Jonathan's ongoing list of questions, comments, concerns...

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
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JonathanZK
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Re: Newbie / Accuracy Questions

Post by JonathanZK » Wed Nov 14, 2018 9:36 am

Well, 14/9 with BiFlex switched off turned out to be a mixed bag...

Image

On the positive side, I only had 6 Obstructive Apneas, which is 4 fewer than average (9.9)

On the neutral side, Snoring is almost unchanged (152 last night, 153.3 average). Ditto for RERAs, which are 50 last night vs 49.9 average.

Negative side, I had 12 hypopneas, which is double average. And PP Count -- whatever that is -- is substantially greater than average. 46 last night, vs 10 average.

I'm starting to feel this is like squeezing a water-balloon. As you push in one side, the other side pops out.

Is this as good as it gets?

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Pugsy
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Re: Newbie / Accuracy Questions

Post by Pugsy » Wed Nov 14, 2018 9:49 am

I have mixed feelings about this machine in general because of the VS2 flagging.
There have been some situations where the machine sensors were faulty and we got an inordinate number of VS2 snores showing up that never really went away with more pressure (and real snores should go away with more pressure).

Care to try something substantially different for one night only? EPAP 12 and IPAP 14. Use BiFlex if it is more comfortable for you and you might like it with EPAP of 12.

Then centrals/CAs...clustered at known probably awake times so I am not so concerned about them at this time.

I really wish you had the auto adjusting version of this machine.

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zonker
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Re: Newbie / Accuracy Questions

Post by zonker » Wed Nov 14, 2018 11:06 am

JonathanZK wrote:
Wed Nov 14, 2018 9:36 am
<snip>
Is this as good as it gets?

no. hang in there. not to discourage but to encourage, this can take some time. i wish i had the technical knowledge to chip in. but you are in the best hands already.

keep trying different approaches as suggested here. and give those changes time to work. many of us have had to try different things until we found what works for us.

good luck!
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JonathanZK
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Re: Newbie / Accuracy Questions

Post by JonathanZK » Thu Nov 15, 2018 7:01 am

Pugsy wrote:
Wed Nov 14, 2018 9:49 am
I have mixed feelings about this machine in general because of the VS2 flagging.
There have been some situations where the machine sensors were faulty and we got an inordinate number of VS2 snores showing up that never really went away with more pressure (and real snores should go away with more pressure).

Care to try something substantially different for one night only? EPAP 12 and IPAP 14. Use BiFlex if it is more comfortable for you and you might like it with EPAP of 12.

Then centrals/CAs...clustered at known probably awake times so I am not so concerned about them at this time.

I really wish you had the auto adjusting version of this machine.
I have to admit, I was dubious about trying such a high EPAP given what the sleep center said about my intolerance for high pressure exhalation, but I gave it a shot anyway, and had the best night's sleep since I started this magic carpet ride. I wouldn't call it a good night, but still better than any other night this November. And the settings were surprisingly comfortable, as you predicted.

The data shows definite improvements as well. Best AHI since I started.

Image

Image

Best AHI to date, no obstructive apneas at all, only 2 hypopnea (average 6.2), no clear airways (average 6.8), RE down to 26 (average 48.2), no PP at all (average 12.4).

And VS2 down to 100 from an average 135.4. It's my third-best night in this regard.

I'm a little concerned about the periodic breathing at 1.75%. I've averaged around 1.97% these two weeks, so last night was an improvement, but what's a normal reading for this anyway? I find descriptions, but not any indication of whether or not my numbers here are good, bad, or indifferent.

Anyway, thank you for the best night of sleep I've had this November.

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Re: Newbie / Accuracy Questions

Post by Pugsy » Thu Nov 15, 2018 7:55 am

Periodic Breathing is only a waxing and waning of the air flow that lasts at least 2 minutes.
A little PB is no big deal.
Zoom in on the PB up close and see if it looks sort of like this one of mine....If so...nothing to even bat an eye over.
Image


Now if you had a truck load of centrals stuck in the middle of the PB and you were having truckloads of PB...then we worry.
Like this one below...a cause for concern.
Please notice the difference in the overall pattern because the difference is really important.
Image

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Re: Newbie / Accuracy Questions

Post by Pugsy » Thu Nov 15, 2018 8:03 am

So last night is a very decent report.

