Flow limitation advise

Hi, I've been on cpap for about 14 wks with only alittle intermittent improvement off and on.
Still haven't been able to sleep through the night.
My main SA symptoms have been insomnia (wide awake feeling) and seldom ever sleepy.
Also have had ongoing fragmented sleep and sleep starts like jerking awake at sleep onset.
Suspect I've had obstructed airway for a long time, like over 12 yrs.
Sleep study shows severe apnea in supine position, mild on side.

My question is about air flow.
Sleep clinic has had me on fixed setting of 7 from start date of 4/1.
On one followup, they said I was doing fine and to take clonazepam when I complained of still not enough sleep.
Not happy with their solution at all.

Visited DME and RT told me variable pressure would works better than fixed so I've been trying that since 7/7.
So I'm looking at Flow Limitation which now registers with switching to variable pressure and it goes between .79 and 2.08 in the last week.
I watched a YouTube video that explains flow limitation and am wondering if there's anything I can do to make that go away entirely?
I see it's tied in with arousals and think that may be the cause of my insomnia and nerve problems.
Any input please?

Usually for flow limitations the pressure is increased slightly.
When using auto adjusting mode (apap) then it's the minimum/starting pressure that is usually increased.
How much....unknown really but usually not much if everything else is within acceptable ranges.

Sylvia54 wrote:I watched a YouTube video that explains flow limitation and am wondering if there's anything I can do to make that go away entirely?

higher pressure.

Sylvia54 wrote:Hi, I've been on cpap for about 14 wks with only alittle intermittent improvement off and on.
Still haven't been able to sleep through the night.
My main SA symptoms have been insomnia (wide awake feeling) and seldom ever sleepy.
Also have had ongoing fragmented sleep and sleep starts like jerking awake at sleep onset.
Suspect I've had obstructed airway for a long time, like over 12 yrs.
Sleep study shows severe apnea in supine position, mild on side.

My question is about air flow.
Sleep clinic has had me on fixed setting of 7 from start date of 4/1.
On one followup, they said I was doing fine and to take clonazepam when I complained of still not enough sleep.
Not happy with their solution at all.

Visited DME and RT told me variable pressure would works better than fixed so I've been trying that since 7/7.
So I'm looking at Flow Limitation which now registers with switching to variable pressure and it goes between .79 and 2.08 in the last week.
I watched a YouTube video that explains flow limitation and am wondering if there's anything I can do to make that go away entirely?
I see it's tied in with arousals and think that may be the cause of my insomnia and nerve problems.
Any input please?

You have a couple of options.
You can TRY a range of pressures, but chances are, if the FLs aren't preceding apneas, the pressure changes will probably only be sleep disturbing.
Or, you can try increasing your settings.......8/8, 9/9, etc. and see if the FLs decrease. For some they do and for some they don't. Some people just have lots of flow limitations regardless of the pressures. And, in some cases, the increase in pressures (particularly with ranges) may only exacerbate the flow limitations.

No hard and fast rules, so proceed with what you find works for you.


Den

.

some folks here think that slowly changing pressures during the night are a big bugaboo, most people don't. raising your minimum pressure to the point where your machine is "in the zone' to prevent most of the events you have, or, most of the flow limitations, if they're causing you arousals, is the idea, then let the auto take care of exceptions during the night.

And......"some folks here"......have had experiences with changing pressures ("slowly changing" or not) and KNOW that they can disturb their sleep. It's a very individual thing and "sleep quality" (with reasonably low events) is very important.
If the pressure changes are bumping the person out of their deep sleep stages and into lighter ones, they may feel like they're not well rested. Their AHI numbers may be excellent because they're spending most of the night in lighter sleep stages.

So, as I said, it's a very individualistic thing. Each person needs to find out what works best for them.


Den

.

Wulfman... wrote:If the pressure changes are bumping the person out of their deep sleep stages and into lighter ones, they may feel like they're not well rested. Their AHI numbers may be excellent because they're spending most of the night in lighter sleep stages..

got any actual data to support this? even zeo sleep stages superimposed on sleepyhead data?

or, is it all assumption?

Wulfman... wrote:

Sylvia54 wrote:Hi, I've been on cpap for about 14 wks with only alittle intermittent improvement off and on.
Still haven't been able to sleep through the night.
My main SA symptoms have been insomnia (wide awake feeling) and seldom ever sleepy.
Also have had ongoing fragmented sleep and sleep starts like jerking awake at sleep onset.
Suspect I've had obstructed airway for a long time, like over 12 yrs.
Sleep study shows severe apnea in supine position, mild on side.

My question is about air flow.
Sleep clinic has had me on fixed setting of 7 from start date of 4/1.
On one followup, they said I was doing fine and to take clonazepam when I complained of still not enough sleep.
Not happy with their solution at all.

Visited DME and RT told me variable pressure would works better than fixed so I've been trying that since 7/7.
So I'm looking at Flow Limitation which now registers with switching to variable pressure and it goes between .79 and 2.08 in the last week.
I watched a YouTube video that explains flow limitation and am wondering if there's anything I can do to make that go away entirely?


I see it's tied in with arousals and think that may be the cause of my insomnia and nerve problems.
Any input please?

