Last Night Trying CPAP .... graphs included

[fredn]

Morning everyone,

So last night I tried CPAP (instead of VAuto) ..... I had pressure set to 12 with EPR set at 3 ....

Let me start by saying I don't think I needed ANY EPR ..... I'm going to try it out straight 12 during the day today and see what it feels like.

I started out real good .... my events up till around 12:45 AM were looking real good.

Then around 1:00 AM I had 3 obstructions, one right after each other ... followed by an awakening.

Then I'm pretty good again until around 2:45AM

2:45-3:00AM I had another group of obstructions ..... then again around 4-30-4:40AM .... both of these times I "MAY" have shifted to sleeping on my back .... it appears that being on my back always needs more pressure ... it even somehow feels different in my mask.

So anyway ... here's the graphs. I'd love some feedback on what some of the more experienced users are seeing ...

The two things that I am going to do are:

1. NO MORE LETTING MYSELF SLEEP ON MY BACK.

2. See how EPR OFF feels and try it tonight turned off.

Plus I'm open to other ideas ..

Fred

[Pugsy]

You might also keep an eye out for the time frame where REM stage sleep is likely to occur.
Look down below the sleeping kid on the right for the hypnogram.
http://en.wikipedia.org/wiki/Sleep
It's harder to evaluate with such fractured sleep but I think you can get the idea. Wee hours of the morning is when REM sleep comes on faster, last longer and where people may have more OSA events and/or need more pressure to deal with those events.
Similar thing with supine sleeping.
You may have won the bifecta....have both supine sleeping makes things worse and REM stage sleep can make things worse...it is common.

[fredn]

You may have won the bifecta....have both supine sleeping makes things worse and REM stage sleep can make things worse...it is common.

This is why I'm not a gambling man

Other than STAY OFF YOUR BACK DUMMY ... got any suggestions for a game plan?

I thought what happened in the early evening looked pretty good ... so I'm thinking CPAP warrants more investigating. Should I just bump pressure up to 13 and try again tonight? Or play with EPR first? Or both at the same time? Or something totally esle?

Got to say when using CPAP there's less to adjust and less graphs to analyze

Fred

[Pugsy]

EPR reduces the exhale pressure by whatever your EPR setting is. So it sort of makes it work like a Bilevel machine...one pressure on inhale and one pressure on exhale...with the max being 3 cm in cpap mode vs a choice of more than 3 cm in bilevel mode.

If you happen to need just a little more pressure sleeping supine or for REM stage sleep then you would either reduce EPR so you get a little higher pressure on exhale or increase the pressure compensate for the whatever reduction using EPR.

You can sort of control supine sleeping but you can't control REM (short of limiting chance of REM with repeated awakenings which would be cutting your nose off to spite your face).

If you are really wanting to experiment with straight cpap mode...I would eliminate EPR if it were me because you are sort of using bilevel pressures when using EPR. It isn't exactly like bilevel because the timing is not quite the same (from my experiments with my VPAP in cpap mode and bilevel mode with same pressure support) but it is close.

You can also do some experiments if you can remain totally on your side (it's not so easy) to see if those clusters are supine related or maybe REM related. I did that experiment way back when I first started therapy. I fixed a barrier that wouldn't move and stayed on my side ( I did it for a week to get more than one night of data) and I still got the clusters that pointed to REM stage sleep...not unexpected because per my sleep study my AHI was 5 times higher in REM than in non REM sleep. So supine sleeping doesn't seem to make my OSA any worse but REM sleep sure does.
Sometimes my REM events needs substantially higher pressures to be eliminated...like up to 18 and 19 but sometimes I would barely see an increase (this was back when I was using an APAP machine with 10 min and 20 max.)
This is why I never spent a bunch of time worrying about using cpap mode...I never know when I might need more pressure and I sure don't want to use 18 all the time to prevent some maybe events that might occur for 30 minutes during the night.
That's like using the atom bomb to kill a fly...way overkill. Not to mention 18 cm is just not much fun to use all the time.

