Help with Silverlining Analysis please

[jabberwock]

Oh boy, do I need help!! I am going to try to post the detailed record graph from last night's sleep below (never tried this before, so bear with me please).

I would really, really appreciate input from anyone who knows how to read these graphs as to how my therapy is doing (not too well I suspect) and what I should be doing to improve it.

I really want to learn how to monitor and adjust my own therapy and find out what works/doesn't work for me.

Thank you for your time.

Bonnie

http://i204.photobucket.com/albums/bb23 ... ne1507.jpg

[Snoredog]

I have no history on you to go by other than what I see in that report, have no idea what even your machine settings currently are other than the obvious, Min=6 and the Max=12 with a bunch of squiggly lines in between.

My opinion based upon what I see in that graph, I see IFL1=enabled, I would try disabling it and compare.

Next, I would leave Min. Ramp pressure set at 6cm and increase initial pressure to 7 or 8cm depending on what you can tolerate as far as pressure goes. If you have difficulty falling asleep, hit the Ramp button and it will drop back down to the Min. or 6cm pressure. I would also set a 30-minute timer on Ramp so you can make use of it. Oh and you did hit the Ramp button just before you ended that last therapy session, that is the reason it is shown shaded in yellow at the end of that session, if you were just trying to hit the power button to turn it off you hit ramp by mistake. There is absolutely nothing wrong with using ramp if you want to get back to sleep at a lower pressure.

The Max or top leak line would indicate to me you have a bunch of mask leak taking place, it is even starting to pull up your avg. leak rate. Any time your leak rate starts climbing above that 0.8L/s (48L/m) you should be taking a closer look at it. That top leak Max line should remain fairly straight if you have your leaks under control. But I also don't think the leak seen impacted what was seen on the graph.

I would also increase the ceiling pressure to 14cm, you have some flat-lining going on. I also see a few Mixed apnea on your report, so I'd pull out any PSG you had and look for the same to be found there and confirm those for what they are.

So my suggestion:

1. Try disabling IFL1 and compare your results.
2. Increase the Max pressure=14cm from 12.
3. Increase the Initial pressure=7 or 8cm depending on how you tolerate pressure.
4. Fix Ramp settings so you can use it, leave it set at 6 or 6.5cm and set a 30 minute timer.
5. I would also change your pressure deliver to .5cm vs. 1cm, this way the machine will increase pressure more slowly by .5cm vs 1cm increments. It will also change the way you view the data in .5 increments vs 1cm.

The other way or option is increasing the Minimum pressure until it blows the top of your head off and eliminates everything seen, but then you might as well stay on CPAP.

[tillymarigold]

1. How do you feel? Way more important than what the numbers say.

2. You shouldn't make multiple changes at once and should give it a week between changes before making more. I'd start by disabling IFL1 though. (All the suggestions above are good ones; I'm just saying to only make one at at time.)

3. What was your titrated pressure? You probably want the range to be about 1-2cm below to 2-3cm above that.

4. Agree about changing it to adjust pressure by .5cm increments instead of 1cm.

[jabberwock]

Snoredog,

Thank you so much for your help with this. A little background if it would be helpful for you... Initially dxed with OSA in 2003, RDI of 37. Initial titration was at 6 cm pressure, given RemStar Plus with HH I used it on and off for 6 months or so, then completely gave up.

Retitrated in November 2004 at 7 cm. Never used it at that. Retitrated in November 2006 at 6 cm. In April, I was feeling so lousy that I decided to try using it again. That is when I found this forum, and have been a voracious reader here ever since. I had been using my RemStar Plus at 6 cm, as set by the DME when I took it in in April. I had a terrible time using it, and figured out why when I got my sleep studies from my GP. I have no idea why it was retitrated at 6 cm. During the Nov 2006 study, I had an RDI of 39, while on cpap at 6 cm and 7 cm. When they bumped it to 7 cm, there was absolutely no difference in the # of AHI. The report indicates basically that the study was useless since I didn't sleep long enough to get good results. I have made an appt with sleep doc for June 25 to ask WTF happened!! In the meantime, I adjusted the pressure on my RemStar to 8 cm, and at least I didn't feel like I was suffocating. Knowing how you feel about the medical profession in general, I don't imagine you are too surprised by this.

That is when I decided to get the 420E to figure out for myself what was going on. I thought I had sent the minimum pressure at 8 cm, but I had it confused with the initial pressure. I have now set both at 8 cm, with a 30 minute ramp at 6 cm. Is it noteworthy that during the flatline pressures of 12 cm that show on my graph, I had no AHI events? I have also raised the max pressure to 14 as you suggested. I thought I had disabled the FL1 last night, but apparently not. I have done so now.