Did I see you mention that you actually slept??? You mentioned all the numbers improving but my actual intent was to get you to report actually sleeping in some fairly solid blocks of time and it looks like you did. The reason being was because the other night's reports were very likely so contaminated with SWJ false positive flagged events it was really impossible to say more than "wow, crappy night".

Did you by chance start out the night on your back and then maybe move to your side and the move back to your back again?

Care to use the same settings again tonight? :lol: One night doesn't not make a trend and I want to see if this holds or not.

I have no idea what the sleep center meant with the comment about "intolerance to the higher pressures". Don't know when whatever happened or why it might have happened or what they were trying when whatever it was happened.

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Re: Newbie / Accuracy Questions

Post by Pugsy » Thu Nov 15, 2018 8:15 am

A word about PB in general and CSR.
PB itself is nothing more than a waxing and waning of the breathing/air flow.
CSR or Cheyne Stokes Respiration is a specific form of PB and there are many forms of PB.
Not all PB is CSR......CSR that is real CSR is what is scary. PB that is barely PB isn't scary at all.
The machine will flag barely PB as CSR and it's not CSR...why...because it's better to alert to a potential problem and let the doctor say "no big deal and not CSR" then it is to ignore it and maybe have it be a real problem. All it looks for is the waxing and waning of the air flow...flags it for the doctors to draw attention to it just in case it is the scary PB.

I have never been able to find out a "number" in terms of how much PB is cause for concern...but near as I can tell....maybe 20% of the night or more and needs to look more like CSR than plain PB like in my example.
I never could find a PB/CSR guideline number to shoot for.

The pressure pulses are nothing more than the machine trying to decide what is going on...they dropped in number last night because not much happened to cause the machine to decide on what to maybe call something. Pressure pulses can happen with or without a flagged event being associated with it.

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Re: Newbie / Accuracy Questions

Post by zonker » Thu Nov 15, 2018 11:23 am

JonathanZK wrote:
Thu Nov 15, 2018 7:01 am
The data shows definite improvements as well. Best AHI since I started.
catfistbump.gif
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Re: Newbie / Accuracy Questions

Post by JonathanZK » Thu Nov 15, 2018 11:27 am

Pugsy wrote:
Thu Nov 15, 2018 8:03 am
So last night is a very decent report.
In comparison to my others, absolutely. In comparison to some that I've people post here, I feel like theres a long way to go...
Pugsy wrote:
Thu Nov 15, 2018 8:03 am
Did I see you mention that you actually slept???
Aside from two very bad nights, I slept. Maybe woke up to urinate or get comfortable, but there were only two when I was utterly disturbed and got only 3-4 hours.

But yes, last night I slept better and felt much more comfortable with the new settings than previous ones. And that in spite of some major stress due to family problems.
Pugsy wrote:
Thu Nov 15, 2018 8:03 am
You mentioned all the numbers improving but my actual intent was to get you to report actually sleeping in some fairly solid blocks of time and it looks like you did. The reason being was because the other night's reports were very likely so contaminated with SWJ false positive flagged events it was really impossible to say more than "wow, crappy night".
I didn't wake up at all, but also had a salty food day due to being on the road a lot, so didnt need to urinate. Tonight will be a better indication, I hope.
Pugsy wrote:
Thu Nov 15, 2018 8:03 am
Did you by chance start out the night on your back and then maybe move to your side and the move back to your back again?
On my back. At some point during the night I turned on my side, but not sure when.
Pugsy wrote:
Thu Nov 15, 2018 8:03 am
Care to use the same settings again tonight? :lol: One night doesn't not make a trend and I want to see if this holds or not.
100%
Pugsy wrote:
Thu Nov 15, 2018 8:03 am
I have no idea what the sleep center meant with the comment about "intolerance to the higher pressures". Don't know when whatever happened or why it might have happened or what they were trying when whatever it was happened.
More on this later... running into a meeting.

Thanks!