Normally I say to keep an experiment for 7 nights to get a good idea what is going on because we simply don't sleep the same each night and we don't know if any changes we are seeing are related to just a normal variance vs a change in a setting.
I say normally because if an experiment seems to cause immediate poor results...I won't try it again. Like when I turned AFlex off and had one of my most horrible nights ever.

Your fractured sleep from last night...that, to me, classifies as pretty horrible results. It might have been a fluke and it might not have but if me, I wouldn't want to chance a repeat.
That said...you are relatively new to therapy if I remember right. Aren't you the one whose wife had OSA and hence your older membership status on the forum....so this is your first machine...if I am wrong then just disregard what I am going to say next.
I think it is too soon to go making large changes quickly just to be playing around and expecting to accurately evaluate your results.
I am not against some experiments...heck I do it all the time but bilevel does take a bit of time for the body to adjust to things.
I had been on APAP for nearly 3 years when I changed to bilevel (that's another story) and I found that once I had a bilevel setting that gave me a decent report that it took me 6 weeks before things finally settled down so that my results were consistent.
My AHI was cut in half when comparing numbers between week 1 and week 6. Not talking a huge change because week 1 AHI was averaging 4 to 5 AHI (but had a couple nights with AHI 1.0 so I knew the settings could work) and at week 6 I was seeing average AHI around 1.0 to 1.5. No changes in anything at all during that 6 weeks. Some nights were really super bragging rights AHI and some night hang my head in shame AHI but with time the hang my head in shame AHI nights became very rare. It continues to this day.

So if you want to experiment...first try to identify for sure if your clusters are supine sleeping related...REM related...and/or both related. That gives you the initial parameters to address and if either one of those are a factor...do you need more pressure some of the time....if so..do you want to use higher pressure all the time or some of the time or lower pressure most of the time and compromise and let a few clusters slide by the defenses.
Don't go changing things willy nilly without goals as to what you want to learn and hope to see. Be prepared for experiment backfires.
Like my turn AFlex off experiment...documented here.
viewtopic.php?f=1&t=67883&p=631376&hili ... mb#p631376

[fredn]

That said...you are relatively new to therapy if I remember right. Aren't you the one whose wife had OSA and hence your older membership status on the forum....so this is your first machine..

That's me

So if you want to experiment...first try to identify for sure if your clusters are supine sleeping related...REM related...and/or both related. That gives you the initial parameters to address and if either one of those are a factor...do you need more pressure some of the time....if so..do you want to use higher pressure all the time or some of the time or lower pressure most of the time and compromise and let a few clusters slide by the defenses.

I'm reasonably certain that sleeping on my back is NG .... I'm pretty sure because I NEVER sleep on my back unless I do it intentionally .... Until recently I was never even able to fall asleep unless I was on either my right or left side. I'm not quite as certain about REM. I don't know what to look for to be able to figure if I am in REM or not ... I'm assuming it has to do with "timing" and "sleep cycles" .... I'll read that article you sent me last post to see what I can learn.

Let me ask .... if it is even this cut and dry ... does "auto leveling" help to prevent an increasing string of obstructions by incrementally increasing pressure and in turn getting to a high enough pressure to stop them. If it does that would seem to tell me that if I have Back Problems or REM Problems that VPAP might be better than CPAP unless it was controlled at an acceptable pressure.

Here's my "gut feelings" (with a little bit on logical thinking thrown it) so far ... based on what I've seen so far ... some of my posts and replies ... and what I've read.

1. Sleeping on my back causes problems .... groups of OSA's seem to show on graphs whenever I intentionally try sleeping on my back

2. REM Sleep seems to cause OSA's ... when I look over my graphs I get groups after being asleep for awhile .... after everytime I wake up the cycle starts again.

3. The higher EPAP pressure last night seemed to make a difference early into sleep cycles. On VAuto it was 7 cmH2O min ... last night it was 9 cmH2O (12 - 3 EPR)

4. Even the 12 IPAP (straight pressure) seemed effective early into the night ..... which "may" imply that a 9-12 (EPAP-IPAP) maybe good "EXCEPT" for "BACK" or "REM"

So based on that I'm thinking to go back to VAuto ..

Set EPAP Min to 9
Set IPAP Max to 20 (that's where it used to be)
Set PS to 3 .... that puts me into the same range that I had with last night's CPAP BUT gives me the ability to adjust higher if needed.

