Flow Limitations and Pressure, Runaway S9?

Thanks Liz. The most rattiest flow patterns do appear though at the highest pressures...any correlation between increased pressures and REM ? How do you know you are in REM (excuse my ignorance), do you have a ZEO or do you look at the fine detail in your flow pattern and if so, what does it look like? Am I making something out of nothing here or would a bilevel machine smooth out my breathing?

It may sound crazy but I am going to keep my ramp at 5 minutes. Previously I had totally eliminated it but have noticed a smoother flow pattern just after the ramp ends as as compared to using no ramp and starting right at therapuetic pressure. Probably some anxieity I guess.

Lou

BigLou wrote:Thanks Liz. The most rattiest flow patterns do appear though at the highest pressures...any correlation between increased pressures and REM ? How do you know you are in REM (excuse my ignorance), do you have a ZEO or do you look at the fine detail in your flow pattern and if so, what does it look like? Am I making something out of nothing here or would a bilevel machine smooth out my breathing?

Lou

Did you get a copy of your full PSG reports and condensed graphs from both of your studies? If not you can get copies from the sleep lab. They will give you a wealth of information on your condition.
I speculated that the ratty areas were REM and then got a recording oximeter and confirmed it. Yes, and I bought a Zeo for kicks, but I don't use it much.
During my PSG, my O2 dropped to 80% during REM, which was when I had most of my apneas. The other big problem though, was arousals. I had over 300 a night during my PSG. I don't think I had slept in over a year.
I still have flow limitations but my AHI stays below 0.5 so I don't worry about them. When I tried APAP the pressure changes seemed to cause arousals and a higher AHI. I still track my data, but now I do what makes me feel like I got some rest.
Last week I tried nasal strips again and lowered my pressure 1cm. I think I am sleeping better. Just dreading the cold and sinus season since I don't have a full face mask yet!
Your data looks pretty good. The number one thing is how you feel. Chasing numbers can defeat the entire purpose.

Liz, I was just talking to a pulse-ox vendor today. I really wanted to get one but didn't know that during REM your o2 sat will decrease. This is some info I can use. I only had about 3 minutes of REM duing my PSG and as low as 81% sat but for a very short time (maybe equivilent to the time spent in REM?...I'll have to check). Yes, I am "tired" of chasing the numbers LIz.

BigLou wrote:Liz, I was just talking to a pulse-ox vendor today. I really wanted to get one but didn't know that during REM your o2 sat will decrease. This is some info I can use. I only had about 3 minutes of REM duing my PSG and as low as 81% sat but for a very short time (maybe equivilent to the time spent in REM?...I'll have to check). Yes, I am "tired" of chasing the numbers LIz.

Same here. I wasn't getting any REM. It was all fragmented and I was braindead.
You might add the minute ventilation to your screen. Mine coorelates pretty closely with my leaks, which don't look as good as yours but are getting better.
If you haven't seen it, there is a video tutorial for ResScan link in my signature below.

Liz, how are you liking the CMS 50F pulseox? Has it performed as you expected? Any shortcomings? Thanks.

Lou

I have the 50H and the 50F. I am happy with both and use both under different circumstances. The F is more comfortable for overnight recording, which is why I got it. The H is better for when I want to use the alarm feature. Like watching tv and might fall asleep, power outage. My O2 drops when I lay down, so dozing off can be ugly.
The biggest difference is the menus. The F keeps a running clock so you don't have to mess with setting the time every night to record and it's easier to turn on, but the alarm feature is 2-3 menu layers down, and a pain to turn off when you are done with it. When I use the H for just the alarm, all I have to do is hit the button to cancel the alarm and take it off. It shuts down. The F has to be powered off.
There is an "I" now, but I don't know what is new on it. I think it might record multiple sessions, but I'm not sure. That would be nice but I will probably wait for the "J".

Last nights report. Am I in REM during the flat minute vent times at about 0345 and 0600? I dont like the higher pressure. What is up with the increased FL at the max pressures here????

BigLou wrote:
Last nights report. Am I in REM during the flat minute vent times at about 0345 and 0600? I dont like the higher pressure. What is up with the increased FL at the max pressures here????