Couple of questions... I don't see where I can change the pressure increments from 1 to .5 . Can I change it on the machine, or do I have to do it through the software? Also, woud you mind explaining to me what the difference is between the pink line and the red line on the leak chart?

Oh, and the ramp you see just before I ended the session this morning was because I woke up with pressure increasing, so I ramped again to try to get back to sleep. However, at that time I couldn't get a good seal on the mask, so I gave up and turned the machine off (and got up for the day).

Thank you!

Bonnie

[jabberwock]

Thanks for your reply Tillymarigold! As you will see from my previous message, I really have no idea what pressure I should be at, so it's really like I am starting from scratch. That's why I am willing to make more than one change at a time right now. Once I feel that the pressures are approximately right, I will do as you suggest and make changes more gradually, one at a time.

As far as how I feel, well, that depends entirely on the day. I actually feel relatively good today, although maybe that's because it's Saturday and I could get up when I wanted to instead of when I had to I felt terrible yesterday, but that's because I could not get comfortable with my mask and it leaked like a sieve, so I gave up and slept without the machine for the last three hours of the night (not a good idea ).

I really appreciate you taking the time to help me with this. Please feel free to make any suggestions or interpretations at any time!

Bonnie

[Snoredog]

those items seen line 2 may be why they stopped at 6 and 7cm pressure. But you are at 6cm now with your machine and there is still a "lot of obstructive activity".

your last lab found titration was at 7cm? Then set your Initial pressure to that value, if they nailed it there then the machine shouldn't be going any higher.

but at therapy hour 5, you were "flat-lining" due to the pressure limit imposed by the Maximum pressure setting of 12cm. During that period (hour 5), you have zero obstructive events, at the same time there was a dramatic increase in frequency of Flow Limitation "Runs" seen in line #6 as Runs.

I'd say your pressure is closer to 12cm based upon that finding, Flow Limitation Runs generally don't result in oxygen desaturations so I wouldn't see that increase in frequency of Runs as a problem if you at the same time eliminated all other obstructive events.

You don't appear to be a chronic snorer persay from what that report is showing, so so I would increase the maximum bump up the Minimum by 1cm and see what happens. IF you again climb to the new maximum pressure and the frequency of events seen only increase then you know why they stopped back at 6 or 7cm. Pulling out your original PSG may explain why also.

I would click on the Synthesis Tab report and double-click on that day and it will pop up with a screen indicating AHI info along with Cycle states and may even suggest a 90% pressure.

[Peterau]

Jabberwock,

Couple of things. When you start the SL software on the first screen down in the bottom right corner there is a ? symbol. Pressing this will bring up the help screen. Select the 420e and it should show you the manual for the software for the 420e. The translation could be better but I found it helped. If it want bring the help screen up (mine want I think its having a problem with the version of Adobe I run)the file is located in C:\SL3\help and is called 139DFU05-00D.pdf.
Second I notice as did the others you are have some leak problems. Your profile shows you use the Hybrid mask. Search the boards you find lots of info on the various issues with this mask.

Peterau

[jabberwock]

Snoredog,

I have had a total of 4 sleep studies including the original in 2003. Until the last one in November 2006, every event noted was a hypopnea. I had no centrals, no mixed, and no apneas. In the November 2006, I had 141 hypopneas, 1 central (at pressure 6) 1 apnea and 1 mixed, both at pressure 7. The central appeared as I was falling asleep (one of the many times I fell asleep that night), and I understand that is not uncommon. Also, never had major desats; mean desats always around 95%, with a couple of times (less than a minute each) went below 90.

The synthesis tab from last night's data shows 10 apneas, 4 centrals and 19 hypopneas, for an AHI of 4.3. The cycle states show 68% normal, 24% flow limited, 7% intermediate and 1% invalid. 90% pressure is 12 cm.

I really appreciate you helping me try to understand all of this.

Bonnie

[jabberwock]

Hi Peterau,

I actually have a hard copy of the manual which came with the software, and I am doing my best to decipher it

Thanks for the suggestion to search for issues with the Hybrid... there may be something I think is normal which is not.

Bonnie

[Peterau]

Just notice we haven't helped you change from 1cm steps to .5 When you establish the connection to the the 420 with the software on the first screen click the second tab "managing the the 420E", click the first selection "settings", then top right under pressure change the selection from 1cmH2O to .5 cm.

Peterau

[jabberwock]

Thanks Peterau! I remembered seeing it somewhere, but I couldn't find it when programming the machine at the LED display.

