moved to auto bipap -- CA went up

I am new to therapy. I was using an airsense 10 for a few weeks and my AHI was low with the apap ( < 1 AHI daily ). It was successful but I couldnt get enough sleep all the time.

It was attributed to the mask (full face). i wanted to use nasal but it was hard for me to exhale against the pressure.. so in came the bipap to try it out as a solution to this.

Last night i used my new device, dreamstation bipap auto. note that I set my own settings similar to what i had with my apap (7-12 range). But I do note the bipap is more complex in options.

my settings:
EPAP 4, IPAP 12. PS min 3 to max 8.

I am not sure how the PS algorithm works. at startup, my EPAP is 4, IPAP 7. but throughout the night is changes. max IPAP 12, max EPAP 6 (why would it not be 4? 12-8=4?)

It was very comfortable and I slept 10 hours but i did wake up many times. My AHI is 2.58 and most of it is CA which i never had before (maybe 0.1 or 0.2 CA).

I think the PS difference is too high?
My 90% IPAP is 10.90

What settings should I be looking into changing? I know 2.58 is a good AHI but I am used to see 0.5 and I am concerned about the CA. I woke up a little lightheaded.. i think the bipap is almost breathing for me and I am very healthy and middle age

Doublev wrote:It was very comfortable and I slept 10 hours but i did wake up many times. My AHI is 2.58 and most of it is CA which i never had before (maybe 0.1 or 0.2 CA).

I'm not surprised.

Doublev wrote:I think the PS difference is too high?
My 90% IPAP is 10.90

yup.

Doublev wrote:What settings should I be looking into changing? I know 2.58 is a good AHI but I am used to see 0.5 and I am concerned about the CA. I woke up a little lightheaded.. i think the bipap is almost breathing for me and I am very healthy and middle age

reduce the max ps, for that matter, think about reducing the min ps.

Try limiting the PS max to 4.
Some people when they do a higher PS (usually over 5) will start to blow off too much carbon dioxide and the blood levels don't get up to where they need to be for the brain to say "Oh...carbon dioxide levels are up there I need to send the trigger to breathe".

Now this doesn't happen to everyone and there are some people who need to use a higher PS for other medical reasons...and I am not saying that is the cause of your increase in centrals but it is possible and it's an easy fix to find out and take care of.

Pugsy wrote:Try limiting the PS max to 4.

Should i keep it at a fixed 4? so min 4, max 4? or what would you do?

Doesn't really matter.
You can try fixed PS at 4 and if the centrals go down to where you are happy with them then you will have your answer.
You can also try 2 or 3 PS minimum. I know you need some PS for comfort on exhale and 4 is more comfortable than 3 and 3 is what you have while awake when comfort matters.

So it's up to you really. Dropping PS down to 4 might just do the trick and you won't need to reduce it further.

I don't know for sure that it's the PS doing it anyway...it's just something that could be doing it and we usually look at it first.

Ok last night I set PS min to 3, max to 4.

AHI last night was higher I have ever seen it in the last month -- 2.87.

I am wondering if the two machines (airsense and dreamstation) calculate events differently?

I feel very well rested. Keeping PS 4 worked very well...

I note the 90% IPAP is only 8.30.. i woke up a number of times and always hit the button to check the pressure.. and it was always at IPAP 7. The airsense I remember waking up and checking the unit and finding it at 10 or so.

The CAs are slightly higher than normal (1.05 vs. airsense it never was more than 0.3)

So what do you think?

Should I care about the higher AHI or just enjoy the rest and not worry about AHI of 3 when I used to get 0.3 with the Airsense?
Anything I can tweak or change from here?

Can you get me a screen shot of last night's detailed data software report?

I don't need all the graphs...just the basic stuff.
See this thread for examples
viewtopic/t103468/Need-help-with-screen-shots.html

How to use imgur to host the image
https://sleep.tnet.com/reference/tips/imgur

How to organize things 3 pages be sure to read all of them
https://sleep.tnet.com/resources/sleepyhead/shorganize

ResMed and Respironics use totally different algorithms when in auto mode.
Not to mention you went from apap to bilevel which is another difference.
I think you are trying to compare apples and oranges here and it doesn't work out too well.

The actual definitions for flagging of any event are all the same except for a minor difference in hyponea criteria...one brand uses a 40 % reduction for at least 10 seconds and the other uses 50% for at least 10 seconds.

You can't really base much on one night's worth of data after a change.
Resmed machines are historically a little more aggressive in their responses (that different auto adjusting algorithm) to anything (except centrals which it ignores unless you are using one of the machines designed to treat centrals and regular apap or bilevel won't do it) so it's possible (in theory anyway) that with the higher pressures you noted on the apap that you may need just a wee bit more baseline pressures with the bipap to get similar results as you had with the ResMed.

I would suggest leaving things as is for a few nights since you report feeling well rested. AHI can change significantly from night to night without any changes in anything and there is some truth the statement that your body needs a bit of time to adjust to any new changes.
I have had nights with the AHI less than 1.0 and the very next night over 5.0 and not change a thing. It just happens sometimes.

The reason I ask for the screen shot is because there's stuff on the report that isn't included in the AHI that might be useful to look at.