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Re: Newbie / Accuracy Questions

Post by Jas_williams » Thu Nov 15, 2018 12:45 pm

The need to urinate is not due to what food you eat but more likely the amount of apnoea you have once these are treated the need to urinate at night passes and there will no need to wake and use the toilet at night

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Re: Newbie / Accuracy Questions

Post by palerider » Thu Nov 15, 2018 2:24 pm

JonathanZK wrote:
Thu Nov 15, 2018 7:01 am
, I was dubious about trying such a high EPAP given what the sleep center said about my intolerance for high pressure exhalation, but I gave it a shot anyway, and had the best night's sleep since I started this magic carpet ride.
Most of us have learned over time to take what many sleep doctors, most Respiratory techs, all DMEs and sleep center people say with a grain of salt...

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Re: Newbie / Accuracy Questions

Post by JonathanZK » Thu Nov 15, 2018 3:46 pm

Pugsy wrote:
Thu Nov 15, 2018 8:03 am
I have no idea what the sleep center meant with the comment about "intolerance to the higher pressures". Don't know when whatever happened or why it might have happened or what they were trying when whatever it was happened.
As I understood, part of the reason they prescribed bilevel was because I had trouble breathing against constant pressure and experienced lots of apneas. But I can't say for sure because I was asleep, and am going by the report. I can publish that in an anonymized format if you think it'd be helpful. What I can say is while I was awake, I didn't particularly like CPAP for that reason.
palerider wrote:
Thu Nov 15, 2018 2:24 pm
Most of us have learned over time to take what many sleep doctors, most Respiratory techs, all DMEs and sleep center people say with a grain of salt...
I'm starting to agree with that sentiment. I found it especially off-putting how little information they provide on the official apps in comparison to what the machine actually collects. It strikes me as dishonest. Moreover, they also overcharged me for the machine; the copay on the insurance was higher than buying it outright -- a fact that highlight's the sleep centers principal interest being separate from my best interest.
Jas_williams wrote:
Thu Nov 15, 2018 12:45 pm
The need to urinate is not due to what food you eat but more likely the amount of apnoea you have once these are treated the need to urinate at night passes and there will no need to wake and use the toilet at night
Indeed? I've always found the correlation between salt intake and urination to be fairly consistent. But I'll be delighted if my 3AM trips to the toilet end up eliminated (no pun intended).

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Re: Newbie / Accuracy Questions

Post by Pugsy » Thu Nov 15, 2018 5:58 pm

I don't really need to see the sleep study report at this time.
What may have happened when they got cpap up to the pressure you need to prevent the apneas your body just couldn't handle exhaling against it and you started waking up from the pressure. They put you on bilevel because that's the first thing that gets done when people can't seem to tolerate the pressure. Bilevel pressures are usually easier because of the difference between inhale and exhale.
What they didn't do was set the EPAP high enough to prevent the apneas from happening.
Since this machine can't auto adjust it just sat there blowing the air at the settings it was set to that weren't doing a good job.
I don't know how or why they came up with these settings or maybe they ran out of time to do much titration in bilevel mode in your situation.

If it wasn't for the snores I would say maybe could reduce that EPAP just a little but there's still more snores than I would like to see if it were my report. They are probably related to the times when you are on your back. When we are supine it is quite common for our OSA to worsen and for us to need more pressure to hold the airway open. The snores are indicative of the airway trying to collapse but not progressing further with the EPAP at 12. With lower EPAP the snores progressed to the OAs and all the other stuff you saw that related to obstruction (hyponeas, RERAs, OAs). The CAs/centrals were most likely arousal related...meaning the obstructive stuff caused you to wake up and maybe hold your breath or something which got flagged as a central. They weren't real centrals but instead SWJ centrals. The absence of FLs on your events graph means nothing....you might have been having a ton of Flow Limitatons but fixed pressure Respironics machine don't even flag FLs. Stupid design IMHO....but they didn't ask me.

You probably need a higher pressure when you are on your back than you need when on your side. Same thing can happen for REM stage sleep. I have the REM thing myself...need 6 to 8 cm more pressure during REM where my OSA is about 5 times worse. Supine sleeping doesn't seem to be that much of a trigger for me.
This is why having a machine that can auto adjust can come in so handy....use lower pressures when lower gets the job done and higher only when needed.

