Reason for Concern?

grounded wrote: ↑

Tue May 26, 2020 8:18 am

Do the waveforms indicate I was fully awake?

I can't tell because I can't see the flow rate pattern prior to all the ugly.
All I can see is the ugly.

Pugsy wrote: ↑

Tue May 26, 2020 9:26 am

I can't tell because I can't see the flow rate pattern prior to all the ugly.
All I can see is the ugly.

Here's what precedes the ugly:

Bear in mind that analyzing flow rate pattern isn't easy and sometimes what I call "iffy" since this is all new to us and we had to learn by trial and error.

This one is iffy....not easy and take what I say with a grain of salt.
Asleep until probably 00:37:00 with a little arousal at 00:37:00....then the rate increases in amplitude a bit but still rhythmic. ...not sure why but probably still asleep. When I am not sure about something I try to err on the side of caution and will assume a flagged event is the real deal when I don't know for sure and it's iffy.

After 00:49:00....looks like awake/arousal related breathing to me. It's very possible that the handful of prior flagged events were the real deal and caused an arousal and then the subsequent flagged events were arousal related SWJ false positives. It's not an easy one though....but since it is possible that real events triggered an arousal than in turn caused possible false positives...that's why I would increase the pressure a bit and see if I better prevented the first maybe real events then maybe I might in turn prevent the maybe arousal events (if those are arousal related).

It's about all we can do anyway with what tools we have available at this time.

Pugsy wrote: ↑

Tue May 26, 2020 9:56 am

It's about all we can do anyway with what tools we have available at this time.

I corresponded with my clinician who then bumped my pressure to 7-15 (from 5-15). She said:

It’s not uncommon to see some central apneas when you’re first starting APAP as well. Typically the centrals will decrease as your brain acclimates to the CPAP. If still elevated, we can look at some more data and see if we need to tweak things further.

So there's hope this is just me getting acclimated and not something more serious.

grounded wrote: ↑

Tue May 26, 2020 1:01 pm

Pugsy wrote: ↑

Tue May 26, 2020 9:56 am

It's about all we can do anyway with what tools we have available at this time.

I corresponded with my clinician who then bumped my pressure to 7-15 (from 5-15). She said:

It’s not uncommon to see some central apneas when you’re first starting APAP as well. Typically the centrals will decrease as your brain acclimates to the CPAP. If still elevated, we can look at some more data and see if we need to tweak things further.

So there's hope this is just me getting acclimated and not something more serious.

Actually don't go into this "central thing" with looking at it as something "serious". It's really not an indication of anything more serious than anything else. Just something that has to be dealt with (and is easy to deal with) in a different manner if it doesn't fade away with time and adjustment.
So look at it as "different' and not so much "more serious".

Do consider trying cpap with EPR off though....sometimes the quick easy fix to too many centrals is something as simple as not using exhale relief (which is what EPR does/is) which creates a bilevel situation which in turn creates the unstable breathing that causes the centrals to happen in the first place. I have seen it work miracles in terms of central numbers reductions. I can't guarantee it will work for you but it might and it would be something quick, easy to try and rather sad if you had a prolonged time with additional worry about the centrals when there was a quick easy trick to reduce that worry.
BUT....if it doesn't...don't go worrying about this "serious" thing because it's a central apnea is really no more serious than an obstructive apnea as long as it can get dealt with and there are ways to deal with it very effectively.

The centrals and your flow rate pattern don't even remotely look like CSR Cheyne Stokes Respiration which is or would be our main concern with central apneas relating to a potential heart issues.

In other words...try to not let is stress you out about something bad going on. It's just something that sometimes happens to some people that might go away with time and if it doesn't go away with time there are very effective options available to deal with it.

grounded wrote: ↑

Tue May 26, 2020 8:18 am

Pugsy wrote: ↑

Tue May 26, 2020 7:07 am

Well obviously if you repeatedly hold your breath for 30 seconds back to back over a period of time of several minutes the oxygen levels will drop.
You aren't asleep though...you are doing it on purpose.....it's not the same thing as when we are asleep.

I did not deliberately and repeatedly hold my breath last night. Not even once. Whatever happened above, I was not "consciously awake". Do the waveforms indicate I was fully awake?

They don't look like sleep breathing to me.

But, your pressure is too low if those are legit obstructives.

bump your min up to 12 and turn off EPR.

palerider wrote: ↑

Tue May 26, 2020 1:25 pm

bump your min up to 12 and turn off EPR.

Interesting - my clinician says EPR is "just fine" and can be set to 2. She seems to have no problem with it.

ETA: I've been sleeping with EPR only enabled for ramp and so it wasn't on for these episodes

grounded wrote: ↑

Tue May 26, 2020 2:38 pm

palerider wrote: ↑

Tue May 26, 2020 1:25 pm

bump your min up to 12 and turn off EPR.

