Help With OSCAR Chart

bossfan · Post by **bossfan** » Mon Sep 28, 2020 1:19 pm

Pugsy wrote: ↑
Mon Sep 28, 2020 12:47 pm
I see a lot of numbers being reported but I don't see any reports of how you are sleeping or feeling in general.
From the looks of the reports I would assume not sleeping so great and thus not feeling as good as we would want to feel but confirmation would be helpful.

I feel like I am sleeping pretty soundly for the 4 to 5 hours before I wake up. When I first wake up I feel tired but after about an hour I feel pretty normal. But to be honest I felt the same way all the time that I did not use the CPAP. So it could be that I'm used to the way I feel and I don't know the difference between poor sleep and good sleep.

I am on medications for diabetes, cholesterol, and hypertension but I don't think that would be affecting my sleep. If my arousals and poor sleep are not apnea related then I don't know what to do other than I need another sleep consult and who knows how that gets done with all the covid complications.

I think that I will raise min EPAP to 9 tonight and see what the numbers show and if there is a slight improvement then I'll go up to 10 and see what that does. After I do the next 2 nights of that I will report back and if I am having the same issues it might be time for me to see a sleep specialist. I appreciate your help so far.

Pugsy · Post by **Pugsy** » Mon Sep 28, 2020 1:36 pm

Actually all your meds could be playing a factor in the poor sleep.

https://www.aarp.org/health/drugs-suppl ... omnia.html

and since I always like 2 sources

https://www.goodrx.com/blog/could-your- ... -insomnia/

There's a thing called sleep maintenance insomnia and it's where we wake up either too many times during the night (we may or may not remember those awakenings) or we wake up prematurely and want to go back to sleep but we can't and medication side effects can play a part. Now I am not saying that your meds are 100% of the problem but they could be a factor.
I take a BP medication myself...it causes daytime fatigue as well as some potential insomnia issues because of the type of BP med class it falls into. I was surprised to see it but it's there.....and I have some fatigue and sleep maintenance insomnia issues.
Now I know I have other issues that are also likely playing a part but I don't totally absolve meds of contributing to the problem.

bossfan · Post by **bossfan** » Mon Sep 28, 2020 1:55 pm

Pugsy wrote: ↑
Mon Sep 28, 2020 1:36 pm
Actually all your meds could be playing a factor in the poor sleep.

https://www.aarp.org/health/drugs-suppl ... omnia.html

and since I always like 2 sources

https://www.goodrx.com/blog/could-your- ... -insomnia/

There's a thing called sleep maintenance insomnia and it's where we wake up either too many times during the night (we may or may not remember those awakenings) or we wake up prematurely and want to go back to sleep but we can't and medication side effects can play a part. Now I am not saying that your meds are 100% of the problem but they could be a factor.
I take a BP medication myself...it causes daytime fatigue as well as some potential insomnia issues because of the type of BP med class it falls into. I was surprised to see it but it's there.....and I have some fatigue and sleep maintenance insomnia issues.
Now I know I have other issues that are also likely playing a part but I don't totally absolve meds of contributing to the problem.

Well that's something for me to consider then I didn't think that my medications could be a contributing factor.

Pugsy · Post by **Pugsy** » Mon Sep 28, 2020 2:03 pm

I have found that it is rare when one problem is 100% to be blamed by one thing only. Most often it is a combination of various little things that adds up to a bigger problem.

Not to mention that ASV therapy itself, when there is nothing else potentially in the mix, .can take quite a bit of getting used to for some people. Months of getting used to it in fact. Heck...even plain cpap we tell people that it can take months to feel better.
Sometimes it's just our brain needing to learn to accept its new best friend.

We all know that sleep is a multi billion dollar industry and why everywhere you see some sort of gadget to help you sort out sleep issues or help you sleep. Sleep is very fragile for a lot of people for a mile long list of reasons.

Pugsy · Post by **Pugsy** » Mon Sep 28, 2020 2:08 pm

FWIW...my AHI is always fairly low but I know my own sleep quality is less than desirable. I can go through the flow rate and spot evidence of anywhere from 20 to 50 arousal segments of breathing...not related to the airway at all. Doesn't surprise me as I remember a lot of tossing and turning from pain issues but I don't remember 20 to 50.

But I see it on the flow rate graphs so I know it is happening. Doesn't surprise me that when I see the high arousal nights be followed by daytime feelings of fatigue or want to nap.
And 4 to 6 hours of sleep...my butt is dragging for sure simply from lack of enough hours of sleep. Sometimes I wake up earlier than I want and can't go back to sleep.....I always plan for a nap when that happens.

bossfan · Post by **bossfan** » Mon Sep 28, 2020 3:55 pm

@Pugsy

Thank you for the follow up comments. As I said in my first post I pretty much gave up and stopped using the machine years ago. So when you say that ASV might need some time to get used to I'm going to give this some time to see if some of this is needing to get used to this before scheduling a doctor consult so that there is more than a few weeks of data to go on. But I am going to try min EPAP of 9 tonight and 10 tomorrow just to see what the numbers look like after those increases.

bossfan · Post by **bossfan** » Tue Sep 29, 2020 8:13 am

@Pugsy

I increased my min EPAP to 9 and my AHI number is better. OA events were 4 and CA events were 3 so those numbers seem OK.

