Gee I wish I had data from the start.....

I'll apologize right now for what I am sure will be a long post (as many of you may be becoming accustomed to from me) but even just trying to get this straight in my own feeble mind has more legs than a centipede. Given what I know will be a long and maundering missive, I will also up front profusely thank anyone with the patience to wade through this and provide any thoughts. A special thanks to my benefactor that led me to EncorePro as well since, while the Pro detailed reports are the same as Viewer, the waveform reports from Pro are providing, I think, some significant clues.

If nothing else, it could prove instructive, cautionary, amusing, or any of the 8 possible combinations of those three traits.

Third night now with the APAP and third that I have data beyond rudimentary compliance information. There are three things that become abundantly apparent even with, and/or because of this little amount of data:

• The three nights (only two of which were moderately successful) my "sleep clinic" sent home an APAP were probably not enough to definitively determine a good fixed pressure
• Consistency is going to be crucial to start to figure out what is going on
• I'm gonna need a lot more data and then go back to have a little chat with my RCP

While I was making a valiant attempt at following Slartibartfast's excellent advice to lock all my various masks purchased away and stick with one to reduce the variables to really establish just what is going on, I ran into a small roadblock with that. My choice was to use the FFM so that I could cover both the nights I that all was good, generally speaking, healthwise but also to cover those nights where my sinuses gave me fits to allow mouth breathing. My Quattro and Zzz-Mask have essentially the same specs so I can essentially change between those with abandon. Believe it or not, there are nights when I like the stiffer mask and forehead support. Go figure.

Sadly, this all fell down about exactly the time I got the APAP and, for the first night at least, I could simply not get comfortable and relaxed with the FFM. Period. Utterly hopeless. So I dragged out the Swift FX with the firm resolution that this would be the consistent mask to gather significant empirical data. As with the best laid plans of mice and men, that fell down last night in the form of tight sinuses making the use of nasal pillows rather problematic. So, out came the trusty Quattro. Perhaps naively, I figured since the flow rates were relatively close and my leak graphs did not show any indications that my mouth was open with the FX, that the change would be small enough so as to keep the variables consistent enough as the dataset is built.

Maybe. But one would sure never know it after last night.

To my first point above, now having the data capable APAP home for 3 nights which is the same duration as I had the loaner to set my fixed pressure, I cannot make any definitive statements about what is going on. Granted, I am not any kind of medical professional and can rely only on critical thinking but... I dunno.

I am still yanking the mask, albeit typically after longer periods than I ever did with the CPAP and, so far, much longer than I ever did at my initial pressure of 5 cm H2O. I've set the APAP to have a range of 7 - 12. Lower than the lower limit just doesn't work for me as, (again to quote Slartibartfast), I felt like I was trying to breathe through a straw. The upper limit is somewhat arbitrary and set significantly higher than the initial 5 or even the 7 suggested over the phone by my RCP. I narrowed the range based on regular comments based on experience that, perhaps the wider range gave the APAP too much room to play in and might needlessly oscillate trying to find a pressure in that broad range. Based on the above, my first three nights show (at a 10,000 foot level):

• First night - Swift FX mask, 90% pressure of 7.9, AHI 0.9, VS 7.0. Never came near the upper pressure boundary.
• Second night - Swift FX mask, 90% pressure of 9.7, AHI 0.7, VS 17.3. Touched the upper pressure boundary for only 2.1 minutes.
• Third (last) night - Quattro mask, 90% pressure of 10.9, AHI 5.7, VS 45.7. Pegged at upper pressure boundary (12) for 75 minutes.

When I look at the waveforms for all three nights, on the first two, I can see what seems to be some ugliness in the form of an event of some kind immediately proceeding the mask yank. On both the first two nights, the APAP hadn't responded significantly with higher pressure but on the second night, it did ratchet up rather higher and quickly a few times during which the mask stayed on and I stayed asleep. On both nights, there were quite a few events that seemed to get a breathing restart with pressure pulses. Both nights have the breath wave form, for the most part, resting nicely and fully on top of the APAP pressure plot.

Last night was just ugly. Some pretty big events by the waveforms where the pressure kept going up along with pressure pulses to get me going again. Both times there was a mask yank, it was preceded by some significantly nastiness (several OAs a minute apart with pressure at max). The second half of the night (when I woke up and put the mask back on) the pressure kept going up to keep pace with the breathing and the latter bit until my alarm went off, the APAP was again pegged at 12 with a lot of the breathing waveform below the pressure plot. There are clearly some events in that latter half of the night but even up to where the alarm went, the APAP was keeping apace of them even though at the upper pressure boundary.

