Post-Surgery Blues: Scoring Question

mollete wrote:

BrianinTN wrote:Given that I sit around 4-5cm most of the night, and things seem to get worse when we go much above that, is an ASV even going to do much for me?

Great question. Let's get The Kid to weigh in.

Hey Kid, you gonna add something here or just stand around and flex for SU?

Oh, Dave. Don't worry, no one can flex their epoch like you can.

SleepingUgly wrote: Oh, Dave. Don't worry, no one can flex their epoch like you can.

I'm feeling very small over here....

"Flex their epoch"?

I think Pugsy just jumped ahead of you in line.

BrianinTN wrote:

SleepingUgly wrote: Oh, Dave. Don't worry, no one can flex their epoch like you can.

I'm feeling very small over here....

They can fix that, you know...

So if you guys can put away all the battery-powered devices for a minute...

...looking at the morning of 7.26, there's a heap of central-based phenomena. It would appear that the ventilatory instablity was there for a while, so perhaps this current stuff shouldn't be a complete surprise...

mollete wrote: ...looking at the morning of 7.26, there's a heap of central-based phenomena.

Er, 7/26? That was pre-surgery. The stuff from this month is the only post-surgery data. (Although that you're seeing all those centrals pre-surgery is perhaps instructive data in and of itself, in that it suggests maybe this won't be self-resolving?)

BrianinTN wrote:Although that you're seeing all those centrals pre-surgery is perhaps instructive data in and of itself..

Correct, the ventilatory instability was apparently always there, so perhaps your initial concern ("Omigod! My AHI is 66!") may be better understood at this point.

...it suggests maybe this won't be self-resolving?

I think at this point it's apples and aardvarks. That was on CPAP 8.0 cmH20, and maybe an expected response in that scenario.

Right now you have at least 5 sets of data: ambient, CPAP, APAP, ambient post-surgery and post-surgery with APAP, and now we have to add the time factor (which should allow some/all of the ventilatory instability to correct).

Sometimes, doing less is more...

mollete wrote: Right now you have at least 5 sets of data: ambient, CPAP, APAP, ambient post-surgery and post-surgery with APAP, and now we have to add the time factor (which should allow some/all of the ventilatory instability to correct).

Plus data from my original CPAP setting of 13, BiPAP S/T (at 20/16), and ASV (min EPAP 4). YEAH SCIENCE!

mollete wrote: Sometimes, doing less is more...

Yeah, I think of that as the corollary to Occam's razor. However, in this particular case, where I can't get back in to see a Stanford doc for a while (and the lead times for scheduling sleep studies are long), I'm unclear how to best go about "doing less." My options, as I see them, are:
1) Stop using xPAP therapy for the time being. This certainly has the greatest emotional appeal to me, since I feel far less functional (and much more emotionally stressed) when using xPAP.
2) Continue using APAP within this narrow band of very low pressures.
3) Fire up the non-PR1 ASV that my old awful DME saddled me with to get rid of their old inventory, and allow it to work within similarly narrow bands of pressures, despite the noise being disruptive to my sleep.

I'll phrase my question carefully: if you were a patient, say, who had data sort of similar to mine, and couldn't get in to see anyone for a while, what might you choose? Hypothetically, of course.

BrianinTN wrote:if you were a patient, say, who had data sort of similar to mine, and couldn't get in to see anyone for a while, what might you choose? Hypothetically, of course.

Hypothetically, I would establish a treatment team. Division of labor would be as previously assigned:

BrianinTN wrote:I'll leave the diagnostic observations to you and the DWing to me.

BrianinTN wrote: opted for surgery this past summer

Sorry to hear about the worrisome results. But for some ENT surgeries, complete recovery, including full remission of any swelling, is not expected until a year. So there may still be improvement to expect. Good luck!

BrianinTN wrote:I'll leave the diagnostic observations to you and the DWing to me.

However, and "IMHO", the application of DWing when CompSAS is underfoot may result in (results) that make it seem as though no progress is being made. If we are going to use the "time heals all" philosophy of CompSAS correction, then the body must see the same set of parameters, all night, every night, for x period of time (and I don't know what x is. Your Stanford guy is talking 3-4 months, the surgery guys reviewed at 6 months, the CompSAS guys seem to talk about 1 month a lot). Sporadic use will not allow equilibration to occur ("Insanity is...").

As an example, if we look back at 2010, where a very aggressive pressure was being used, some terrific runs of PICs were seen:



However, if we review patterns of use, there was no real opportunity for equilibration. Only a few days utilization, partial use during some nights, skipping nights:



TS, there are strong suggestions that equilibration would occur with consistent use.

