Not new to CPAP; mixed apnea and desperate for correct equip

I'm hoping someone can make some sort of recommendation because I've become too complex for my cpap company, sleep specialist and neurologist. I have mixed sleep apnea, and at my sleep study in 2013 had severe REM sleep apnea, and moderate at other stages.

After original sleep study, I was put on CPAP therapy, which worked for the most part. (I do question how it did with the REM apnea, since it was more severe). Since January 2015, my machine (respironics system one CPAP) hasn't been sufficient.

The problem is prior to CPAP, when I had just central apnea, and repeatedly jerked awake without attaining any sleep, my system learned not to sleep. It's response to apnea is to wake up just enough to be conscious and breathe. Not enough to move. I'm pretty certain I rouse prior to the length of time it takes the machine to register an episode of apnea.

Because of this my Ahi "looked" fine, because I spent most of the time awake. Sleep specialist would look at numbers and determine no problem. I did take one med that helped me sleep through the apnea, then it was clear the machine was not suitable because my apnea was as high as 12. I have a sleep app and a fitbit, and it's obvious that I have no REM sleep; I'm exhausted, fall asleep immediately straight to deep sleep, then as soon as I approach REM I'm awake.

Long story short, they were finally convinced I had a problem and are looking into a APAP for me. I've been given a loaner unit. It's still not working. We seem to have it set up just fine for inhalation but I think the EPR system is not working properly.

The unit I'm trialing is the Resmed Airsense S10. I can NOT use the comfort setting -- the change isn't fast enough for the apnea to not wake me up. However, whether or not the EPR works varies from night to night. I keep having to switch it. EPR off, I drown in air and wake up. Too low, I wake up (no snoring ... I'm guessing it's CSA). And the EPR level I need from night to night changes. Last night it was set to 2. Woke up at 2 am with a terribly sore chest, burping air. Last night no better but night before that level was fine.

I understand the algorithm for the dream station Autoset is different, and that the increase in pressure after EPR is not dependent on me taking a breath but will happen when I'm supposed to breathe. I'm hoping that this machine will work.

My concern is though that it's a softer algorithm and it won't increase quickly enough to deal with the REM apnea.

My other question is pertaining to a bipap machine. My understanding (correct me if I'm wrong) is that the exhalation support is held constant at a certain pressure, similar to the ResMed algorithm. Is there any machine that adjust the exhalation support as well?

I'm beyond exhausted .. I've been sleep deprived since January and am experiencing local sleep and microsleeps. Can anyone here offer me some guidance?

Thank you so much.

Two things - have you been investigated for 'silent GERD' or acid reflux that wakes you without you're realizing why? And have you researched ASV machines that are more suited to central apnea than the 'regular' machines that don't address it at all?

aspen wrote:Is there any machine that adjust the exhalation support as well?

Are you talking about exhale relief or the difference between inhale and exhale?
The Respironics Auto Bipap (PR System One model 760 or DreamStation Auto BiPap) will allow for adjustable PR (Pressure support which is the difference between inhale and exhale_).
ResMed bilevel machines have a fixed PS.
EPR creates a fixed bilevel support like function on the ResMed machines.

The exception might be the bilevel machines in the ASV model line...those (both Respironics and ResMed) have auto adjusting PS.

What loaner were you given?
Have you used available software to look at the detailed reports?
Can you share with us a typical detailed report?
If you don't have a clue about software
https://sleep.tnet.com/equipment
and some examples
viewtopic/t103468/Need-help-with-screen-shots.html

Sounds like you might benefit from a bilevel ASV machine...hard to say for sure without more information though.
Very expensive and a lot of hurdles to cross to get insurance to pay.

Please register here at the forum...you can't post image links until registered and logged in and it's really helpful if we can see what the software shows.
Helps us help you better.

Julie wrote:Two things - have you been investigated for 'silent GERD' or acid reflux that wakes you without you're realizing why? And have you researched ASV machines that are more suited to central apnea than the 'regular' machines that don't address it at all?

Yes, I've been investigated for GERD/reflux; two different ENTs and I'm good.

I'm not sure what an ASV is. I will take a look, but given that I'm dependent on a provincial program for purchase of the unit, I doubt that will even be available.

Thank you, Julie.

I'll see if I can be logical here.

Currently trialing a Resmed Airsense 10. I can't use the comfort setting because it doesn't ramp up quickly enough to fix the severe REM apnea. Regular setting is GREAT. once we figured that out, then the new issue involved the EPR. First it was set at 3. Too much relief and I stop breathing, which means I guess I didn't then trigger the pressure increase to start again. Boom awake. A few of those jolts awake and the night is done.