Interesting - my clinician says EPR is "just fine" and can be set to 2. She seems to have no problem with it.

Most of the time for the majority of the people using any form of exhale relief is indeed just fine and not a problem.
Unfortunately there are a few people (very small minority) who find that the inhale/exhale difference that using exhale relief will be a trigger for an increase in the number of central apneas. It has to do with the exchange of blood gases and primarily the blood levels of carbon dioxide.
Using exhale relief or bilevel pressures can cause a few people to blow off too much carbon dioxide so the levels don't increase in the blood to the point that the brain says "oh...carbon dioxide level is up...need to send the breathe signal"...so you don't breathe and that's a central apnea...no effort to breathe. It's actually the carbon dioxide levels in the blood that drive the "breathe human" trigger and not oxygen levels which is what most people think drive our breathing.

EPR creates a bilevel pressure situation...one pressure for inhale and one different pressure for exhale...we call that difference pressure support. It can be 1 cm to much higher difference when using a machine that will allow the pressure support to go higher than the 3 cm that EPR is limited to.
I have a friend who gets 15 to 20 centrals per hour when she uses a 4 cm difference between inhale and exhale. We thought for sure she needed one of those fancy high end machines that will treat centrals but we tried using a 3 cm pressure support and her centrals dropped down to less than 1.0 per hour. Go figure that one....a little 1 cm difference made all the difference in the world for her.

The reason we suggest turning EPR off...just to see if you are one of that small minority that has that gas exchange problem where your carbon dioxide levels just don't get high enough for the brain to send the "breathe human" signal.
If it makes a big difference then you can play with EPR to see if there is a line in the sand where EPR causes centrals and below that line it doesn't. Like my friend that found out at 4 it was a problem and at 3 no problem. She really needed the exhale relief because here pressure needs were in the high teens so going totally without any exhale relief would be a problem for her. We got lucky and found a workable compromise and she didn't have to go buy that high dollar fancy machine that would treat her centrals.

Now you might not be one of those people...it might make no difference at all but it is something you can do to see for yourself if you are in that very small minority or not...and it hurts nothing to give it a try.

grounded wrote: ↑

Tue May 26, 2020 2:38 pm

palerider wrote: ↑

Tue May 26, 2020 1:25 pm

bump your min up to 12 and turn off EPR.

Interesting - my clinician says EPR is "just fine" and can be set to 2. She seems to have no problem with it.

ETA: I've been sleeping with EPR only enabled for ramp and so it wasn't on for these episodes

Every chart you've posted has had EPR turned on.

But, ok, if you want to take her advice, that's fine, I'll quit making suggestions.

Sorry - I didn’t realize my therapist had remotely enabled EPR. I had previously disabled it, except for Ramp.

Thanks for the great explanations on this!!

Update: Last night was crazy bad. My alarming SpO2 recorder woke me up at least 10 times. Somewhere around 1:45 with that big desat (80%) I got this massive headache that lasted all night. As you can see, EPR was Off. Getting desperate here....

EPR was indeed on during the first segment until 01:15 then you woke up and turned it off I guess.
I can tell because of the 2 pressure lines showing on the pressure graph.

The ugly cluster at approx 02:00 and then the obvious break in therapy makes me wonder if you were actually asleep when that cluster happened.

Pugsy wrote: ↑

Thu May 28, 2020 7:55 am

EPR was indeed on during the first segment until 01:15 then you woke up and turned it off I guess.
I can tell because of the 2 pressure lines showing on the pressure graph.

That's what happened. I must have not breathed for quite some time to get my Sp02 down to 80. I distinctly remember that alarm waking me, then me breathing hard to get it back up.

The ugly cluster at approx 02:00 and then the obvious break in therapy makes me wonder if you were actually asleep when that cluster happened.

I was awake numerous times last night, but I don't think I was consciously awake then. My Sp02 was ok so it didn't alarm. This is the sequence leading into that ugly:

and then after:

None of that second ugly looks like asleep breathing to my eye.
Maybe half asleep or something. It's not mandatory that we remember and arousal for it to have happened.
Your oxygen levels during that time were within acceptable levels.

What I would do if it were me....not use the pulse ox for a night so that the alarm itself didn't disturb sleep (loss of contact alarm itself is a potential arousal factor)...and also not use EPR...and see what happens.

Pugsy wrote: ↑

Thu May 28, 2020 10:45 am

What I would do if it were me....not use the pulse ox for a night so that the alarm itself didn't disturb sleep (loss of contact alarm itself is a potential arousal factor)...and also not use EPR...and see what happens.

Tonight's plan is to leave EPR off (assuming I can fall asleep without it) and wear the pulse-ox, but set it to alarm under 82 and see what happens.