I may be straying to the subjective a bit but, is it possible the mask yanks the first two nights even before the breathing got real ugly came about simply because the FX can be removed almost with a hand swipe? When taking off the Quattro, you gotta mean it or it's going to stay there so perhaps it remained on my beautiful face even with potentially subconscious hand swipes getting me past a few of the events. Again, dunno.

To my other two points way way above here, I can't help but think that only 2 semi-successful nights with an APAP could possibly have drawn a conclusion about a suitable fixed pressure. I would have to say from what I see that 5 was laughably low and 7 not a whole heap better based on what I am seeing when inferring the most from a small dataset. I would also have to say that 3 nights with this machine leave me utterly unable to draw any definitive conclusions at all.

To my RCP's defense, given the benefit of the doubt, I am reasonably sure that he has a big caseload and doesn't have time to lavish the attention he may well want to on each patient. Whatever the reason, I think that there still isn't enough information for him or myself to make any definitive statements and gathering as much information in one place as possible and then going to have a visit is perhaps worth the trip.

All I can say is... wow. Looking at the waveforms from last night alone is rather sobering.

Are you looking at your leak charts along with everything else?

I'm wondering what's happening leakwise right before the mask yanks? My guess is that there is leakage prompting you to remove the mask, and you probably have a lot more leakage (sooner, bigger, more annoying) with the Quattro than the FX. I could be wrong, too--I often am.

I did look at the leak charts as I was curious (the first couple of nights) with the FX if I was a mouth-breather. Shoulda mentioned that in the rambling post, I guess since it is very relevant. Considering I am, of course, learning what I am looking at, I don't think so but I could be wrong too. As I saw it, the only significant leak shown each night is a short spike just as the mask was in the process of being yanked and usually lasting until the machine shut itself off. Didn't see anything of significance (I don't think) prior to the yanks.

My average leaks were:

• First night - 3.0 with 6 mins of large leak
• Second night - 2.3 with 0 mins of large leak
• Last night - 3.9 with 2 mins of large leak

The first two nights were pretty dang good nights sleeping even WITH yanking the mask and I was feeling better in the AM. Today... not so much. Still no headaches but feeling a bit draggy.... A cluster of OAs with APAP at max top pressure limit last night before the mask pull.

trike-mike wrote:To my other two points way way above here, I can't help but think that only 2 semi-successful nights with an APAP could possibly have drawn a conclusion about a suitable fixed pressure.

Hi,

Did you have a titration study in a sleep lab or at a hospital? If not, then I'd go back to square one, perhaps with a new sleep doctor. There are often 20 or more channels of data that is collected, far more than what an APAP on auto can do. There are all kinds of issues that an APAP simply cannot detect or treat. You need to get a real sleep study, and then let a board certified sleep doctor read the results. Without that, you don't know if you even have the right kind of machine, let alone know what settings to use.

-john-

John,

That is the one bit that I have not had. My sleep clinic sent me first home with a monitoring box to see if I had OSA. That went so poorly I assumed the response back would be either "no data, try again if you can stand it" or "boy.... you gonna die".

From that there was a diagnosis of sleep apnea. How accurate the details of the diagnosis were, I don't know but past symptoms plus what I can see tell me that I have it and this pitiful test seems to confirm it.

I won't even call it a titration study that I had after that. They sent home an APAP to use for 3 nights, only 2 of which were moderately successful. This resulted in what even a layman could tell was too low of a pressure.

They seem to be no more responsive than that. Even just a query about pressure and should we look at it closer got a cavalier statement to raise it a couple of points (and wasn't even particularly definitive in that it was stated as "I guess we could raise it to X or Y".

I know full well that I am missing an immense amount of professional input here. When the annual health plan change comes up at the end of the year, I shall be picking a different one where I will have a real sleep study done. Unless I should happen to need a BIPAP (which I don't think I do), I do have a good APAP now that will fill any typical pressure needs so I am equipped well. I have already had a near neighbor PM me with a good sleep clinic nearby me (the one he goes to) so as soon as I am able, I am off to that.

Until such time I do try to reach out to my RCP, getting little back and try to keep up with it as a layman along with some thoughts from here (pretty good statistical universe to draw from here) and from friends who are doctors (but not necessarily specializing in sleep).

Third (last) night - Quattro mask, 90% pressure of 10.9, AHI 5.7, VS 45.7. Pegged at upper pressure boundary (12) for 75 minutes.

I would open up the top pressure a bit. Check for when the leaks happened. And continue testing with the quatro for now. At least with the full face mask it handles mouth breathing.