CPAP company switched it to 2 (although I know how to as well). One really decent night sleep. Then last two nights I`m drowning in air, waking up burping and this morning by 2:00 my chest was overinflated and too sore to go back to sleep. Boom awake. 2:15 a.m. this time. So TOO MUCH pressure now at same setting, which means I would have to put it back down to 3. Having to manually guess where settings are each night is the reason I have to nix CPAP in the first place.

My cpap company just let me know I can pick up a Dreamstation Auto CPAP this afternoon.

I`ve tried to figure out the algorithm differences online. Could you explain how the Dreamstation Autoset AFLEX works? From what I'm reading it is not a "set" pressure difference like the Resmed unit. But I can't deduce whether it would allow differences in exhalation support without me trying to keep setting it.

And I understand the changes to inhalation support are more like the comfort setting on the Resmed unit .. "softer" .. which means that might be an issue.

I have both units for a week. I don't think I will be approved for a bipap machine because my AHI is LOW (because I rouse before the machines register, unless I'm medicated. I think this week I'll play with some medications that I know make the situation worse.

Oh and I don't have a clue about software, and haven't been able to even get the Resmed loaner software/app functioning for some reason. Perhaps because it's a loaner. I'll look at those links.

I haven't slept properly since January 2016 after a relapse, save for two times when I was taking a med that forced sleep -- AHi went up to 12 at that time.

Pugsy wrote:

aspen wrote:Is there any machine that adjust the exhalation support as well?

Are you talking about exhale relief or the difference between inhale and exhale?
The Respironics Auto Bipap (PR System One model 760 or DreamStation Auto BiPap) will allow for adjustable PR (Pressure support which is the difference between inhale and exhale_).
ResMed bilevel machines have a fixed PS.
EPR creates a fixed bilevel support like function on the ResMed machines.

The exception might be the bilevel machines in the ASV model line...those (both Respironics and ResMed) have auto adjusting PS.

What loaner were you given?
Have you used available software to look at the detailed reports?
Can you share with us a typical detailed report?
If you don't have a clue about software
https://sleep.tnet.com/equipment
and some examples
viewtopic/t103468/Need-help-with-screen-shots.html

Sounds like you might benefit from a bilevel ASV machine...hard to say for sure without more information though.
Very expensive and a lot of hurdles to cross to get insurance to pay.

Please register here at the forum...you can't post image links until registered and logged in and it's really helpful if we can see what the software shows.
Helps us help you better.

Without knowing the kind of apnea you are having it's pretty hard to give meaningful advice. Even though you say you don't know anything about software, I would suggest you need to learn to have much of a chance of solving you SA issues. You are going to have to trail a fully data capable machine, which has a SD card slot so you can collect breath by breath data, then sue a free software called sleepyhead to plot and look at that data, and to post the information so the many experts here can advise.

The Sleepyhead software is available through a link at the top of the page and there is a fantastic guide also. Pugsy has done a yeoman's job of providing instructions. If you get confused you can ask specific questions here, or better yet get a friend to help you. ITs hard enough to learn geek when you at fully awake, alert and on top of things, sleep deprived it's very difficult!

Without actual data to look at, Most advice is more bloviating rather than helpful.

Best Wishes, and hope that you can get the help you need to get this thing controlled.

Respironics Flex exhale relief works differently than the ResMed exhale relief.
C Flex is pretty much cpap mode....A Flex is pretty much auto adjusting mode (apap) and BiFlex is what it is called on the BiPap machines and yes, it is in addition to the PS settings available on the BiPaps.

How Flex works...the machine will adjust the amount of exhale relief depending on the air flow or how forceful your breathing happens to be.
How they determine which gets what..dunno. I just know that Flex can vary.
It's not a 1 cm per setting thing like it is with the ResMed machines and instead the most exhale relief a person can get using any of the Flex options is 2 cm drop during exhale (even with the setting at 3) depending on how forcefully you breathe....if you are a shallow breather you won't get as much of a drop as you would if you breathe more forcefully.

Also with Flex it's more about the timing of the drop than the actual drop...it's "smoother" for lack of a better descriptive word.
I have used both brands...EPR and Flex...and while they are both forms of exhale relief that are quite decent they don't feel exactly the same.
I found that A Flex seemed to match my own breathing rhythm the best...very natural like.