Hypopneas are still a problem with 32 events. I haven't reviewed the charts yet to see how much of the hypopneas were preceded by some kind of arousal.

I think that I will increase my min Epap to 10.0 tonight and see what happens. It looks like my max Epap hit 11.90 so if I increase the min Epap to 10.0 then is there enough of a spread from 10.0 to 12.0 or would I need to increase max Epap?

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bossfan · Post by **bossfan** » Wed Sep 30, 2020 6:51 am

@Pugsy

Last night I increased min EPAP from 9.0 to 9.5 and yikes my AHI shot up to 17.29 and I had a large increase of CA events with a total of 21. Hypopneas are still not controlled either I had 46 events.

Could the increase of min EPAP from 9.0 to 9.5 have caused the higher AHI and CA events. Should I back down the min EPAP to 9.0? I wanted to get your thoughts as although I have only 2 weeks of data I have reached the point where I think I need to make an appointment with a doctor. Thank you.

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Pugsy · Post by **Pugsy** » Wed Sep 30, 2020 10:13 am

Obviously back off on the EPAP minimum. Yes, it is possible that too much EPAP can trigger centrals...this might be the reason you were put on this type of machine in the first place.
It is also possible that a good chunk of these flagged events were SWJ false positives so if you didn't sleep so great for some reason or other.

In all honesty I think that most likely the bulk of your hyponeas are likely arousal related false positives and more pressure as in EPAP won't fix arousal related flagged events.

The only other thing I can think of to try (assuming asleep hyponeas and not SWJ hyponeas) is more baseline PS and I really hesitate to offer that idea since it can also cause centrals but then your machine is supposed to deal with centrals...
That's going out on a long skinny limb and pure speculation on my part which I don't like doing but if you want to try it for one night...that's up to you.
PS minimum of maybe 5.5 or 6.

bossfan · Post by **bossfan** » Wed Sep 30, 2020 10:43 am

Pugsy wrote: ↑
Wed Sep 30, 2020 10:13 am
Obviously back off on the EPAP minimum. Yes, it is possible that too much EPAP can trigger centrals...this might be the reason you were put on this type of machine in the first place.
It is also possible that a good chunk of these flagged events were SWJ false positives so if you didn't sleep so great for some reason or other.

In all honesty I think that most likely the bulk of your hyponeas are likely arousal related false positives and more pressure as in EPAP won't fix arousal related flagged events.

The only other thing I can think of to try (assuming asleep hyponeas and not SWJ hyponeas) is more baseline PS and I really hesitate to offer that idea since it can also cause centrals but then your machine is supposed to deal with centrals...
That's going out on a long skinny limb and pure speculation on my part which I don't like doing but if you want to try it for one night...that's up to you.
PS minimum of maybe 5.5 or 6.

@Pugsy
Thank you for replying. I had some OK numbers when the min EPAP was set to 9.0 so I will back down to there and see what happens.

Can you explain the PS minimum please? I'm willing to try that for one night to see if any improvement but I'd like to understand that setting a bit better. Thank you.

Pugsy · Post by **Pugsy** » Wed Sep 30, 2020 11:10 am

PS is pressure support and really just the difference between inhale and exhale. It's used to increase IPAP and keep EPAP lower when more EPAP causes a problem of some sorts. Most of the time it's used for aerophagia kind of problems but with your machine it can also increase rapidly and briefly to force you to breathe...that's when you see the big jump on the pressure graph that goes up fast and back down just as fast.
Baseline PS is where it starts...right now it is at 5 cm so there is always a 5 cm difference between inhale and exhale. It potentially can increase a lot more than 5 cm if it needs to breathe for you.

There's long been a general rule of thumb for bilevel machines...EPAP for OAs and IPAP for hyponeas. There are 2 ways to get more IPAP....either more EPAP or more PS. Your PS is already at 5 which is more of a normal usual PS....Most in lab titrations come out with the person needing a 4 or 5 PS to get a job done. More PS can also cause centrals in some people....small number of people for sure but it's a possible. I just saw it happen in this thread
viewtopic/t180394/Holy-AHI-Increase--Wh ... ng-on.html

But then I have a friend who uses a bilevel machine with PS of 6 because he likes it and gets no centrals....so it's not a given that more PS always causes centrals. It's one of those YMMV things.

If you want to try higher PS....back off on the minimum EPAP a bit...don't add it to 9 cm. Back off to maybe 7 or 7.5 or 8 minimum EPAP.
You aren't having that many OAs and more IPAP should help out a lower EPAP deal with OAs.

bossfan · Post by **bossfan** » Wed Sep 30, 2020 11:47 am

Pugsy wrote: ↑
Wed Sep 30, 2020 11:10 am
PS is pressure support and really just the difference between inhale and exhale. It's used to increase IPAP and keep EPAP lower when more EPAP causes a problem of some sorts. Most of the time it's used for aerophagia kind of problems but with your machine it can also increase rapidly and briefly to force you to breathe...that's when you see the big jump on the pressure graph that goes up fast and back down just as fast.
Baseline PS is where it starts...right now it is at 5 cm so there is always a 5 cm difference between inhale and exhale. It potentially can increase a lot more than 5 cm if it needs to breathe for you.