I would say no. Maybe deep. See how the min. vent cooresponds with the leak line? I don't know what or how Resmed records or calculates to get that data. I'm just speaking from my experience with patterns in my data. Even with the flow limitations, you aren't having OA's, or at least ResMed isn't flagging them as such.
Your data looks alot like mine. My flow limitations are during REM. My flatlines with leaks tend to be deep.
Just a couple of questions..
What was your titration pressure?
Were you awake for that first hour or did you really fall asleep that quickly?
Were you awake for 30 min before you turned off the machine at 0730?
What do you have the EPR set at?

Edit: Didn't mean to repost the screenshot.

Hi Liz

Titration was 10 straight CPAP. Now (via my own experimentation) in APAP 9.8-11.4........tried max of 11.8 last night and did not feel any better today.
EPR is set at 2. Not sure if I was awake or not around 0730. From what I've read, the machine is supposed to respond to the flow limitations (that occur first, possiblbly a precursor to an apnea), but why does the FL continue with the pressure. This causes an increased inspiratory flow rate......like big time. I know this must be affecting my sleep quality via increasing arousals. I had a score of 17 on the arousal index at my titration.

Was thinking that an auto bi-level machine may help with my unstable respiration that occurs at these times. Don't know. I may need more pressure according to the APAP to ward off events and but a bi-pap would give more exhalation relief therefore possibly allowing me to breathe more naturally.....BUT would a lower EPAP with a bi-level (than would an S9 Auto EPR of 3) let some events slip through but result in more restful sleep? I hope I'm not confusing myself??!!

BigLou wrote:Hi Liz

Titration was 10 straight CPAP. Now (via my own experimentation) in APAP 9.8-11.4........tried max of 11.8 last night and did not feel any better today.
EPR is set at 2. Not sure if I was awake or not around 0730. From what I've read, the machine is supposed to respond to the flow limitations (that occur first, possiblbly a precursor to an apnea), but why does the FL continue with the pressure. This causes an increased inspiratory flow rate......like big time. I know this must be affecting my sleep quality.

Was thinking that an auto bi-level machine may help with my unstable respiration that occurs at these times. Don't know. I may need more pressure according to the APAP to ward off events and but a bi-pap would give more exhalation relief therefore possibly allowing me to breathe more naturally.....BUT would a lower EPAP with a bi-level (than would an S9 Auto EPR of 3) let some events slip through but result in more restful sleep? I hope I'm not confusing myself??!!

Have you tried your titration of 10 on CPAP.
Sometimes we get carried away with the bells and whistles.
I did, and wound up going back to my titration pressure of 7 with no EPR. 2 months wasted.
I'm sensitive to pressure changes and the EPR, a pressure change, was causing arousals.
You are having centrals which can be caused by too much pressure. You are not having OA's. So what do the FL mean? I don't know but I think they mean less than we think. I don't chase them. Everytime I increased my pressure, my data got worse. When I dropped the EPR, my data got better and I felt better.
If I were you... I would drop the max incrementaly and see where the OBSTRUCTIVE apneas reappear.

How long did you run at CPAP at your titrated pressure before you switched to APAP? Ref my first comment.

I also have Flow Limitation but less than you: do.

See it here:



The following is my recent 30 days Stats:





All the the other events that you and I have, while being on CPAPs, are meaningless, imo.

In my case I have both plain OSA and FL.

As I posted above in the 1st page, Flow Limitation is synonym with UAR and RERA.

Do you have Upper Airway Resistance Syndrome (UARS)?

Clinical Features

Patients with UARS have symptoms similar to those seen in OSAS, although there are some distinct features. Much of the research performed has attempted to identify and describe a group of patients with significant daytime sleepiness and disrupted sleep, but without the other dominant clinical features seen in OSAS. Typical symptoms reported by patients with UARS include excessive daytime sleepiness, fatigue, difficulty concentrating, morning headaches, and unrefreshing sleep. There can be also be a significant impairment in daytime functioning; a recent study demonstrated that subjects with UARS performed worse than patients with obstructive sleep apnea hypopnea syndrome and normal control individuals on different aspects of the Psychomotor Vigilance Task. In a separate study, upwards of 30% of subjects with UARS had abnormal sleep-onset latency on the Maintenance of Wakefulness Test. Individuals with abnormal airway anatomy are at increased risk, including those with a decreased retrolingual space, narrow nasal passages, or a small neck circumference. Patients are typically not obese, with a mean BMI often <25 kg/m. They are also usually younger than those in whom OSAS is diagnosed, with a mean age of approximately 38 years. Snoring is not a requisite symptom, with 10% to 15% or more of patients having never or only intermittently snored.

