Not such a goodknight

Snoredog · Post by **Snoredog** » Tue May 29, 2007 2:10 pm

My opinion:

1. Your pressure is all over the place in response to FL's it goes from 6cm to 19.5cm.
2. You obviously need to disable IFL1 parameter (Command on FL), uncheck the box in Advanced settings.
3. Control your mouth breathing, leak is out of control. Your leak rate should not go higher than about 0.8L/s on that report if that is under control.

The machine is going nuts chasing those FL's, look at the "RUNS" it is nearly a solid blue bar. Next look at your cycle states, if it was under control your Normal cycles should be well over >90 not down in the 60's.

You need to disable the IFL1 parameter and bump your Min. pressure up to about 8cm. You first have to "settle" things down then tweak it once you get there.

MrPaul · Post by **MrPaul** » Tue May 29, 2007 2:23 pm

First thanks all for all the advice.

Last night I put up the minimum pressure to 8 (from 4). I'll try disabling the IFL1 setting tonight to see what it does.

rested gal · Post by **rested gal** » Tue May 29, 2007 9:50 pm

MrPaul,

Thanks for posting the 96 hour graph. Looks like you're leaking air like crazy. Probably mouthbreathing during your sleep.

"My wife did say I was blowing a lot of air out of my mouth if I was sleeping on my back"

And that was when she was awake to notice it. You can bet that a lot more mouth air leaks were going on most of the night. Gonna have to get them under control -- try a chin strap first if you like your present mask. Other alternatives...a full face mask or one of the methods you can read about in these topics:

Links to: Mouth leaks - Air Leaks - Tape - DIY Guard
viewtopic.php?t=8011

It's really hard to know what you might need to tweak in the pressure range or regarding IFL1, until you take care of the massive leaks. Air gushing out the mouth is not going where it's needed. Looking at what your graph showed with the minimum pressure raised to 8 , I do agree with Snoredog that it's time to try turning off IFL1.

MrPaul · Post by **MrPaul** » Wed May 30, 2007 9:03 am

Hi All,

OK Another day another set of reports. Turning off IFL1 didn't seem to make much of a difference. Are there still large leaks? Where do you see that in the reports?

rested gal · Post by **rested gal** » Wed May 30, 2007 12:48 pm

MrPaul wrote:Hi All,

OK Another day another set of reports. Turning off IFL1 didn't seem to make much of a difference. Are there still large leaks? Where do you see that in the reports?

You're right, MrPaul...turning off IFL1 didn't seem to make a difference. You're still getting the most yo-yo'ing pressure line I've seen (to not have IFL1 on.) Your leak rate seems ok.

Here's an experiment to try, if you want to:

Stay in autopap mode. Keep IFL1 off for the moment. Set the max and min pressures for the same number -- 10 max, 10 min. "Start" pressure at 10.

In other words, run the machine in autopap mode, but with the pressures set as if it were a straight cpap machine at 10. Keep it like that for a few days, then continue keeping it at "10" for a few more days, but with IFL1 turned back on.

I'm not a doctor, so it's up to you if you want to try some straight pressures to see what kind of data you get that way.

MrPaul · Post by **MrPaul** » Wed May 30, 2007 1:08 pm

Rested gal, thanks for the suggestion.

My last tritrated CPAP rate was 12, I don't mind setting it at 12-12-12 in apap mode but is that any different then 12 in CPAP mode?

Also given the leak rate does it indicate that I am not mouth breathing (or at least not significantly)?

Is this possibly a hardware issue (i.e. Mask or Hose or something else)?

Snoredog · Post by **Snoredog** » Wed May 30, 2007 1:43 pm

My opinion:

TOO many CA's seen on your report.

Disabling IFL1 DID help your situation, your FL "RUNS" are much lower than before but still a lot of work needs to be done.

Suggestion:

You need to reduce the number of Central Apnea seen, observe your detailed report, look at the pressure "peaks" they correlate with CA's above on line 2 in the detailed report.

That means those are more than likely are pressure induced Centrals, you need to LIMIT the pressure settings on the machine then adjust the "Command on Apnea" setting, which currently defaults to 10cm. You need to lower the "A 10" parameter or "Command on Apnea" parameter from current 10cm setting to 9cm setting. This will then limit how the machine responds above 9cm pressure instead of 10cm, basically it won't respond to an apnea above 9cm pressure instead of default 10cm pressure. This should eliminate the Centrals seen on the latest report.

