokes a week or 2ago, associated with the Complex sleep apnea syndrome you mention above, but it didn’t seem to go over well even though it was just a question.

What, you mean this?

as a part of my learning let me ask outright from one of them- is that Cheyne Stokes?

IDK what you're referring to, but he don't have any CSR.

I think it went over fine.

Some things:

1. I think you have to be careful tossing around CSR. It can open up a serious can of worms.

2. If you do want to consider CSR you need to follow Da Rules:

In adults Cheyne-Stokes breathing is scored when both of the following are met: (1) there are episodes of ≥ 3 consecutive central apneas and/or central hypopneas separated by a crescendo and decrescendo change in breathing amplitude with a cycle length of at least 40 seconds (typically 45 to 90 seconds), and (2) there are five or more central apneas and/or central hypopneas per hour associated with the crescendo/decrescendo breathing pattern recorded over a minimum of 2 hours of monitoring.

and in the previous submissions I did not see anything that met either criteria, much less both. About all you say is there was waxing and waning.

3. Some of those events were SWJ and should be discarded anyway. This is obviously easier when you have NPSG to do that with.

4. The current submissions show a more pronounced waxing and waning. Yes they do look CSR-y, but given the settings change (max EPR) one might (should) consider CompSASy stuff.

5. If the OP has a tendency to CompSAS, we need to return to one of my original questions:

How'd you end up on 14 cmH2O?

Is some of this from unnecessarily aggressive pressures? If so the answer isn't ASV, it's stop arbitrary dial wingin'.

thank you for kindly explaining this.

I was looking at patterns but was unaware of other dx criterion. Hadn’t really looked that deeply at it to be honest.

I hope our tired vet figures this out soon!