There's long been a general rule of thumb for bilevel machines...EPAP for OAs and IPAP for hyponeas. There are 2 ways to get more IPAP....either more EPAP or more PS. Your PS is already at 5 which is more of a normal usual PS....Most in lab titrations come out with the person needing a 4 or 5 PS to get a job done. More PS can also cause centrals in some people....small number of people for sure but it's a possible. I just saw it happen in this thread
viewtopic/t180394/Holy-AHI-Increase--Wh ... ng-on.html

But then I have a friend who uses a bilevel machine with PS of 6 because he likes it and gets no centrals....so it's not a given that more PS always causes centrals. It's one of those YMMV things.

If you want to try higher PS....back off on the minimum EPAP a bit...don't add it to 9 cm. Back off to maybe 7 or 7.5 or 8 minimum EPAP.
You aren't having that many OAs and more IPAP should help out a lower EPAP deal with OAs.

Thank you I understand all of that. So if I set my min EPAP to 7.5 and my min PS to 5.5 then my min IPAP will then be 13, is that correct?
But before I started to change my settings I had a min EPAP of 8 and min PS of 5 which would be a 14.0 IPAP. So is the lower IPAP of 13 a problem?

I think I'll take a conservative approach on PS and increase it from 5.0 to 5.5 instead of 6.0 and a middle of the road approach on EPAP of 7-8 and set it to 7.5. I'm just trying to see if adjustments will help my AHI and hypopneas. So I'll be conservative with the adjustments and see if there are improvements. If you think this is too conservative then let me know, otherwise I will report back tomorrow and I really appreciate the time that you are spending on this with me.

Pugsy · Post by **Pugsy** » Wed Sep 30, 2020 12:01 pm

Yes. That is correct. Minimum EPAP plus Minimum PS will equal minimum IPAP.

You may not have read this or if you did...might not have understood it as it was written for in lab sleep techs but it gives various scenarios as to how to titrate
http://www.isetonline.org/yahoo_site_ad ... 190318.pdf
They start with titrating for OA management and go from there based on what is seen.

ResMed has a similar guide but to show you it is like showing you apples and oranges. Different brands and different algorithms and different approach and it's not as technical anyway.

bossfan · Post by **bossfan** » Wed Sep 30, 2020 2:01 pm

Pugsy wrote: ↑
Wed Sep 30, 2020 12:01 pm
Yes. That is correct. Minimum EPAP plus Minimum PS will equal minimum IPAP.

You may not have read this or if you did...might not have understood it as it was written for in lab sleep techs but it gives various scenarios as to how to titrate
http://www.isetonline.org/yahoo_site_ad ... 190318.pdf
They start with titrating for OA management and go from there based on what is seen.

ResMed has a similar guide but to show you it is like showing you apples and oranges. Different brands and different algorithms and different approach and it's not as technical anyway.

I did read that but I have read it again, think I understand the concepts so tell me if I have this right:

EPAP responds to OA events. PS responds to CA events.
When I first posted my EPAP min was 8.0 and PS min was 5.0. We increased EPAP min to 9.0 to see if that would help any OA events that was contributing to high AHI score. Seemed to help as my AHI went down.

We are now increasing PS min from 5.0 to 5.5 to see if it helps with the CA and if the hypopneas I'm having are central then the increased pressure might help.

What I am not clear on is my original settings gave me an IPAP of 13.0. With a PS of 5.5 and EPAP of 7.5 my IPAP is still 13.0. I thought that we were going for a higher IPAP to see if that helps with the hypopneas, or is the increase in PS what will hopefully help the hypopneas if they are central hypopneas?

Pugsy · Post by **Pugsy** » Wed Sep 30, 2020 3:28 pm

You raise some valid questions which I don't have a clear cut answer for.
It is entirely possible that those hyponeas are central in nature but the machine sees them (and treats them) like obstructive.

EPAP is a critical setting but IPAP with an increase in PS also helps out with the obstructive stuff as well.
We do it when people have bad aerophagia and need more pressure but their bellies simply can't tolerate a consistently higher EPAP all night...so we add in PS and the pressure alternates between EPAP and IPAP and IPAP helps hold the airway open.

Don't feel bad about not understanding that document totally....I had to read it about a dozen time for the bulk of it to make sense.

If those hyponeas are central in nature...the machine isn't going to respond. It's just not in the algorithm to do it. The algorithm was written based on the fact that most hyponeas are obstructive in nature. I have seen the Respironics machines mislabel events.
I have seen it call centrals full blown OAs. It's not perfect....no machine ever is but we have to deal with what we have.

See this report....this person has Cheyne Stokes Respiration and all those OAs you see flagged are really central apneas.

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