You should set your:

Minimum pressure to 7cm (enable a 30-minute autoramp)
Initial pressure=8cm
Maximum pressure=10cm
Leave IFL1 disabled
Lower A 10 parameter from 10cm to 9cm.

Then look for fewer CA's on your next detailed report. The sleep lab missed your titration at 12cm, you start having CA's at 10cm pressure (again correlate those pressure peaks seen on last report with the CA's seen above).

With those CA's seen, you need to stay below 10cm pressure period.

Mask leaks are still a MAJOR problem. I don't know what mask you are using but from the report it appears to be junk. If you cannot control those leaks you need to toss that one for another. That top "pink" max leak L/s line should be a solid line.

Note: The detailed report shows you are at risk of having pressure induced Central Apnea. These can be caused by too high pressure. Observe the pressure "used" right before the CA's tics seen on line 2 of the Detailed report and you will see they correlate with higher pressure. My guess is your threshold is lower than the default on the machine. This is why there is so much pressure activity. When you assume this particular machine is only about 60% accurate at differentiating central apnea from obstructive apnea, then many of those other Apnea seen are probably central apnea as well. The machine is highly accurate when the central apnea has an open airway where it can hear cardiac occiliations, but studies show that only about 60% of central apnea has an open airway. So if the airway is closed on some of those centrals, the machine won't be able to detect it. That is 6 out of 10 centrals seen, so 4 of those logged apnea could very well be central as well (could be reason there is so much activity on your report).

RG's suggestion of setting Min-Max both to 10cm may also work, but from what I seen it needs to be at 9cm not 10cm. IF 10cm was the magic number, the machine should NOT be responding the way it is based upon default A 10 parameter and it is. I believe your threshold is lower than 10cm, most likely 8.5-9cm.

But you won't know that until you try it for yourself.

Note: Masks; keep in mind that if you start switching masks around with different CO2 retention rates can impact what is seen on your report. If you are using like a Swift, it will flush out more CO2 than a mask with greater deadspace like a CF2. For these machine tweaks, you should stick to the same mask so you can compare otherwise your results could be flawed.

tillymarigold · Post by **tillymarigold** » Wed May 30, 2007 2:43 pm

Snoredog wrote:You need to reduce the number of Central Apnea seen, observe your detailed report, look at the pressure "peaks" they correlate with CA's above on line 2 in the detailed report.

CAs are centrals? I thought they were just regular apneas where your heart started pounding. The manual says they're "apneas with cardiac oscillations."

Hmm. I had no apneas at all in my sleep study, but I'm averaging about one or two "Apneas," two "Apnea/CAs", and a "Hypopnea" per night (total AHI is usually just under 1), in addition to my FLs.

Snoredog · Post by **Snoredog** » Wed May 30, 2007 4:08 pm

tillymarigold wrote:
Snoredog wrote:You need to reduce the number of Central Apnea seen, observe your detailed report, look at the pressure "peaks" they correlate with CA's above on line 2 in the detailed report.
CAs are centrals? I thought they were just regular apneas where your heart started pounding. The manual says they're "apneas with cardiac oscillations."

Hmm. I had no apneas at all in my sleep study, but I'm averaging about one or two "Apneas," two "Apnea/CAs", and a "Hypopnea" per night (total AHI is usually just under 1), in addition to my FLs.

MrPaul · Post by **MrPaul** » Wed May 30, 2007 6:46 pm

Wow you guys are making me feel like an Apnea freak case.

I'm going to try the settings that snoredog suggested with my current mask (its an Acclaim 2 I'll try to adjust it a little bit) and see what happens. Assuming that doesn't totally fix the problems I'll try mouth taping and/or the ConfortGel Mask I recently bought. I'm trying not to change too many things on one night just to make sure one thing doesn't interfere with another.

I do appreciate all the help though!

Snoredog · Post by **Snoredog** » Wed May 30, 2007 6:57 pm

MrPaul wrote:Wow you guys are making me feel like an Apnea freak case.

