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AMK wrote:What does a healthy flow limitations graph look like for someone getting good sleep?

Usually really boring flow limitation graph using a ResMed machine.
Mine is a good example of really boring. Not much activity at all. Click on image to enlarge for better viewing if needed as it appears the right side is cut off initially.

AMK wrote:

What does a healthy flow limitations graph look like for someone getting good sleep? My graph looks like the one in this thread and I too am exhausted.

+1 to this....I am in the same boat

Wow that's a lovely boring flow limitation graph. Mine's a mess compared to that. My apap is 5-9 and my average 95% is 8.88. I'm thinking I should raise it to 7-10, get a 95% from that, and try the straight cpap.

Pugsy wrote:

robysue wrote: Can anybody help me out here: If RERAs are a problem, is the A10 "for Her" Auto algorithm supposed to be better at addressing the issue than the regular A10 algorithm?

I think that RERAs are flagged in the special "for her algorithm" and not in the regular apap setting...and while I don't know if the for Her special algorithm would actually make that much of a a difference here in this situation it is why I asked which model AutoSet this person might have. I don't know if the absence of any RERAs on this report above means that there weren't any or they weren't flagged. I am still trying to figure out what might be something that is flagged only in the the for Her special algorithm.
I also don't know if the "for Her special apap algorithm" would maybe help someone with UARS better but it's another reason for having it available "just in case".
On paper it sounds like the for her special apap mode might be worth trying for UARS since it seems like UARS patients tend to be sort of super sensitive anyway.

don't they still use manual scoring in sleep labs to register arousals? I wonder whether the RERA detection is reliable in CPAPs

tan wrote: don't they still use manual scoring in sleep labs to register arousals? I wonder whether the RERA detection is reliable in CPAPs

I don't know how much manual vs electronic scoring is used in sleep lab settings....perhaps Morbius could answer that question better.

I would tend to at least trust RERAs flagged by the machines though because I suspect that a lot of work went on behind the scenes in coming up with whatever they did to decide that they have some sort of way to flag the breathing pattern they flag as RERAs.
There's likely some sound reference behind the scenes where they compared what the machine flags against what was perhaps manually flagged. Is it 100 % perfect.....of course not but then manually scoring isn't necessarily 100% perfect either.

From my own experience with my PR S1 machine that does flag RERAs....when I had a crappy night's sleep for whatever reason it wasn't unusual to see a much larger number of RERAs being flagged. Usually in my situation it was factors outside sleep apnea that caused the sleep disturbance and the RERAs flagged just confirmed the crappy sleep.

So while the absence of RERAs doesn't guarantee perfect sleep or feeling the miracle....when I see a lot of RERAs the first thought that goes through my mind is "something is causing crappy sleep" and that gives us something to look for or do in an attempt to fix the crappy sleep.
It may or may not be related to sleep apnea or the airway collapsing but it is at least something to try to fix to stand a chance at feeling the good numbers we might otherwise be seeing and not feeling.

AMK wrote:Wow that's a lovely boring flow limitation graph. Mine's a mess compared to that. My apap is 5-9 and my average 95% is 8.88. I'm thinking I should raise it to 7-10, get a 95% from that, and try the straight cpap.

Sounds like a good strategy. Remember that when you go with straight pressure with EPR, your set pressure = IPAP and so EPAP = IPAP - EPR. For example, if you did straight pressure = 10 with EPR of 3, your IPAP = 10 and EPAP = 7.

EPAP is what is needed to eliminate Obstructive events. IPAP reduces Hypopneas and Flow Limitations. So use the EPR to make it comfortable to breathe and still eliminate FLs and RERAs.

In your case, a good strategy could be to go with a straight pressure of 11 with EPR set to 3. If on this setting for 7 days, you still see Obstructives, you can then increase the straight pressure to 11.5 and repeat.

Guest1 wrote:

AMK wrote:Wow that's a lovely boring flow limitation graph. Mine's a mess compared to that. My apap is 5-9 and my average 95% is 8.88. I'm thinking I should raise it to 7-10, get a 95% from that, and try the straight cpap.