Patients with UARS are also more likely to report symptoms of frequent nocturnal awakening with difficulty falling back to sleep. This is thought to be a potential reason for increased complaints of insomnia amongst patients with UARS, including sleep onset and sleep maintenance problems. In addition to difficulties with acute insomnia, patients with UARS also have an increased likelihood of carrying a diagnosis of chronic insomnia. Other notable complaints include parasomnias, especially sleepwalking, sleep talking, and sleep terrors. Patients may also have symptoms of abnormal autonomic function, including lightheadedness or dizziness on rising from a supine or sitting position, cold hands and feet, and low resting blood pressures (defined as a systolic BP <105 mm Hg with a diastolic BP <65 mm Hg). In a study of 400 patients with UARS, more than 20% met criteria for low BP, a significantly higher prevalence when compared with people who have OSAS (0.6%) or insomnia (0.9%). Interestingly, all subjects in the study had evidence of a small oral cavity on examination with a narrowed airway space dimension on cephalometric radiographs, consistent with other reports. Lastly, patients with UARS have increased rates of symptoms such as gastroesophageal reflux, muscular pain, diarrhea, abdominal pain, depression, and anxiety. This has led some authors to suggest a link between UARS and functional somatic syndromes, such as irritable bowel syndrome, chronic fatigue syndrome, and fibromyalgia. In a study of 75 subjects equally divided into three groups (UARS, mild to moderate OSAS, and severe OSAS), those with UARS were more likely to report symptoms of headache, irritable bowel symptoms, and sleep-initiation insomnia. Subjects with UARS were also more likely to have alpha intrusion during slow-wave sleep, a polysomnographic finding described in a number of fatigue syndromes. In children with UARS, symptoms consistent with attention deficit disorder or attention deficit hyperactivity disorder may be present, with behavioral changes leading to poor school performance.


________________________________________
Clinical Features Associated With UARS

Daytime symptoms:

Excessive daytime sleepiness
Fatigue
Morning headaches
Myalgia’s [muscle pain]
Difficulty concentrating


Sleep disturbances:

Frequent nocturnal awakenings
Difficulties initiating sleep
Insomnia
Bruxism [teeth clenching]
Restless leg syndrome
Unrefreshing sleep

Autonomic nervous system:

Hypotension
Orthostasis [maintenance of an upright standing posture]
Cold hands and feet

Functional somatic syndrome associations:

Depression
Anxiety
Chronic fatigue syndrome
Irritable bowel syndrome
Fibromyalgia

Polysomnographic abnormalities Increased RERAs:

Increased nocturnal arousals
Increased CAP rate [cyclical alternating pattern in EEG]
Alpha intrusion during sleep

Treatment

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. In a study of 15 heavy snorers with clinical evidence of UARS, treatment with nasal CPAP was associated with decreases in observed nocturnal arousals on polysomnography and decreases in mean sleep latency times on multiple sleep latency testing (MSLT) after several nights of treatment. A follow-up study of 15 subjects (in the original description of UARS) with daytime sleepiness and fatigue and who had undergone a therapeutic trial of positive pressure therapy reported similar findings. After treatment with approximately a month of nasal CPAP, significant improvements were seen in mean sleep latency times on MSLT (5.3 minutes vs 13.5 minutes), Pes nadir pressure (–33.1 cm H2O vs –5.3 cm H2O), amount of slow-wave sleep (1.2% vs 9.7%), and EEG arousals (31.3 vs 7.9 events/hour of sleep). Along with an improvement in sleep latency times on MSLT, there were subjective reports of improved daytime symptoms. Lastly, in a study of 130 postmenopausal women with chronic insomnia and evidence of UARS (n=62) or normal breathing (n=68), treatment with either nasal turbinectomy or nasal CPAP was associated with improvements in subjective reports of sleep quality as measured with a visual analog scale as well as mean sleep latency times on polysomnography.19 Despite the growing body of evidence supporting the use of positive pressure therapy for UARS patients, it remains difficult to obtain therapy. In a follow-up study of more than 90 patients conducted 4 to 5 years after the initial diagnosis of UARS was made, none of the subjects were receiving CPAP treatment; the main rationale given was that their insurance provider declined to provide the necessary equipment.1 Formal follow-up clinical evaluations of these patients noted significant worsening in their sleep-related complaints, with increased reports of fatigue, insomnia, and depressive mood. More disturbingly, prescriptions for hypnotics, stimulants, and antidepressants increased more than fivefold.