With any exhale relief and any drop in exhale pressure there's always the possibility that the drop will go below a line where the airway could maybe collapse if a person is maybe at the bare minimum pressure to hold the airway open.
This is what it sounds like might be happening with you and EPR...X amount of pressure without EPR seems to hold the airway open but add in the drop from EPR and your pressure on exhale drops down to where the airway can close. This is easily fixed by simply starting out a little bit higher so that when it does drop the airway is still help open better because the drop doesn't take you below that "line" where the pressure just can't do a good job.
No need to guess at the needed settings at all...just start out the night with a little more.

In other words sometimes a little more starting pressure is needed when any sort of exhale relief is used when the person is already maybe real close to a pressure where the airway can collapse.

Your chest or lungs doesn't "over inflate"...the pressure doesn't force the lungs to do anything..instead the soreness you are experiencing is most likely simply the chest wall muscles being a bit sore from the "work" needed to exhale against the pressure. Chest wall muscles are like any other muscle...give them some sort of work or exercise that they aren't used to and they will get sore.
It's a feeling very similar to costrochronditis...hurts a bit to inhale or exhale but as the muscles get better used to the "work" the soreness will go away.
These machines don't breathe for you (that's where the machines like the ASV with a back up rate come in and those do breathe for you) and they can't forces your lungs to inflate...even at 20 cm they can't even blow up a balloon.

Now sometimes we needed more pressure during some parts of the night and not other parts of the night...so might be what is going on with you as to why current settings aren't always working so great but do okay for some parts of the night.
The usual culprits for pressure variation needs are either sleeping on your back or REM stage sleep...or maybe a little of both.
It's quite common for our OSA to be worse when on our backs and to need more pressure when on your back vs on your side.
Same thing for REM stage sleep...Some people will have their OSA much worse in REM and need a lot more pressure in REM...I am one of those.

How do we figure out what might be going on....those software reports that I mentioned. Helps to get some idea what might be going on at least on paper to give us an idea where to start trouble shooting.
Your telling us subjectively feelings doesn't really give us much to go on. I can tell you that everything you have said...I have seen many, many times before on this forum and it's all fixable in some way or another but I prefer doing offering ideas based on the data. I don't like guessing at all.
Especially since there is some question as to the status of centrals in your situation. Some ideas might make the centrals worse and we sure don't want to do that.

The DreamStation APAP will flag centrals (calls them Clear Airway apnea events) and will work with SleepyHead....let's see what happens with the reports after tonight's sleep and see what is going on and that will give us a starting point.
No sense in doing much with the ResMed at this time since you are changing machines anyway. They have different algorithms and different ways of doing things so not much use to look at the ResMed report at this time (assuming you have detailed data).

You may or may not need an ASV machine....they are very expensive and insurance will require some hurdle jumping.
Let's cross that bridge if and when we need to based on what happens with the APAP DreamStation.

Are you in Canada? I see your mention of provincial coverage. Whole different ball game in Canada for getting anything other than regular cpap...depends on the province and what the doctor writes the order for.

Yes, I think that's what is happening with me and EPR. However, I've been successful at 3, then not. Then successful at 2, then not. It changes. I'm not sure whether it's a collapsing airway, or my system forgetting to breathe. I don't wake up choking, just need a big couple of breaths and my heart rate is up.

Yes I understand not overinflated, but it's what it felt like last night. The company warned me about too high pressure though causing more central apnea. Is that true or not?

Yes, as I described in another message .. my pressure needs change all over the place. Running from 10.5 to almost 13 on the current unit. I have severe REM apnea, and moderate at other stages. My study showed AHI in REM of 60, 29 at other stages. Plus the heat/relapse/over tired/med or position changes to pressure.

SleepyHead downloaded. Ummmm seriously dumb question. How to get the data on my laptop? /blush/ I have no SD card slot. Another way?

Thank you Pugsy! Lots of good info.

Pugsy wrote:Respironics Flex exhale relief works differently than the ResMed exhale relief.
C Flex is pretty much cpap mode....A Flex is pretty much auto adjusting mode (apap) and BiFlex is what it is called on the BiPap machines and yes, it is in addition to the PS settings available on the BiPaps.

How Flex works...the machine will adjust the amount of exhale relief depending on the air flow or how forceful your breathing happens to be.
How they determine which gets what..dunno. I just know that Flex can vary.
It's not a 1 cm per setting thing like it is with the ResMed machines and instead the most exhale relief a person can get using any of the Flex options is 2 cm drop during exhale (even with the setting at 3) depending on how forcefully you breathe....if you are a shallow breather you won't get as much of a drop as you would if you breathe more forcefully.

Also with Flex it's more about the timing of the drop than the actual drop...it's "smoother" for lack of a better descriptive word.
I have used both brands...EPR and Flex...and while they are both forms of exhale relief that are quite decent they don't feel exactly the same.
I found that A Flex seemed to match my own breathing rhythm the best...very natural like.