Sounds like a good strategy. Remember that when you go with straight pressure with EPR, your set pressure = IPAP and so EPAP = IPAP - EPR. For example, if you did straight pressure = 10 with EPR of 3, your IPAP = 10 and EPAP = 7.

EPAP is what is needed to eliminate Obstructive events. IPAP reduces Hypopneas and Flow Limitations. So use the EPR to make it comfortable to breathe and still eliminate FLs and RERAs.

In your case, a good strategy could be to go with a straight pressure of 11 with EPR set to 3. If on this setting for 7 days, you still see Obstructives, you can then increase the straight pressure to 11.5 and repeat.

Does CPAP mode register FLs?

I would rather leave the upper limit open and would instead be increasing the lower limit. My personal experience is better with higher EPR.

tan wrote: Does CPAP mode register FLs?

It does with the ResMed machines but doesn't with the Respironics machines.
FL flagging isn't available on the Respironics machines unless in auto adjusting pressure mode.
With the ResMed machines it doesn't matter because the graphs are available no matter what the mode unless the machine doesn't do FL graphs at all....like my S9 36007 model...it doesn't give me FL graphs at all.

Guest wrote:
All this info is available on the titration document on pubmed or aasmnet websites.

Guest, can you provide more info/detail (in order for me to google) or a link to information like this?
Thank you.
E25

Guest1. how does EPAP eliminate Obstructive events?

elizabeth25 wrote:

Guest wrote:
All this info is available on the titration document on pubmed or aasmnet websites.

Guest, can you provide more info/detail (in order for me to google) or a link to information like this?
Thank you.
E25

E25 and AMK: You should read this whole pdf doc.

www DOT aasmnet DOT org SLASH Resources SLASH clinicalguidelines SLASH 040210 DOT pdf

This explains how a titration is done including with BiPap titration. Since a Resmed A10/S9 with EPR is a bipap with EPR = IPAP-EPAP, you should read the BiPAP titration guidelines (specifically guideline #4.3.2 and subguidelines). You can use EPR as a tool to make sure you are breathing out at minimum possible pressure to tackle all Obstructive Apneas and still have a bit more IPAP (upto 3cm with EPR), to tackle the Hs and RERAs and FLs.

A few quick thoughts, some of which have been said already.

Sometimes, it just takes a while to feel the effects even if your CPAP therapy is working in terms of breathing. Your body and brain spent years getting used to being strangled regularly during the night. Your metabolism, chemistry, and sleep patterns may take a while to get back to "healthy." I think of it as being like stopping drinking, smoking, drugs, etc.

I think quite a few of us end up feeling better when we change the minimum pressure above where your AHI is essentially zero. It might be UARS, it might be something we don't have a label for. Try it and see how it works for you. Turn it back down if it doesn't work for you.

Here is last night's graph with 10-12 pressure, no ramp and EPR set to 2.

I removed the mask in my sleep (this happens a lot) so I only used it for a couple hours but this is the lowest my AHI has been.

Flow limitation is still pretty much the same. What can I do to get a boring FL chart?

pablmd wrote:Here is last night's graph with 10-12 pressure, no ramp and EPR set to 2.

I removed the mask in my sleep (this happens a lot) so I only used it for a couple hours but this is the lowest my AHI has been.

Flow limitation is still pretty much the same. What can I do to get a boring FL chart?

Are you limited to full face masks? When I went through ff mask h-ll, I did that constantly. It was only when I switched to the cloth nasal mask, that it stopped as my problems were clearly due to mask discomfort.

I leave others to comment on the rest of your questions.

Are you experiencing any nasal congestion at all at night? Sometimes nasal congestion will show up as flow limitations.
So if any nasal congestion is present that needs to be dealt with first.

Your flow limitation graph is far from horrible but generally more pressure is needed if the FL is related to the airway collapsing.
I think you can see where your pressure increases along the same time frame where your FL graph is more active.
If you wish to continue using EPR than you might try 11 minimum and 12 maximum. I don't see any need to open up or increase the maximum because the machine isn't likely to go there anyway but you could if you wanted to.