You have a couple of options.
You can TRY a range of pressures, but chances are, if the FLs aren't preceding apneas, the pressure changes will probably only be sleep disturbing.
Or, you can try increasing your settings.......8/8, 9/9, etc. and see if the FLs decrease. For some they do and for some they don't. Some people just have lots of flow limitations regardless of the pressures. And, in some cases, the increase in pressures (particularly with ranges) may only exacerbate the flow limitations.

No hard and fast rules, so proceed with what you find works for you.


Den

.

Thanks everyone for your help. Wulfman; My prescription was changed last week when I followed up with an APRN at the clinic. He took more time with me, said average AHI of 5 is good enough. I don't know if they look any further than compliance, AHI, and snoring (maybe). He changed my 7/7 to and 8/8 and said to use my slumber bump belt to stay on my side. Think it would irritate me too much, trying to sleep with two therapy devices. Anyway, the clinic medical assist. sets the pressure on my apap from 7/7 to 4/20, I'm sure that's not what he told her. She messed up some other things so that's when they said to take my machine to the DME. This RT suggested I try the wide range rather than a fixed setting. The first night on it was pretty restless, think I remember a pressure increase blew off my nasal pillows at one point, lol. Then I was blowing my nose a lot the next morning. The machine showed pressure was up to 11 so I guess that's the high end of range necessary for when I shift to my back off and on? I've since tried it up to 12 but lately machine shows high pressure btwn 9.5 and 10.5. I've been alternating between 7 & 8 for starting pressure but maybe I'll just set it btwn 7 and 11 for a week and see what happens. Also, some on here say they don't use Ramp after the first week. I'm still starting at 6 for the first 30 minutes. RT said I should be using ramp starting at 4 but I don't follow that since it feels like I'm not getting air at 4.

Sylvia54 wrote:Thanks everyone for your help. Wulfman; My prescription was changed last week when I followed up with an APRN at the clinic. He took more time with me, said average AHI of 5 is good enough.

5 is a pretty crap level, it's like having someone poke you with a sharp stick every 12 minutes, on average, all night long.

Sylvia54 wrote:to 4/20, ... I've been alternating between 7 & 8 for starting pressure but maybe I'll just set it btwn 7 and 11 for a week and see what happens. Also, some on here say they don't use Ramp after the first week. I'm still starting at 6 for the first 30 minutes. RT said I should be using ramp starting at 4 but I don't follow that since it feels like I'm not getting air at 4.

many RTs are .... mindless automatons that just repeat what they've been told, without any understanding.

like setting the machine to a minimum of 4, or starting with 4... if you don't like the ramp, don't use it, it's *purely* a comfort feature if you have problems *while awake* with the pressure. since you have problems with the low pressure, well, that's just another thing to ignore from the RT of ignorance.

the max pressure is (typically) much less important than the min pressure, get the min pressure right, and the max pressure doesn't matter. focus on that.

Sylvia54 wrote:Thanks everyone for your help. Wulfman; My prescription was changed last week when I followed up with an APRN at the clinic. He took more time with me, said average AHI of 5 is good enough. I don't know if they look any further than compliance, AHI, and snoring (maybe). He changed my 7/7 to and 8/8 and said to use my slumber bump belt to stay on my side. Think it would irritate me too much, trying to sleep with two therapy devices. Anyway, the clinic medical assist. sets the pressure on my apap from 7/7 to 4/20, I'm sure that's not what he told her. She messed up some other things so that's when they said to take my machine to the DME. This RT suggested I try the wide range rather than a fixed setting. The first night on it was pretty restless, think I remember a pressure increase blew off my nasal pillows at one point, lol. Then I was blowing my nose a lot the next morning. The machine showed pressure was up to 11 so I guess that's the high end of range necessary for when I shift to my back off and on? I've since tried it up to 12 but lately machine shows high pressure btwn 9.5 and 10.5. I've been alternating between 7 & 8 for starting pressure but maybe I'll just set it btwn 7 and 11 for a week and see what happens. Also, some on here say they don't use Ramp after the first week. I'm still starting at 6 for the first 30 minutes. RT said I should be using ramp starting at 4 but I don't follow that since it feels like I'm not getting air at 4.

I would feel like CRAP with an AHI of 5.
I reset my own machine almost immediately from 18 cm. to 10 cm. and realized AHIs of less than 1.0.

Based on your comments, I would suggest YOU taking control of YOUR therapy as soon as possible.
If you're not already, I'd strongly recommend using Sleepyhead software to monitor your therapy.
I'd also suggest making notes (note pad or computerized documents) on what seems to be working or not.
And, listen to the little voice inside your head.......tweak your therapy according to what seems realistic to you.
We can theorize and speculate to our hearts content on the forum, but in the end, YOU need to be in charge and decide.


Den

.

