Treating flow limitations not logged by ResMed

[super7pilot]

First a bit of back story. Had a sleep study late last summer. Found I have moderate sleep apnea. Which consisted of the following.
AHI-22
OA-3
Mixed-2
Central-2
Hypopnea-101

So hypopnea's are my kryptonite
With the help of many folks working with me and through OSCAR. My AHI is down to .77 average since starting pap therapy. So I do feel a lot better than pre-pap. But despite the low AHI I feel like there is room for improvement as I still at times get sleepy in the day and have days with nagging mild headaches. (but still much improved from the past)

So I set up OSCAR with a user defined flag of 60% flow restriction for 8 seconds to look for unflagged Flow Limitations that might still be disrupting my sleep.
And what I found were a lot of 60% FL flags. Going back to the start of therapy. My index for 60% FL's are at 4.52. And some days were as high as 10.

I would like to try "if possible" to bring that down. As can be seen in my charts. I do have a lot more CA's now than in my study. So the treatment emergent CA's don't seem to be going away. So my question for the forum. Would switching from the AirSense to the AirCurve be an option so I could manage the timing of the pressure support at the bottom of my exhale in an attempt to prevent those partial airway collapses?

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[Pugsy]

show us a couple of zoomed in screen shots like your others but this time include CA/Central flagged event please.

I personally don't think that those are treatment emergent centrals.....I need proof that they are the real deal before I start worrying about them.

[super7pilot]

Here you go. My sleep study was a class 1 in lab and showed only 2 Central Apneas and 2 mixed. In the last week I have had several nights with no apneas at all. So it seems consistently inconsistent.

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[Pugsy]

It's normal to have an occasional real central apnea. There are what we call sleep transition centrals or sometimes called sleep onset centrals. Seeing them does NOT mean treatment emergent central apnea.
It's normal to have a handful of centrals. This might be what you are seeing.
At any rate....doctors don't go down the "treatment emergent central apnea" road and start worrying until you are having at least 5 centrals per hour average over the entire night and every night. Your number of centrals doesn't qualify at all.

Now if you have a report with back to back to back centrals like I did the second half of the night below....then we have a different talk. I haven't been worried about this because I have only had it happen twice like this in over 15 years.

[super7pilot]

I think we have a miscommunication.
I was actually asking about how does one treat those 60% flow restrictions. Esp as I'm already at EPR-3 on the airsense 11. Wondering if moving to the Aircurve 11 V/auto might allow me to change the point of the inspiratory pressure increase to stent my airway. It's my understanding that the Airsense11 EPR is a bit slow to react to inspiration and the pressure increases after you start to inhale. Which creates a short negative pressure and results that chair shaped flow wave. And maybe I'm very wrong in how I interpret all those 60% restrictions.

I have a regular appointment at my VA next Monday and will also talk to her about this. I'm hoping that as this is the VA and not a regular insurance thing. They might be more open to me trading up. But I'm just trying to glean any info from those with more experience than I. if the VA says no. I'll use info from cpap forums and buy a refurb or low hour V/auto on my dime.

[Pugsy]

I think we have a miscommunication.

Perhaps..... but I got the impression that you were afraid to increase the pressure (which is what is need for flow limitations unless nasal congestion is what you are seeing) or use more EPR (if you could but I know you can't with current machine) because you felt like you had treatment emergent central apnea and was afraid to maybe cause more centrals by using more pressure (EPAP). So I was just trying to relieve some of that worry.

As far as what pressure to use....I have no idea which is why I didn't go there with my response.
My response was to mainly alleviate concerns about possibly causing more centrals.
I have no idea if the Bilevel model will accomplish what you want but it is worth trying. I use a bilevel AirCurve 10 VAuto and have for years just because I feel I sleep a little better with it but it's no miracle maker for sure.

[super7pilot]

Ah ok, I'll give pressure button a nudge tonight and see what happens.

[Nocibur]

And maybe I'm very wrong in how I interpret all those 60% restrictions.