Other interventions, such as surgery or oral appliances, have also been used with some success in the treatment of patients with UARS. Procedures such as uvulopalatopharyngoplasty, laser-assisted uvuloplasty (LAUP), septoplasty with turbinate reduction, genioglossus advancement, and radiofrequency ablation of the palate have all been described in the literature.37-40 A study of LAUP in nine patients with UARS who underwent uvulopalatopharyngoplasty (n=2), multilevel pharyngeal surgery (n=1), or LAUP (n=6) reported improvements in subjective daytime sleepiness as measured with Epworth Sleepiness Scale scores.37 In the two patients for whom postoperative polysomnographic data was available, significant improvements in Pes nadir pressures were seen. But patients had several interventions and it is difficult to assess which one was successful. A study of 14 patients with UARS who underwent radiofrequency ablation of the palate also reported improvement in subjective sleepiness, with concurrent improvements in Pes nadir levels and reports of snoring.40 However, prior reviews of the available literature have noted that many of the studies evaluated small numbers of patients, consisted of uncontrolled case reports or series without clear characterization of the subjects enrolled, and had no consistent end points for an adequate evaluation of efficacy.39 Further investigation is required to determine the specific role for surgical intervention in these patients. Other authors have also reported successful treatment of UARS with use of oral appliances, although these studies suffer from the same limitations as the surgical literature.41 In children, orthodontic approaches, such as maxillary distraction or use of expanders, have also shown promising results



Source: http://www.chestnet.org/accp/pccsu/uppe ... e?page=0,3



________________________________________


IMO, you need be on CPAP or APAP for a year to see results.

I am saying it because a year and a half ago I had Flow Limitations almost as bad as you have now or even worse,
and now it improved as you see in my above graph and Stats.



See my graphs from last year.



On CPAP @ 9cm EPR= off




Stats for above:




So if you have Flow Limitation Syndrome (FLS), and you can tell it yourself by the above symptomes, then you don't need others to tell you that you have it and all the "advice" that posters give you about pressures, APAP yes or no, low oxygen disaturation, oxygen pulse monitors, central apneas, AHI, etc., are for the birds b/c
FLS differs from OSA and CSAS, entirely. Most posters don't know about treating FL (see Liz's post) but inspite, they do give misleading "advice".

Pugsy wrote:

avi123 wrote:I would raise the max pressure by 2 cm and see if the pressure graph still "kisses" the top limit line. It should not. The leak graph that you have is typical to using nasal pillows. Those pillows vibrate in the nostrils and causing the jagged graph.

Get off the nasal pillows causing vibration and jagged graphs. You have no idea what you are talking about again.
When was the last time you used a nasal pillow mask?
They do NOT vibrate in the nostrils. Please quit dissing the nasal pillow masks. Despite your personal feeling about them they do a darn good job for a lot of people.
How come you only tell the men this garbage and not the women? Misogynist?

2 cm increase in minimum pressure is not warranted and even if it was that is way too much of an increase way too fast.
There is zero sense in making such a huge jump in the situation. Totally unneeded since the obstructive events aren't an issue.

Misogynist, a very popular word DOWNUNDER this week.

BigLou wrote:Hi Liz

Titration was 10 straight CPAP. Now (via my own experimentation) in APAP 9.8-11.4........tried max of 11.8 last night and did not feel any better today.
EPR is set at 2. Not sure if I was awake or not around 0730. From what I've read, the machine is supposed to respond to the flow limitations (that occur first, possiblbly a precursor to an apnea), but why does the FL continue with the pressure. This causes an increased inspiratory flow rate......like big time. I know this must be affecting my sleep quality via increasing arousals. I had a score of 17 on the arousal index at my titration.

