Please help- No Improvement w/ BI-PAP

Yes...that's what I want.
Those look "real" to me and not like post arousal centrals.
We could try to better reduce the OAs and hyponeas and cross our fingers and hope the centrals reduce but I doubt they will.
Won't hurt to try though. Raise the Max IPAP to 25 and see what happens. We know it wants to go to 15.5.

Some people just have centrals that we don't know why they have centrals. They may or may not have obstructive apneas at the same time.
Some people don't have centrals on the diagnostic sleep study but they develop centrals as a response to cpap pressures (and it doesn't necessarily mean high pressures either...they can happen with as little as 5 or 6 cm pressure).

Sounds like you just probably have both centrals and obstructives even without pressure...complex sleep apnea.

I suspect you need one of those fancy bilevel ASV machines...and I would suggest the ResMed AirCurve 10 ASV...for 2 reasons mainly...one being I think the algorithm might suit your obstructive apnea stuff better and two being there's no software yet for the just recently released DreamStation BiPAP ASV model.
Now if you got the prior model Respironics PR System One model 960...we have software for that.
ResMed's ASV algorithm is more "aggressive" or more quickly to respond ...IMHO and I have owned and used both brands of ASV machines. I can use less pressure with the ResMed than I would need with Respironics to get the same results. Less pressure is always nice...the potential disadvantage though is when it changes it changes a lot faster.

I would be pushing for the ASV machine if it were me. You've more than proven that current less expensive models of machines haven't gotten things under control. Time to move on to the big guns.

This may help you understand the mechanics behind ASV. It's put out by Respironics but the basics are the same no matter which brand. You set the machine so that the obstructive stuff gets prevented and the machine can give you a burst of pressure to kick start your breathing when you don't breathe on your own. EPAP parameters are real important when it comes to Obstructive stuff prevention.
http://www.isetonline.org/yahoo_site_ad ... 190318.pdf

It's interesting that your centrals don't seem to correlate to pressures and you have some periods of time where they aren't horribly numerous and if you said you spent a lot of time awake wearing the mask then we might blame them on awake breathing but since you say you don't then I doubt we can put the blame on anything other than their being a real central...and the flow rate graph looks like you were asleep when they happened.

Thanks so much for your help!

The strange thing is about once every 60 days or so I have a night like this:

http://imgur.com/a/E7g2w

Taking that last image into consideration (IPAP 9.5, EPAP 8, AHI 1.6) what do you suggest for a minimum EPAP?

Well....wouldn't it be nice if that one out of 60 night was your usual and the ugly crap was the random?

Does make a person wonder what changed during that night that was different from all the other nights.
Only thing I can think of is sleeping position...if your obstructive apnea is worse on your back and that night you didn't sleep on your back but that doesn't explain the lack of centrals because centrals really aren't know to be position specific.
Something was different but figuring out what might be like looking for a needle in a haystack with those really "normal" nights being so rare.

Actually all I would change (I like to change only one thing at a time whenever possible) is just open up max IPAP and let the machine go where it thinks it needs to go and see what happens. It won't go up there without what it thinks is a good reason.

With your PS range being so small (and the machine not even using all of the available PS) if the machine wants to increase IPAP very much it will drag EPAP up right with it so I don't see a need to change EPAP at this time.

I haven't read the whole thread, but those CA look nasty and an ASV may be in your future. going by your chart with having 11 as your median, that is where I'd start with the epap, I'd also have min PS:4 and see if that improves the I:E ratio and tidal volume a bit. I'd also lift your max ipap because you are maxing it out at 15. I'd get it out of the way and set to 25 for now

although it's resmed, this my help with background to how they set up a bipap
https://www.resmed.com/us/dam/documents ... lo_eng.pdf

I woke up eager to see if it worked. No good news to report unfortunately.

IPAP went up to 19, EPAP to 17.5

AHI 36.9
CA 144
OA 142
HYP 44

It felt like I was up most of the night because the pressure that high was very uncomfortable. Maybe I'm better off just keeping the max IPAP at 15?

How much better was it (or less bad) when you were using CPAP mode with Flex of 3?

I think there is cpap mode available on your machine.