With any exhale relief and any drop in exhale pressure there's always the possibility that the drop will go below a line where the airway could maybe collapse if a person is maybe at the bare minimum pressure to hold the airway open.
This is what it sounds like might be happening with you and EPR...X amount of pressure without EPR seems to hold the airway open but add in the drop from EPR and your pressure on exhale drops down to where the airway can close. This is easily fixed by simply starting out a little bit higher so that when it does drop the airway is still help open better because the drop doesn't take you below that "line" where the pressure just can't do a good job.
No need to guess at the needed settings at all...just start out the night with a little more.

In other words sometimes a little more starting pressure is needed when any sort of exhale relief is used when the person is already maybe real close to a pressure where the airway can collapse.

Your chest or lungs doesn't "over inflate"...the pressure doesn't force the lungs to do anything..instead the soreness you are experiencing is most likely simply the chest wall muscles being a bit sore from the "work" needed to exhale against the pressure. Chest wall muscles are like any other muscle...give them some sort of work or exercise that they aren't used to and they will get sore.
It's a feeling very similar to costrochronditis...hurts a bit to inhale or exhale but as the muscles get better used to the "work" the soreness will go away.
These machines don't breathe for you (that's where the machines like the ASV with a back up rate come in and those do breathe for you) and they can't forces your lungs to inflate...even at 20 cm they can't even blow up a balloon.

Now sometimes we needed more pressure during some parts of the night and not other parts of the night...so might be what is going on with you as to why current settings aren't always working so great but do okay for some parts of the night.
The usual culprits for pressure variation needs are either sleeping on your back or REM stage sleep...or maybe a little of both.
It's quite common for our OSA to be worse when on our backs and to need more pressure when on your back vs on your side.
Same thing for REM stage sleep...Some people will have their OSA much worse in REM and need a lot more pressure in REM...I am one of those.

How do we figure out what might be going on....those software reports that I mentioned. Helps to get some idea what might be going on at least on paper to give us an idea where to start trouble shooting.
Your telling us subjectively feelings doesn't really give us much to go on. I can tell you that everything you have said...I have seen many, many times before on this forum and it's all fixable in some way or another but I prefer doing offering ideas based on the data. I don't like guessing at all.
Especially since there is some question as to the status of centrals in your situation. Some ideas might make the centrals worse and we sure don't want to do that.

The DreamStation APAP will flag centrals (calls them Clear Airway apnea events) and will work with SleepyHead....let's see what happens with the reports after tonight's sleep and see what is going on and that will give us a starting point.
No sense in doing much with the ResMed at this time since you are changing machines anyway. They have different algorithms and different ways of doing things so not much use to look at the ResMed report at this time (assuming you have detailed data).

You may or may not need an ASV machine....they are very expensive and insurance will require some hurdle jumping.
Let's cross that bridge if and when we need to based on what happens with the APAP DreamStation.

Are you in Canada? I see your mention of provincial coverage. Whole different ball game in Canada for getting anything other than regular cpap...depends on the province and what the doctor writes the order for.

Aspen, as far as how to the data from your device to your computer: You can bus a USB Sd card reader pretty cheep, I think mine was like $10 U.S. at my local drug store. That will allow you to read the card. I am assuming your loaner device has a SD card, or at least a slot for one. If you don't have a SD card but do have the slot you can also buy one of the SD card really inexpensively, don't need a big one, I am using a 8 GB I think. Holds many many many days worth of data.

Cheer!

aspen wrote:The company warned me about too high pressure though causing more central apnea. Is that true or not?

Well....yeah it can happen to some people but it doesn't necessarily happen to all people. I would see pressures of 18 often (probably in REM) and I have never had anything more than an occasional central hear and there which is normal.
Plus it doesn't necessarily have to be high pressures for some people....sometimes it's any pressure even as little as 5 or cm.
You can read about it here...now I am NOT saying that is what is going on with you because I don't have enough information yet but it explains a bit how cpap pressure creates the unstable breathing that causes centrals.
https://www.youtube.com/watch?v=CU-XTcf ... e=youtu.be
And some people can have complex sleep apnea even without cpap ever being used.

aspen wrote:Yes, I think that's what is happening with me and EPR. However, I've been successful at 3, then not. Then successful at 2, then not. It changes. I'm not sure whether it's a collapsing airway, or my system forgetting to breathe.

Use the software to see what type of events you are having.
When a setting works some nights and not other nights then most likely it's either REM or Supine Sleeping that is the culprit. We simply don't sleep the same way each night. When have a fixed pressure machine we have to set it to cover all possible worst case scenarios...if your events are mainly obstructive then we figure out what to best work in the worst case. Using the apap will help with that and give you an idea when and what is going on.