Was thinking that an auto bi-level machine may help with my unstable respiration that occurs at these times. Don't know. I may need more pressure according to the APAP to ward off events and but a bi-pap would give more exhalation relief therefore possibly allowing me to breathe more naturally.....BUT would a lower EPAP with a bi-level (than would an S9 Auto EPR of 3) let some events slip through but result in more restful sleep? I hope I'm not confusing myself??!!

Set your machine to CPAP mode with a pressure of 10 cm. with no EPR or to a pressure of 12 cm. with an EPR of 2 (to compensate for the 2 cm. drop on exhale).

In APAP mode with a range of pressures, you have a self-perpetuating cycle (problem). The first flow limitation or snore starts jacking up your pressures. Then, as the pressures increase, you're probably subconsciously reacting to the pressure increases and the machine reads those reactions as additional flow limitation and keeps increasing pressure. This continues until it reaches the maximum pressure and/or you wake up.

.

Guest wrote:

BigLou wrote:Hi Liz

Titration was 10 straight CPAP. Now (via my own experimentation) in APAP 9.8-11.4........tried max of 11.8 last night and did not feel any better today.
EPR is set at 2. Not sure if I was awake or not around 0730. From what I've read, the machine is supposed to respond to the flow limitations (that occur first, possiblbly a precursor to an apnea), but why does the FL continue with the pressure. This causes an increased inspiratory flow rate......like big time. I know this must be affecting my sleep quality via increasing arousals. I had a score of 17 on the arousal index at my titration.

Was thinking that an auto bi-level machine may help with my unstable respiration that occurs at these times. Don't know. I may need more pressure according to the APAP to ward off events and but a bi-pap would give more exhalation relief therefore possibly allowing me to breathe more naturally.....BUT would a lower EPAP with a bi-level (than would an S9 Auto EPR of 3) let some events slip through but result in more restful sleep? I hope I'm not confusing myself??!!

Set your machine to CPAP mode with a pressure of 10 cm. with no EPR or to a pressure of 12 cm. with an EPR of 2 (to compensate for the 2 cm. drop on exhale).

In APAP mode with a range of pressures, you have a self-perpetuating cycle (problem). The first flow limitation or snore starts jacking up your pressures. Then, as the pressures increase, you're probably subconsciously reacting to the pressure increases and the machine reads those reactions as additional flow limitation and keeps increasing pressure. This continues until it reaches the maximum pressure and/or you wake up.

.

Hi again BigLou!

I think that our Guest is telling you things very important!

When I said "aparently so" what I meant was "Yes, you are causing sleep fragmentation". The kind of "self-perpetuating cycle (problem)" our Guest discribes is what I tried to tell you about in my way too long and complicated post. I believe that you could stroke out doing that.

May we find good health!

Todzo

Taringa542 wrote:

Pugsy wrote:

avi123 wrote:I would raise the max pressure by 2 cm and see if the pressure graph still "kisses" the top limit line. It should not. The leak graph that you have is typical to using nasal pillows. Those pillows vibrate in the nostrils and causing the jagged graph.

Get off the nasal pillows causing vibration and jagged graphs. You have no idea what you are talking about again.
When was the last time you used a nasal pillow mask?
They do NOT vibrate in the nostrils. Please quit dissing the nasal pillow masks. Despite your personal feeling about them they do a darn good job for a lot of people.
How come you only tell the men this garbage and not the women? Misogynist?

2 cm increase in minimum pressure is not warranted and even if it was that is way too much of an increase way too fast.
There is zero sense in making such a huge jump in the situation. Totally unneeded since the obstructive events aren't an issue.

Misogynist, a very popular word DOWNUNDER this week.

Comment,

See this post from 2008 saying the same as I do now:

Swift LT vs. Opus 360

by Georgio on Wed Dec 10, 2008 1:33 am

"My Opus 360 has been showing a jagged leak line for a few weeks....tonight trying the LT and hope to get a more controlled leak rate....will let you all know what the data shows".

link: viewtopic.php?f=1&t=36877&p=322355&hili ... 60#p322355

So who is a meshuggener?