BlackSpinner wrote:I would open up the top pressure a bit. Check for when the leaks happened. And continue testing with the quatro for now. At least with the full face mask it handles mouth breathing.

I am going to do just that. I did use the Zzz-Mask last night as I was reading a bit before sleeping and the forehead support on the Quattro rather interferes with that (reading with book to the side and closing the eye blocked by the support). The flow rates at pressure are near enough to the same on both of them to be equivalent.

That being said, last night, I remember at one point yanking the mask before falling asleep again (and didn't wake enough to put back on for two hours). Looking at the data this morning, I can see just at that point a very large leak and ugly wave forms that, taken in concert with my layman's view of cause and effect are consistent with what the machine would perhaps see with the circuit open. Also at that point, while I woke, there was no previous events (perfectly normal breathing with pressure low-mid range). From that, two things:

• I suspect that the Zzz-Mask with its lighter structure and easier to push off may have had a big leak induced by some movement I made. The change in therapy and/or essentially instantaneous loss of therapy may have woken me and in my sleep yanked rather than fixing the leak
• I need more consultation. I'll be setting an appointment for the earliest I can get into the RCP (likely late in the week or even next week) and take in my data for a consult.

I didn't see any anomalous leaks on the night when the pressure pegged high and I had significant OAs at pressure. The other, I suspect, contributing factor was that I was quite stuffy and in the throes of a slight case of bronchitis that I am in the process of clearing. Felt rather crappy when I went to bed that third night. Last night's aggregate data, aside from the leak/yank event, is consistent with the first two nights on the APAP using the FX with the third night high pressure festival being a bit of a flier.

That being said, in advance of getting to my RCP for an in depth professional analysis, I will nudge the upper boundary a mite to see if that carries any flier nights that I may yet have between now and then. I'm gonna also have to be more rigorous and, even though they are technically the same, the easier leak inducement of the Zzz-Mask may have gibbled my results. Again. The Quattro really does stick and if you're gonna take it off, you need to mean it.

I'll just have to read with one eye at night for the next while

One thing you might try, just to see what the data will show:

Set the machine in APAP mode but with the min/max pressure the same -- both set at 10 cm H2O.

Note: If the two pressures don't want to let you set them the same, turn off A-Flex. Turn on C-Flex instead, at whatever level you want, 1 (for just a little drop in pressure when exhaling), 2 (for more drop), 3 for the most drop in pressure C-Flex can give.

With both the minimum and maximum pressures set at 10 in APAP mode, the machine will work just like a plain CPAP at a single pressure of 10.

The reason for doing this experiment in APAP mode, instead of simply setting it to CPAP mode at 10, is to let the machine gather all the data "APAP" mode gives. In CPAP mode, I think it would not record flow limitation data.

I'd try several nights at min 10, max 10. If you can manage to keep the mask on all night, that would be good. For most people, apneas hit hardest during REM sleep. The first REM cycle is usually a fairly short one, and usually happens about 90 minutes after you go to sleep. Each successive REM cycle happens about every hour and a half, and each REM cycle usually gets longer as the night goes on. So, we usually have our longest period of REM before waking up in the morning. Data gathered near morning when the person is likely spending the longest amount of time in REM could be very informative.

That is also an interesting thought. I shall give that a shot too as well, if nothing else, to give myself and my RCP more data points to go on.

Rested Gal - Who is that handsome dog you have as you avatar!!

trike_mike:

A full clinical sleep study is needed before you can determine what pressure to set your cpap machine. When they set the pressure do not change it for a year but keep monitoring the results just to make sure nothing is out of wack. My sleep study doctor changed mine after 6 months and within a week I had to go back to the original sleep study setting. When they wire you up the computers do a good job of telling them what pressure you need.

As for the mask. Remember, everyones face configuration is different and fitting a rigid piece of plastic with straight lines against it is going to leave gaps. These gaps cannot be resolved by the gel portion part of a mask because those lines are straight also although flexible. I have found that a product like Remzzs is the only solution (it fits over the gel portion). First, it absorbs any oils the face my secrete during the night and those oils are the culprit in making the mask slip and make the horrible noise when it leaks.

I have just experienced a Resmed Quattro mask problem where my old mask had 36 holes in the exhaust portion and the new mask had 33. This caused excessive noise, leakage you wouldn't believe and headaches. Of course I attribute the headaches to "cranking down" the mask to my face during the night to stop the leakage.

Conclusion, if your AHI is where you want it leave that portion alone. However, if it isn't, get a sleep study. In the long run the money it cost you will be well spent. To have air rectify a problem to me is one of the greatest inventions (no chemicals to ingest). As for the mask, keep experimenting and notice changes in design from one model to another