Does that reasoning sound decent? Don't think I have anything to loose over last night ... but certainly being able to increase should only help

Again ... Thanks ... Fred

[jweeks]

Does that reasoning sound decent? Don't think I have anything to loose over last night ... but certainly being able to increase should only help

Fred,

That sounds like a reasonable experiment. The thing that I am most curious about is isolating the positional stuff (sleeping on your back) from REM effects. The breathing pattern and events might have been due to REM, or it might have been a double-whammy with both REM effects and position conspiring against you. Some folks have many if not most of their OSA issues during REM. I am just the opposite, my issues are much more pronounced due to position. You might be having both effects.

-john-

[Pugsy]

REM stage sleep is hard to determine just by looking at the cpap machine software. One has to look at the normal time frames where REM seems to occur and try to correlate them with similar time frame on the software reports.

Maybe this hypnogram will make it a bit easier. Generally (remember this isn't an absolute) we see the first REM stage around 90 to 120 minutes into sleep...and as the night goes one it occurs more frequently and lasts longer until we reach the we hours of the morning where we can see a lot more REM.
Also remember that when we have frequent awakenings...those awakenings are going to mess with the normal sleep cycles...that's why we want awakenings to a minimum...we feel like crap because we don't get the right % of sleep stages that are needed for the restorative powers of sleep to work its magic.



Have you got a copy of your sleep study? Often it will mention the various sleep stages along with sleep positions and it is pretty easy to spot if supine sleeping or REM sleep seems to be a factor in AHI. They aren't always a factor though. Some people won't see much of a change in either the number of events or pressure needs with either. It is common though...but not a 100% certainty that everyone in the whole world will have horrible numbers of apnea events with supine sleeping or need massive pressure increases to deal with them.

My feelings have always been....good sleep is primary goal and if I happened to have worse OSA or higher pressure needs supine sleeping (or same argument with REM stage sleep worse OSA) and I just don't want to or can't limit myself to side sleeping....hey, that's why we have the machines anyway...let the machine do its job.
If more pressure is needed for part of the night...use auto adjusting pressures. If auto adjusting pressures disrupt sleep...compromise maybe. I would compromise if auto adjusting pressures created a problem for me like with sleep disruptions or higher pressures caused aerophagia.. I am lucky...they don't bother me but I know some people the auto adjusting features are a problem.

If a machine is properly adjusted...the machine does its job preventing events no matter when or where or why they occur and I don't really care if it prevented 1 event or 100 events as long as they were prevented.

Let me ask .... if it is even this cut and dry ... does "auto leveling" help to prevent an increasing string of obstructions by incrementally increasing pressure and in turn getting to a high enough pressure to stop them.

Yes, if those obstructions seem to require a little more pressure than initially is being delivered..that's the "job" of the machine when in auto adjusting mode. The minimum pressure that is being used is real important though. These machines don't go from 5 to 10 or 10 to 15 or whatever in a blink of an eye in response to an obstruction that may need more pressure.
Remember the triggers are snores and flow limitations and not the actual obstructive event...it's the level of flow limitation that remains after an obstructive event has cleared that machine looks at and says...hmmm maybe we need a little more pressure so here I go...

Does that reasoning sound decent?

Yes, it is sound reasoning. Your choices are.. use auto adjusting mode with a minimum pressure that does a decent job most of the night but is close enough to what maybe might be needed at other times during the night that it can get there quickly enough...
or
you can use cpap mode and maybe use a constant pressure a little higher all night in hopes that the little higher pressure all night is sufficient to maintain an open airway with minimal tissue collapse.

This principle applies to apap mode or bilevel auto mode. Only thing with bilevel is we get to have the comfort of EPAP and IPAP difference making it easier to exhale. The basic logic is pretty much the same...minimum APAP and EPAP minimum needs to be a good starting point.