Also remember the definition of 90% pressures (or leaks for that matter) ....number where you were at OR BELOW for 90 % of the night. It's not where you stayed at for 90% of the night. The fact that you might wake up and see one thing and have the 90% number be something else doesn't mean anything.
Most people forget (or don't know) about the "or below" part of the definition. And the "or below" part is real important.

Doublev wrote:. . . PS . . . max 8.

My statements to follow are a general opinion, not a suggestion for you personally. Pugsy and palerider are best for that sort of thing.

Starting point for bilevel titration is generally, I believe, a PS of 4. And I would always start our using a fixed 4 PS until I got my other mins and maxes sorted out, during a home-titrating using trending data.

In my opinion, PS rarely NEEDS to be more than 4 (or 6) unless something is causing O2 to remain low, such as obesity hypoventilation.

A higher PS than that may seem more comfortable, but I still wouldn't play with it at first in a home titration until OSA was consistently well-titrated away using a fixed 4 PS

In my opinion, a variable PS can especially do a number on anyone with unstable breathing causing CA, which is why I personally prefer the idea of using fixed PS before messing with a variable one. Once breathing is stable for a while, THEN experimenting with variable PS becomes an option, according to my personal preference for someone with an increase of CAs.

But hey, just me, as a nonpro. And my beliefs on the matter are at least as influenced by my personal experience as a patient as by my interpretation of any lab/center bilevel titration protocol.

Pugsy wrote:Can you get me a screen shot of last night's detailed data software report?

I don't need all the graphs...just the basic stuff.

Ok, i followed the instructions. My charts do not have "flow limit". here is the screen shot: http://imgur.com/a/8WQnh

When so many graphs are shown it makes it harder to see the important basics because it makes the graphs too small.
Don't need anything past the leak rate.
Flow limitation graphs are only available on Respironics machines. Your machine flags flow limitations up on the Events graph. Things are so scrunched together on the Events graph it's a bit difficult to see well.

What I was wanting to see was if you had a lot of snores (also flagged on the events graph) or Flow limitations showing up and those 2 items aren't part of the AHI.
You have a little bit but not huge amounts.

You have some breaks in therapy so we know you woke up at least a couple of times. Did you spend much time awake wearing the mask and using the machine? Some of those CAs/centrals could possibly be awake/semi awake breathing irregularities getting flagged by mistake.
Especially any see right next to a known awake time. Like the little cluster seen when you restarted the machine between 10:15 and 11:00. That cluster was pretty much right away and I wonder if you were awake.

Awake stuff doesn't count. The machine only measures air flow but it can't tell if you are asleep or not. They can and will flag awake flow irregularities as some sort of event.

So some of what you are seeing flagged could very well be what we call SWJ or Sleep/Wake/Junk and we mentally remove those items from the evaluation process.
I think give it some time and keep these settings for a few nights to see if things settle down a bit.
There is a lot of truth to the "give it time" thing.

When I first used it, yes, i was awake and just browsing on the ipad.

Then I had to get up for an hour or two for a work problem.. then i woke up with the kids woke me up and went back to grab some more Zzzs.. I am sure the last couple of hours were not good with all the noise in the home.
between then were bathroom breaks. but, yes, a lot of waking up.

I agree, I will give it a few days. if I didnt have the airsense I would not even question these numbers because, while i am not an expert, i dont think there is anything particularly alarming. If you see anything concerning let me know.. but I hear AHI < 5 is normal and so this falls into it.

But I have 2 machines now so am trying to find out which one is better.. i really, really like the dreamstation (it is so gentle and comfortable -- it really is "dreamy" to me) but the airsense did give better numbers.. but the airsense felt very industrial and way too strong. I think dreamstation just has a softer fan motor (i can tell when you run it without putting on the mask -- the airsense blows a lot of air and the dreamstation doesnt) and also i think the slower response of dreamstation doesnt make it so sudden but more gradual and comfortable.

My sleep behaviors are the same with airsense (lots of waking up).. but you are right, let me try and get a few days of 7-8 hours uninterrupted and see what happens.

Doublev wrote:

Pugsy wrote:Can you get me a screen shot of last night's detailed data software report?

I don't need all the graphs...just the basic stuff.

Ok, i followed the instructions. My charts do not have "flow limit". here is the screen shot: http://imgur.com/a/8WQnh

I don't get how people can say that when what they create looks nothing like what is requested... like, yours has several superfluous charts which just squeeze down the ones that are helpful to look at.

Pick the machine that is more comfortable to you and you like using the best.
Don't pick a machine just because you can get better AHI numbers with it because AHI numbers don't guarantee squat.
We can tweak the more comfortable machine to get better numbers if numbers seem to be all that important to you but AHI of 0.0 doesn't guarantee anything but a nice match score.

To me there is no question..bilevel is simply more comfortable. I can do apap but I really like bilevel.
Plus I learned that over long term that switching to bilevel let me sleep about 45 minutes longer and don't know why. That extra 45 minutes helps a lot in how I feel during the day.

So if you are having to choose....comfort should be number one factor because if you aren't comfortable you don't sleep so good and sleeping is the name of the game.