I didn't really expect any miracles last night...but I was kinda hoping for one.
You need a machine that will do stuff that this machine can't.

What about sleeping positions...do you mainly sleep on your back or side or mix?

Can you get me a screen shot of last night's detailed report...no need to zoom in on anything. I mainly just want to see the relationship (if there is one) with the pressures in general with the centrals.

It was much worse. On CPAP set at 10.5 my AHI averaged around 12-14. There is a CPAP mode on this machine. I was thinking to take out the old machine though. I prefer to sleep on my back propped up w several pillows. Sleeping on my sides has given no improvement. In fact some of my worst nights have been when I made an effort to stay on my sides. All of my good night's (AHI under 5), all 6 of them lol, I have slept on my back the whole night propped up on pillows.

I will get you that screenshot today.

Thank you!

Well an AHI of 10 ish is better than 30 ish.

CPAP mode is going to be the same no matter which machine is delivering it unless they are different brands.

What was the breakdown into category of events in cpap mode and 10 ish AHI?

About the back sleeping...while it is common for OSA to be worse on our backs and maybe need more pressure it's not necessarily always the case with everyone. I mentioned it only as a possible explanation for the good vs bad nights. Since you really prefer back sleeping propped up and the AHI was just as bad on your side I see no reason to dwell on sleeping position. I always felt that it was important to get the sleep first and if one position allows for better sleep in general and the other doesn't then do the one that is more comfortable. I think the only exception to that might be a person I know who needs 18 or 19 cm on his back and only 9 on his side and since side sleeping is just as comfortable for him he tries to stay on his side as much as possible. I can't as I blame him on that one. As you have found out those higher pressures are a bitch.
I try to avoid back sleeping but not because of the OSA or pressures. For me it's simply more back pain on my back and the pain wakes me up. I also know that it's really hard to stay off one's back even when they prefer not going there and sometimes measures to prevent back sleeping cause just as many problems as the back sleeping does.

Do you happen to have one of those overnight recording pulse oximeters to see what your oxygen levels are doing on those really ugly AHI nights?
Might be interesting to see.

We can play around with some various setting tweaks but I don't really hold out much hope to change the outcome enough to get you where you need to be.

Since you had centrals on the diagnostic sleep study without cpap then the usual triggers (pressures or pressure support) wouldn't likely be a contributing factor but I suppose we could play with them a little and see if we get lucky.

One thought...using the bipap and keep it in auto mode so that we get FL flagging (which isn't available in fixed cpap mode) and sort of mimic cpap mode.
Try higher fixed pressure all night similar to cpap mode.
You can do that by setting PS minimum and max to 0.0 and EPAP min at one number and IPAP max at the same number.
Which number....depends on the AHI event category breakdown that you had when using cpap at 10 and was seeing 10 ish AHI. If mainly obstructive stuff we go a little higher than 10.5.

My gut tells me though that you simply need that other high dollar ASV machine.
Is the doctor that you have been seeing for all this a board certified sleep doctor or have you been following with your PCP who just sent you for the sleep test and doesn't really understand what all is going on?

I'm with puggsy and think an ASV will be the one you have in the end. but bpap should get your oa and h in order
I haven't used an auto bipap, I have only used the manual modes. the titration link also uses manual mode. so I have nothing else to add on auto

before you go back to cpap, I'd try fixed biap, it may be more comfortable and I'm guessing you have a bit of COPD and why you are propping up on pillows.
I'd set epap 11(your median pressure) as your minimum and ipap 16 your max which is only one above your 15 it will give you a PS:5 which may be enough...turn off auto to manual bipap... or use 10 min 15 max, if 15 is your upper limit.

if that works better, you can have a look at the trigger and rise time to fine tune your comfort.

Pugsy,

MRI was yesterday. Doctor called first thing this morning to tell me I have a growth on my pituatary gland ad will need further testing. She seems quite confident that this is the cause of all my problems, and the inconsistent results with PAP.

Ahhh.... fix the known problem first and see what happens with the inconsistent BiPap stuff later once the known problem is fixed.

Good luck. At least you have a possible explanation for all the craziness.