I'm going to try the settings that snoredog suggested with my current mask (its an Acclaim 2 I'll try to adjust it a little bit) and see what happens. Assuming that doesn't totally fix the problems I'll try mouth taping and/or the ConfortGel Mask I recently bought. I'm trying not to change too many things on one night just to make sure one thing doesn't interfere with another.

I do appreciate all the help though!

talk to your wife about that mouth leaking and/or snoring. The snoring may be inaudible so she may not hear anything there. Too bad you didn't have a Full Face mask to try so you could compare results on the reports. You could try a ACE bandage as a chin strap, if leak and snoring goes down you know which direction you should be going.

Mouth leaks allow therapy pressure to escape resulting in skewed data seen on reports and resulting in more events. You just have a lot of "activity" seen on your report, meaning you haven't found the combination of machine settings yet to settle things down.

With continued mouth/mask leaks and snoring CPAP may be the way to go as CPAP doesn't care about snoring or a little bit of mouth leaks. I call it one-way therapy. Your PSG report should also have noted those CA's.

MrPaul · Post by **MrPaul** » Wed May 30, 2007 7:13 pm

My wife says I only snore when I lay on my back, though maybe that's the only time I snore loudly.

I actually have a chin strap from when I first got my setup (4-5 years back), I just don't think I've ever been able to sleep with it on, hence the mouth taping seems to be a more comfortable short term alternative.

[/list]

MrPaul · Post by **MrPaul** » Thu May 31, 2007 10:22 am

Hi All,

Another set of results.

Still seems like an awful lot of runs? I think the leaks max line looks a bit smoother, but its somewhat hard to tell. Snoredog/rested gal what's next?

tangents · Post by **tangents** » Thu May 31, 2007 11:14 am

Seems to me you're on the right track, MrPaul. Look how nice and low your leak graph is! Your AHI is around 1.0 as well, which is good, too. The question is - how do you feel today?

I would think you'd still want your cycle states more in the normal and less in the intermediate and flow limited states. I'm thinking that the crux of your problem is your acoustical vibrations (snoring). But I'm not anything approaching an expert. My novice opinion is that you could try sleeping only on your side, and see what the graph looks like then.

I'll be interested to follow this thread and see what Rested Gal and Snoredog have to say.

Cathy

rested gal · Post by **rested gal** » Thu May 31, 2007 1:01 pm

tangents wrote:I'm thinking that the crux of your problem is your acoustical vibrations (snoring).

I think so too, Cathy.

MrPaul, you've tried IFL1 off now, and I don't see that it made an appreciable difference in the way the pressure is behaving for you. I think one thing and one thing only is what's driving the pressure up so suddenly and repeatedly for you. Snores. Snores -- whether audible to the bed partner or not. I believe if you set the minimum pressure up high enough to knock the snore index down considerably you will start seeing less pressure run ups.

Do you usually have a somewhat stuffed up nose? Or does it seem to get more stuffy when you lie down? Any allergies that cause nasal congestion for you, especially when laying down?

Your leak rate isn't awful, imho. But it isn't great. Looks like there is still some leaking going on, and my bet would be mouth leaks. I think your snoring is associated with mouth being either open or closed with very loosely closed lips letting air be breathed in through your mouth.

Personally, I would not give the random occasional CA's you're getting a second glance. As few of those as have been showing up even on your wildest pressure climb nights, I don't think they are significant or troublesome at all. I would not change the advanced setting "Command for max pressure on apnea" from the default of 10 cm. I'd leave that advanced setting right where it is.

You know, despite all the crazy pressure up/downs (I really think snoring is the culprit for those swings) your AHI has stayed very good all along.

You asked about what would be the difference in running the machine in cpap mode at 10 cm and running it in APAP mode at 10/10. I don't know this for sure, but in APAP mode the machine might be looking at more things about the air flow. I don't know if CPAP mode would let the machine note as much about the air flow (in regard to flow limitations that are not yet an hypopnea or apnea) as APAP mode does. Anyway, staying in APAP mode for the "straight pressure" experiments would definitely keep the data gathering happening in the same way for sure. That's my untechie take on it, anyway.

Snoredog wrote:something strange is going on with mask/mouth leak and snore which appears to be what is driving up the pressure.

Yup, looks more and more like the snores are the culprit.