Yeah probably. You seem to believe that Resmed "flow limitations" and Oscar "flow restrictions" can be used interchangeably. I don't believe they can. Resmed flow limitation is calculated using a combination of flatness index, breath shape index, ventilation change, and breath duty cycle. IDK what the Oscar flow restriction calculation is based on but I'm pretty sure it's flow exclusively, so it's simply looking more aggressively for apneas and hypopneas.

[Nocibur]

it's simply looking more aggressively for apneas and hypopneas.

Especially since they dropped their default to 8 seconds.

I mean, you could keep PWing till you got like 2000 events per night...

[super7pilot]

it's simply looking more aggressively for apneas and hypopneas.

Especially since they dropped their default to 8 seconds.

I mean, you could keep PWing till you got like 2000 events per night...

Not sure what PWing means. But I'm sure it was meant as a pejorative.

So if I'm still getting sleep disruptions and ResMed claim via their one algorithm for everyone that my sleep is great. Should I then just stop trying to get better therapy because ResMed thinks it knows my sleep better than I do? Man that's a scary way to think.

I'm sorry if you feel that investigating one's therapy beyond an all for one algorithm is some sort of fools errand.

[super7pilot]

And if PWing isn't a pejorative. Then please accept my apologies.

[Nocibur]

Damn that woman and her PMs! And I had such a great "pejorative" reply all set to go!

[super7pilot]

Pugsy. Most of my CA's seem to be of the low Co2 type. I generally will have a max of 1-2 CA's that look to be real centrals on my Flow Rate chart. So not fussed about them. Turned up the pressure last night from 12 to 12.4 and the user events increased dramatically. But the CA's went down by more than half.
In the end. My goal is to try and limit those sleep disrupting breathing restrictions. Does anyone with some knowledge or experience think using the same pressure and PS on the AirCurve as your AirSense with EPR-3 but altering the inspiratory air pressure timing make the stent more efficient at the same pressure? It is my understanding (and perhaps I'm wrong) that the PS in the AirCurve can be adjusted to trigger the pressure increase just before you have finished exhaling. (like ignition advance on an engine) Whereas the AirSense waits until you have started inspiration. So a delay that renders the EPR less effective at stenting flow Limitations.

All along, My apnea's and Hypopnea's were well controlled at 6-7cm just 10 days into therapy. But my FL's were high and only started relenting at 10-12 with EPR-3

Either way I'm going to lobby my local VA for the AirCurve. or I will buy one.

Nocibur, Bummer when one has the trigger half way pulled and you hear "Cease Fire"

[Nocibur]

PWing is akin to DWing.

DWing ("dial wingin'") pertains to arbitrarily changing machine settings and hoping for positive outcome.

PWing ("parameter wingin'") refers to arbitrarily changing definitions ("Da Rules") and hoping for... actually IDK what the point of doing that would be. Seems to me it would be far better to review the waveforms and then decide what (if anything) needs to be done.

For instance, in the 2 events under your current PWing, IMO they're just a couple of harmless central apneas that weren't even central apneas until you changed the criteria (I think I'll change PWing to Cwing) from 80% reduction to 60% reduction and 10 second duration to 8 second duration. The ResMed algorithm needs to follow AASM Definitions (DWing would be a better descriptor than CWing or PWing but it was already taken) so they weren't scored as anything, nor should be.

That said, no law that says we can't play fast and loose with Da Rules, especially since we have a limited number of parameters to work with, when it makes sense and we got some basis to do so.

ResMed thinks it knows my sleep better than I do

ResMed does not think it knows your sleep better than you do. Frankly, ResMed doesn't GAFF about your sleep. I mean, they'd like to (like be able to exclude all Wake from calculations) but they're in the Breathing Business, not the Sleep Business. Sleeping is an assumption. And IYAM, and based on some of the other parameters, what the 60% Restriction/8 second Rule has found is a pile of disturbed sleep. If you're looking to fix FLs look specifically at the FL graph.

[Nocibur]

Nocibur, Bummer when one has the trigger half way pulled and you hear "Cease Fire"

Even worse when it's a Claymore and the button was pressed the third time...