Now I have done extensive experiments with straight bilevel mode on my BiPap machine...fixed EPAP and IPAP. Pretty darn good results because I think the higher IPAP helps EPAP (overall pressure average is higher than when using APAP mode) a lot by better job holding the airway open and thus preventing the need for the greater pressures in the wee hours of the morning. I might have a random little cluster pop up that likely if I was in auto mode would raise the pressure but overall it doesn't happen often and the clusters aren't huge in numbers. This is where I would compromise if I happened to be sensitive to pressure variations.
I would accept a random small cluster as acceptable result...AHI of 0.0 has never been my goal.
Good quality sleep with minimal sleep disruptions and feeling decent the next day has always been my primary goal.
AHI of 0.0 is real easy for me to get if I never go to REM sleep.. If I have a lot of fragmented sleep my AHI is nothing but then I simply don't sleep well and I feel horrible the next day.

Don't get me wrong..it's not that I totally ignore the AHI and all that but I don't base my "success" on a number. Numbers often don't tell the whole story. I discovered a long time ago that if I broke up my "clusters" that I felt better the next day...more rested.
I think that in my case those little clusters likely caused some sort of mini arousal (that I may or may not have remembered) and thus messed with my sleep cycles and I simply was getting enough Deep Sleep and REM sleep where most of the restorative work is accomplished. This is why one of my first questions to anyone complaining of feeling like crap despite a nice report on paper is going to be "is your sleep fragmented, waking up often, tossing and turning (because if they remember tossing and turning a lot then I know they were awake) "

You could probably find a straight cpap mode set of settings that will do an acceptable job...or straight bilevel mode that would do an acceptable job...you might or might not have to make a compromise.
Me....since auto adjusting mode doesn't seem to bother me at all...I choose to just let the machine do the work it is designed to do.
I feel just as well rested in auto mode as I do in straight mode. If I didn't I would use the mode that let me feel the best.

Since each person can respond differently to auto mode in any machine...then auto mode may not be for everyone.
There is no right or wrong...just whichever works best for the individual.

[fredn]

Have you got a copy of your sleep study?

I don’t have details … only a summary sheet from both the 1st Sleep Study, and the Titration. I don’t think there’s any way for me to determine what happened when. There’s a summary set once the right pressure was found … but again, not what happened when.

If a machine is properly adjusted...the machine does its job preventing events no matter when or where or why they occur and I don't really care if it prevented 1 event or 100 events as long as they were prevented.

And so the plot thickens

Your choices are.. use auto adjusting mode with a minimum pressure that does a decent job most of the night but is close enough to what maybe might be needed at other times during the night that it can get there quickly enough...
or
you can use cpap mode and maybe use a constant pressure a little higher all night in hopes that the little higher pressure all night is sufficient to maintain an open airway with minimal tissue collapse.

Given those two choices, “IF” the VAuto mode can “deliver what’s needed” then I vote for VAuto … Using only what pressure is needed. My Problem is I don’t know if it can … and likely a “lack of patience” and a “lack of experience” is causing me to jump around and try different things …. When I probably should stick with one until I determine whether it will work or not.

Now I have done extensive experiments with straight bilevel mode on my BiPap machine...fixed EPAP and IPAP.

When I look at my Machine I see CPAP, VAuto, and Spontaneous (S) Mode … is S Mode the same as a straight bilevel?

You could probably find a straight cpap mode set of settings that will do an acceptable job...or straight bilevel mode that would do an acceptable job...you might or might not have to make a compromise.
Me....since auto adjusting mode doesn't seem to bother me at all...I choose to just let the machine do the work it is designed to do.

What types of issues does one have with an auto adjusting machine?

There is no right or wrong...just whichever works best for the individual.

With a bunch of combinations to try until we find what works.

Thanks for your help and your time … you’re a big help in understanding things … and hopefully helping us find “what works” for us.

[Pugsy]

My Problem is I don’t know if it can … and likely a “lack of patience” and a “lack of experience” is causing me to jump around and try different things …. When I probably should stick with one until I determine whether it will work or not.

Yes, it is very hard to not yield to the temptation of wanting to change things to see if something else is "better".
Here's the deal...yeah tonight such and such setting MIGHT be better tonight and tomorrow night a slightly different setting MIGHT be better (remember we simply don't sleep the same way every night) but we don't have a crystal ball so we don't know what is going to happen each night.
We simply don't have any way to set up settings that are going to be perfect for every night that we are going to go to sleep.
This is why we have acceptable ranges that we live with.