TS2, there are tons of variables that must be considered here (one of the reasons that mollete does not DWing).

I get your point. I know there have been a lot of changes, which given your theory about needing time for things to "settle in" makes any sort of scientific evaluation difficult at best.

Obviously, from the patient perspective, your central conclusion is immensely frustrating because it implies the potential for literally years of experimentation and tweaking, rather than days or weeks or even a couple months. It would also cast doubt, as framed, as to the usefulness of an in-lab titration, yes? If the whole point is that the body needs proper time to acclimate, then a set of data points that are, in effect, random shocks wouldn't be very useful.

As for compliance, I'm not altogether sure what to do about that. When you saw partial nights in the data, it was always me giving it a go and being exasperated by my frequency of cognizantly waking up. I usually tried, if at all possible, to get the requisite minimum 4 hours of xPAP therapy.

On nights where I didn't use it at all, other than the occasional ones where I was traveling and it was infeasible to take my machine, I was generally saying, "Damn it, I feel like a zombie, and I have crucial work tomorrow that just cannot wait, so I HAVE to get at least a reasonable night of sleep tonight." (My Epworth before "treatment" was actually OK; it goes up in flames while on xPAP, especially the higher the pressure.) So given that I can't sit like a bump on a log for years on end, yeah, I dunno. I know a lot of people around here are kind of sissy-ish and give up easily, but I don't think that's the case for me. I have literally hundreds of nights of me trying to make it work (170ish just in this CPAP data, plus the BiPAP and ASV data separately). I just flat-out feel more exhaustion and daytime sleepiness the next day after using xPAP than not, regardless of the pressure settings.

BrianinTN wrote:Obviously, from the patient perspective, your central conclusion is immensely frustrating because it implies the potential for literally years of experimentation and tweaking, rather than days or weeks or even a couple months. It would also cast doubt, as framed, as to the usefulness of an in-lab titration, yes? If the whole point is that the body needs proper time to acclimate, then a set of data points that are, in effect, random shocks wouldn't be very useful.

I think you have to treat this whole thing from 2 angles.

First, you need military sleep hygiene. Looking at that history, assuming all the clocks are correct, and poor compliance notwithstanding, if you improved your sleep hygiene by 300% you would only get up to "awful".

Second, it depends on how you want to deal with the CompSAS. Your DLs show the potential for improvement with machine use (there was even some good areas at 13 cmH2O), as shown in graph above (although the stretches are very short). If we are to look your overall use of 166 days:



it is clear that the sporadic use would NEVER allow equilibration to occur. You can't use for a couple days, then try it again after a couple weeks to see if things got better.

While surgical and CPAP CompSAS take time, ASV does not. It takes effect in about 15 - 20 minutes (or often less). That's when it's being used appropriately, treating chain centrals (which is what you got).

Yeah, I get you. One qualifier that I'll add is that some of those gaps are periods of time when I was on the BiPAP S/T and the ASV -- but even adding those in, it's still not going to look great. Some of the gaps are me just giving up entirely, saying, "I just can't do this anymore," during especially busy periods in my life...and then later trying to return to it when things are a bit more calm.
EDIT: I amend my previous statement. I pulled up my old ASV data, and it has180 days of treatment logged on its own. Add in the BiPAP S/T time, and in retrospect, I think my compliance efforts are actually pretty decent, all things considered.

I am trying to do better on the hygiene piece, as you saw from my previous post, but I find that to be very hard. Previously, it was the nature of my job (I headed up both US operations and several projects working with teams around the globe for my old company, which meant a lot of wacky hours and deadlines). Right now, it's school, which will end in June but has been stressful and exhausting in its own right and has made any sort of rhythm hard. And, add to all of that the fact that I am a stresser and a worrier, which often makes it impossible for me to settle down at night lest I toss and turn for hours. So, rather than that, I generally try to wait to get into bed until I'm ready to sleep.

Yes, I know. Blah blah blah excuses blah blah blah.

Given your last comment, maybe the thing to do is to pull out the behemoth ASV and see how it copes.

BrianinTN wrote:EDIT: I amend my previous statement. I pulled up my old ASV data, and it has180 days of treatment logged on its own. Add in the BiPAP S/T time, and in retrospect, I think my compliance efforts are actually pretty decent, all things considered.

Over 948 days (6/21/2010 - 1/24/2013)? "IMHO", you'd need to double utilization to get to "decent".

In order to expect equilibration to occur, the body must see the same thing every night. Clearly, there is a difference between "utilization" and "consistent utilization".

Looking at the aforementioned time period:



The goal is to paint a solid blue bar in the red box.

Is the ASV file uploadable?