Bonnie

[jabberwock]

Well, last night was a little better in that the pressure did not max out, so it was more comfortable for me. I slept fairly well, with the usual awakenings to turn over and/or adjust the mask.

I am posting the detailed report from my second night, and would very much appreciate analysis/opinions/suggestions as to what improved and what still needs to be done. Yesterday I upped the min pressure to 8, turned off FL1, changed pressure increments from 1 to .5 and changed ramp time to 30 mins (still at 6 cm ramp). I forgot to change the max pressure from 12 to 14.

http://i204.photobucket.com/albums/bb23 ... ne1607.jpg


Thank you for your assistance.

Bonnie

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CPAPopedia Keywords Contained In This Post (Click For Definition): Ramp

[tillymarigold]

You did max out actually. And are you sure IFL1 is off?

Actually, are you sure that's the right chart? Yesterday was June 16 and today is June 17, and that's labeled June 15.

Still not sure why you insist on using a minimum pressure higher than your titrated pressure. Your minimum pressure should be lower than your titrated pressure. Higher is not necessarily better.

[Snoredog]

I think maybe you wanted this one to be displayed instead?
http://i204.photobucket.com/albums/bb23 ... ne1607.jpg

From viewing that report, I doubt you feel any better from the night before, if anything, I'd say you probably feel a lot worse.

It appears disabling the IFL1 stopped the runaway pressures. However, changes made appear to have gone in the wrong direction as I see it. Big increase in frequency to CA's seen on line 2 from the prior report. Machine appears to be tripping the A10 parameter which limits any apnea response at 10cm pressure not clearly indentified by cardiac oscillations (hour 14.75 is an example).

I guess you could make the argument that those events at that same hour above were caused by the increasing or changing pressure, but they look like Mixed apnea to me and without cardiac oscillations seen it should have responded with pressure and I'd be willing to bet nearly every other apap would have also responded there with pressure seeing a double apnea.

At this point, I would drop the Minimum pressure back down to 6.5cm to 7cm and/or leave it in CPAP mode at those pressures. Your case is obviously complex, since different pressure(s) don't seem to stablize your situation any. If you go back to your prior studies that is why they kept landing back at the 6-7cm pressures.

I haven't seen enough data yet to say you have CSDB, but you are close, with presence of Mixed & CA, difficulty tolerating increasing CPAP pressure (events get worse) or finding a pressure that simply offers stabilized sleep. I'd say you are close. So unless you can blow through those events seen and find stabilization of sleep you may be stuck at the lower pressure and letting those residual events go by. The only other place where your obstructive events were completely eliminated was at 12cm pressure on the prior day's report where it was flat-lining.

You could also experiment if you want with the A10 parameter, that is identified as "Command on Apnea". Your threshold may be lower than the established "10cm" quota of most APAP's. If you know you are at risk of CA or MA events with increased pressure or above a certain pressure threshold, then you input that pressure in the A 10 parameter and the machine will then avoid responding to pressure. I would even try setting the A10 parameter to 8cm. So you would try:

1. Lowering Minimum pressure back down to 6.0 or 6.5cm.
2. Leaving IFL1 disabled (it eliminates runaways).
3. Change the A 10 or Command on Apnea parameter from default=10 to 8cm. Now the machine won't respond to any apnea above 8cm (instead of 10) unless it can be clearly identified as obstructive. You don't have to worry about the CA's because machine will avoid those when it sees the cardiac oscillations.

4. Also you might try lowering the Maximum pressure to 10cm. This may mean the machine "pegs" out or flat-lines at 10cm but that appears to be the pressure if you stay at or below that it doesn't kick up a bunch more CA's. Also, if it is "pegged" out at a pressure due to the Maximum pressure setting it essentially becomes "straight CPAP" or pressure that is stabil like CPAP. Optionally, you could re-enable IFL1 and set the Maximum down to 9cm and let her rip, it will peg out at 9cm and become stabilized pressure just like CPAP.

Worth a try anyways. If you are using an interface like a swift or nasalaire you might consider one that doesn't vacuum out so much CO2.

[jabberwock]

Thank you so much tillymarigold, you are absolutely right... I posted yesterday's chart by mistake

I have replaced the link. Would you please go back and have a look at it again?

I am using a higher min because I don't believe I was titrated correctly. My last PSG where I was titrated at 6, shows an RDI of 39/h, with no difference between pressure 6 and 7. It was noted on the report that "There was not enough consolidated sleep at any pressure to make any diagnostic determinations." And I find that I feel like I am suffocating at a pressure of 6.

Thanks.

Bonnie