When I look at my Machine I see CPAP, VAuto, and Spontaneous (S) Mode … is S Mode the same as a straight bilevel?

Yes, on the S9 VPAP Auto machine S mode is straight bilevel with fixed pressures...EPAP and IPAP won't vary at all.

What types of issues does one have with an auto adjusting machine?

Most commonly some people are simply sensitive to the variations in pressure. They wake up often (even low level awakening that they may or may not remember) and the sleep cycles get messed up.

Aerophagia issues if the machine wants to go higher and for some reason the higher pressures are the sole cause of excess aerophagia discomfort. Like maybe someone doesn't really have any aerophagia issues at say 12 cm pressure but at 13 cm they have a lot of discomfort. It can be at any pressure though...even single digit.

We used to have a lot of leak issues with the older technology machines with auto adjusting because the machines would sense a leak..increase pressure a little to try to maintain therapy pressure...but the increase in pressure caused the leak only to be worse so then more pressure and a nasty little circle developed....chasing the leak or feeding the leak monster.
It can still happen now but nearly as much as it used to. It was pretty easy to spot though on the reports.
It's easier to set your mask fit adjustments for a fixed pressure or something close to it. The mask might seal well at 12 cm and not so well at 16 cm.

Also..the chance of centrals with higher pressures. Actually it doesn't have to be higher pressures that trigger centrals..people seem to panic about using a little more pressure because they think that centrals are a foregone conclusion with an increase in pressure when actually centrals can happen even at relatively low pressures like 6 cm. There are a few people who may see centrals rear their heads at say 12 cm pressure but not have any at 11 cm but it doesn't happen nearly as often as people think it does. There are people using straight cpap pressure at 19 cm and having no centrals at all. Higher pressures don't automatically mean that centrals will occur...yes..they can occur but they can just as easily occur at the single digit pressures if that person is going to end up with complex sleep apnea.
I regularly see pressures kissing the 20 cm line...briefly but I see it...I don't have any increase beyond what I normally might see at say 10 cm.
Besides...the auto adjusting machines won't respond to centrals and if it is wanting to increase the pressure then there is something going on it wants to try to address. Should the situation arise where a person needs higher pressures to fix whatever the machine is trying to fix and that pressure does cause centrals to pop up...there are machines designed to address the central issue if a compromise can't be reached.
Last reading I saw was that centrals popping up solely because of cpap pressure (remember it can be either single or double digits) was maybe 10 to 15 % of the people who start cpap therapy. Sometimes the centrals go away on their own...sometimes they need a special machine or a compromise.
The chance of centrals popping up isn't nearly as high as people want to think it is and even if it does happen there are things that can be done.

I can't think of any other big issues with auto mode. Some people do well with auto mode and some don't. Some simply just feel better in auto mode and can't put a finger on the reason.

[qwertydvorak]

Just a side note on a way to avoid sleeping on your back. An old snorer's wives' trick is to sew a pocket into the back of a t-shirt and put velcro on it so that you can seal it. Then put a tennis ball in there. When you roll onto your back in your sleep it won't be comfortable and you will roll back onto your side.

[Otter]

During your OA clusters, your respiratory rate is extremely low. I've only see that in my own data when I meditate with my mask on. It confuses the bits out of my S9. The machine scores an enormous number of events, many of them OAs. I think it just doesn't know what to do when my RR rate goes below 5 breaths per minute.

Your tidal volume goes up for most of the low RR period, but drops to zero a few times. So does minute ventilation. This may indicate a very scary respiratory problem, but I think maybe your machine just doesn't understand that anyone could breathe that slowly.

Your sleep breathing patterns may be very different, but when I'm in REM, my RR goes up. What you're doing during those OA clusters looks like something else. Do you remember being awake relaxing or even meditating?

I think it's worth looking at those two sections more closely. Please zoom in on Flow, RR, and TV until you can see each breath. Maybe what we're seeing there is not apnea at all but slow, deep, unobstructed breathing that goes beyond the assumptions of ResMed's algorithm.