Wulfman... wrote:

Sylvia54 wrote:Thanks everyone for your help. Wulfman; My prescription was changed last week when I followed up with an APRN at the clinic. He took more time with me, said average AHI of 5 is good enough. I don't know if they look any further than compliance, AHI, and snoring (maybe). He changed my 7/7 to and 8/8 and said to use my slumber bump belt to stay on my side. Think it would irritate me too much, trying to sleep with two therapy devices. Anyway, the clinic medical assist. sets the pressure on my apap from 7/7 to 4/20, I'm sure that's not what he told her. She messed up some other things so that's when they said to take my machine to the DME. This RT suggested I try the wide range rather than a fixed setting. The first night on it was pretty restless, think I remember a pressure increase blew off my nasal pillows at one point, lol. Then I was blowing my nose a lot the next morning. The machine showed pressure was up to 11 so I guess that's the high end of range necessary for when I shift to my back off and on? I've since tried it up to 12 but lately machine shows high pressure btwn 9.5 and 10.5. I've been alternating between 7 & 8 for starting pressure but maybe I'll just set it btwn 7 and 11 for a week and see what happens. Also, some on here say they don't use Ramp after the first week. I'm still starting at 6 for the first 30 minutes. RT said I should be using ramp starting at 4 but I don't follow that since it feels like I'm not getting air at 4.

I would feel like CRAP with an AHI of 5.
I reset my own machine almost immediately from 18 cm. to 10 cm. and realized AHIs of less than 1.0.

Based on your comments, I would suggest YOU taking control of YOUR therapy as soon as possible.
If you're not already, I'd strongly recommend using Sleepyhead software to monitor your therapy.
I'd also suggest making notes (note pad or computerized documents) on what seems to be working or not.
And, listen to the little voice inside your head.......tweak your therapy according to what seems realistic to you.
We can theorize and speculate to our hearts content on the forum, but in the end, YOU need to be in charge and decide.


Den

.

Last night I went over the comments again and set the machine at 8/12. Felt somewhat unrefreshed early this morning but feeling better as the day goes on, more clear-headed. So glad now that I questioned the sleep Dr's prescription of 7/7 and got it changed. Followup with clinic APRN helped somewhat and then I got good advice here to increase starting pressure by alittle when I'd put it back to 7/11. Sleep was still fragmented but I'd also cut back the clonazepam to only 0.25 mg., still got close to 6 hrs total. Hope it's not just a fluke. No LL or PB events last night, AHI down to 2.69. Also with being awake off and on during the night and I've noticed that period of time increases the AHI reading on the machine, so it's probably lower than 2.69. I'll have to give my RT some credit too for memorizing that "range is better than fixed pressure". I have gotten quality help and encouragement from the DME admin assistant who has sleep apnea herself and uses cpap.

palerider wrote:some folks here think that slowly changing pressures during the night are a big bugaboo...

they can be IF such higher pressures cause loss of proper seal. If not, then I rather think, it ain't a big deal

Cross your fingers because if you're a real UARSnik,


According to this article in the Chest website from 2011 authored by the followings:

Olukayode Ogunrinde, MD; Herbert J. Yue, MD; and Christian Guilleminault, MD, BiolD

Dr. Ogunrinde is Clinical Fellow, Department of Sleep Medicine, Stanford University; Dr. Yue is Clinical Fellow, Department of Sleep Medicine, Stanford University; and Dr. Guilleminault is Professor, Division of Sleep Medicine, Stanford University Medical School, Redwood City, California.

Drs. Ogunrinde, Yue, and Guilleminault have disclosed no significant relationships with the companies/organizations whose products or services may be discussed within this chapter.



Over the past few years, numerous articles have been published that have increased our understanding of the features of upper airway resistance syndrome (UARS). UARS has been previously described as a distinct clinical syndrome, although there is ongoing controversy and some consider it to be part of a spectrum of sleep-disordered breathing that includes primary snoring, obstructive hypopnea syndrome (OHS), and obstructive sleep apnea syndrome (OSAS). However, patients with UARS present with different polysomnographic abnormalities and do not meet generally accepted criteria for either apneas or hypopneas. The lack of education about UARS in the medical community has allowed these patients to go undiagnosed and untreated. Increased research into UARS will help us to identify the optimal treatment for these patients, as well as to educate clinicians about this relatively under-recognized population.
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The optimal treatment for patients with UARS is not currently known. Continuous positive airway pressure (CPAP) has been quite useful in the treatment of sleep-disordered breathing and there are some notable positive results in CPAP treatment of UARS Among those patients who have been treated, typically with CPAP therapy, many have experienced symptomatic improvement. The current fund of knowledge regarding UARS has been growing, and we are beginning to understand the underlying pathophysiology.

tan wrote:

palerider wrote:some folks here think that slowly changing pressures during the night are a big bugaboo...

they can be IF such higher pressures cause loss of proper seal. If not, then I rather think, it ain't a big deal

the rants against the evils of auto machines aren't about leaks caused by high pressures, which, really, are a separate issue, the assertion is that the slowly changing pressures, over the course of minutes, somehow jolts everybody out of their 'deep sleep stages' and into lighter ones. (I've never seen anybody proposing this actually produce anything resembling evidence of this, or indeed, an understanding of actual sleep stages and what they do, and how the brain cycles between them.)

avi123 wrote:Cross your fingers because if you're a real UARSnik,

or, better yet, put avi123 on your foe list and ignore his ravings and gloomy postings.