At any rate...just continue with these settings for a few nights and lets see what happens.
The peeing during the night....like Jas says...probably related to the OSA events more than salt intake. Did you know that nocturia is one of the most common symptoms of sleep apnea? I had it myself and it was the first symptom to go away once I got my therapy settings optimized (my titration study didn't get it right either).
There's a medical reason behind the nocturia that is caused by sleep apnea....the short version is that when we have an apnea event the heart is stressed and when it gets stressed it dumps a stress hormone called ANP into the blood stream.
https://en.wikipedia.org/wiki/Atrial_na ... ic_peptide
When that stress hormone makes its way to the kidneys the kidneys kick into over drive...and when kidneys work hard we get an abundance of urine produced.
I doubt seriously that your nocturia is related to your diet at all but was instead related to the sleep apnea that wasn't being effectively prevented at the pressures you were using.

Let's get a few nights under your belt and see for sure we are close here...then decide on further options.

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Re: Newbie / Accuracy Questions

Post by palerider » Thu Nov 15, 2018 6:07 pm

JonathanZK wrote:
Thu Nov 15, 2018 3:46 pm
As I understood, part of the reason they prescribed bilevel was because I had trouble breathing against constant pressure and experienced lots of apneas. But I can't say for sure because I was asleep, and am going by the report. I can publish that in an anonymized format if you think it'd be helpful. What I can say is while I was awake, I didn't particularly like CPAP for that reason.
Well, that is a thing, and that's why EPR exists on regular cpaps, and one of the reasons that some people do better on bilevel... but once you step to bilevel, you can handle higher pressure, because the pressure *difference* makes it easier to exhale, even if the exhale pressure is higher than you had on cpap.
JonathanZK wrote:
Thu Nov 15, 2018 3:46 pm
palerider wrote:
Thu Nov 15, 2018 2:24 pm
Most of us have learned over time to take what many sleep doctors, most Respiratory techs, all DMEs and sleep center people say with a grain of salt...
I'm starting to agree with that sentiment. I found it especially off-putting how little information they provide on the official apps in comparison to what the machine actually collects. It strikes me as dishonest. Moreover, they also overcharged me for the machine; the copay on the insurance was higher than buying it outright -- a fact that highlight's the sleep centers principal interest being separate from my best interest.
I don't know if it's dishonest, or just aiming at the lowest common denominator... the people that you look at and wonder "who dresses them in the mornings, cuz they're surely not smart enough to do it themselves?" I'm sure if you think about it, you could think of several people that you just KNOW would be totally confused by the sleepyhead reports. The ones that walk up to the people at the little carts handing out samples in the store and say "are you handing out samples?" "no, I just like to wear this funny hat and apron and stand behind counters".

Unfortunately, we suffer because of them.
JonathanZK wrote:
Thu Nov 15, 2018 3:46 pm
Jas_williams wrote:
Thu Nov 15, 2018 12:45 pm
The need to urinate is not due to what food you eat but more likely the amount of apnoea you have once these are treated the need to urinate at night passes and there will no need to wake and use the toilet at night
Indeed? I've always found the correlation between salt intake and urination to be fairly consistent. But I'll be delighted if my 3AM trips to the toilet end up eliminated (no pun intended).
Nocturia (nighttime peeing) is a common side effect of untreated sleep apnea... your breathing stops, your heart pumps harder cuz your brain is freaking out, your BP goes up, and your kidneys get the signal to reduce fluid load to lower the BP... (that's oversimplified, cuz I don't feel like typing all the details) but that's the basis of it. Pugsy has a link with more info if you're interested. (I see she posted it while I was typing this).

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JonathanZK
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Re: Newbie / Accuracy Questions

Post by JonathanZK » Fri Nov 16, 2018 3:12 pm

Well, not as good as the previous night, but I have to say, I didn't feel too badly about this sleep. I've definitely had worse night. I do remember waking up a couple of times -- turned on my side and dozed off. And I was unusually groggy this morning, and lazy getting out of bed (which was kinda nice).

Image

In the next caps, I zoomed on the periodic breathing episodes. Not sure what to make of them...

Image

Image

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