Does your computer have an available USB port? If so, you can use the card reader adapter thing that TASmart mentioned.
If it doesn't have any sort of available port...what kind of computer is it?
There's some data available on the LCD screen beyond just generic AHI...you just have to go a little deeper...it will break down into central/obstructive and hyponea index.
https://sleep.tnet.com/home/files/resme ... -guide.pdf

xxyzx wrote:so barotrauma is not a problem for anyone at all ?

if he has mixed apnea he does need an ASV

Neither of those has been proven to be happening yet.
No reports of gastric symptoms to support your wild ass guess of "barotrauma".
Haven't seen any reports of any kind either from a machine or sleep study that point to centrals being of the number to constitute a diagnosis of complex sleep apnea. What I said was

Pugsy wrote:You may or may not need an ASV machine..

and he is in Canada...you just don't go out and buy one of those in Canada...you think it's hard getting ASV here in the US...move to Canada and see what the hurdles are. It can be done but it takes more hurdle jumping to get it done.

Pugsy wrote:
and he is in Canada...you just don't go out and buy one of those in Canada...you think it's hard getting ASV here in the US...move to Canada and see what the hurdles are. It can be done but it takes more hurdle jumping to get it done.

For the record, I am a she . And yes, Canada. I picked up the Dreamstation Autoset this afternoon and our little company doesn't even have ASV available. They may only be available through hospitals here? Not sure. The most available to me is the auto BiPap.

And no sd card readers in town so there is now a delay. I will be back when I have some sort of report available. The Dreamstation doesn't even list CSA events as does the Resmed, which is frustrating.

aspen wrote:And no sd card readers in town so there is now a delay. I will be back when I have some sort of report available. The Dreamstation doesn't even list CSA events as does the Resmed, which is frustrating.

The DreamStation calls centrals Clear Airway Events and while they don't distinguish between Obstructive Apneas and Clear Airway Apneas on the LCD screen AHI they will do it on the software.

You will have a small amount of limited data on the LCD screen. It's pretty pitiful for sure but it's better than nothing (barely).
I actually have used a Respironics (prior to the DreamStation) so I am familiar with it and own a PR System One BiPap Auto model 760. Not a crap machine for sure. Yeah, different brands and different algorithms but they both get where they are suppose to go (prevent apneas) even though they might take a slightly different road to get there.

Sorry about the he/she thing. I had no way to know..if it bugs you too much then do as I have and make a gender selection in your profile and it will help avoid confusion later but I can't guarantee it will totally eliminate it. I am a she and have the "F" selected and I was referred to as a "he" just a couple of days ago. I will try to remember you are a she...but no guarantees and I do get tired of typing he/she when I don't know and most often take the lazy way out and just do "he".

Let's see what happens with the new machine once you get the card reader and all that.
You might get lucky and this work out well for you. Gotta start somewhere and this is as good as any. Should the DreamStation start showing the numbers of centrals that can't be explained away as maybe awake breathing or there is significant problems with centrals we can talk about your options or needs at that time.

Like I said...ASV may or may not even be needed. If you only had centrals after starting cpap (had none on the diagnostic study done without cpap) then it's possible that the unstable breathing causing the centrals will resolve on its own. It can happen with just some time for some people. Not all people of course but it can happen so not impossible to get lucky and have them go away on their own.
Cross that bridge if/when we come to it.
Having a few centrals is actually normal anyway...it's normal to have what is called a sleep onset central or sleep stage transition central.
They don't always cause a problem and don't always need to be "fixed".

intubating helps very well with all kind of breathing related problems ... why not just do that?

xxyzx wrote:how long should they suffer before they get the right machine

I have no control over that. What do you want me to say...that she should refuse to use what she has because it might not work...well, hell, it might just work.
How do you propose to change her situation?
Maybe she doesn't have thousands of dollars to buy a machine that she may or may not need just because you say that's what she should get without ever knowing for sure what is going on.

xxyzx wrote:ASV handles centrals better

Well, yeah...but so far we don't know for sure what the central situation is...and/or how it relates to anything.
Again...for your reading clarification.
I said that ASV may or may not be needed...we don't have enough particulars to know what's going on for sure. Now if you are so smart you can see her sleep studies from where you are at and privy to details we aren't....care to share.

xxyzx wrote:why suffer them needlessly hoping to get used to them or hoping they go away

if the xpap is causing them the answer is an ASV not hoping and waiting that the suffering wont keep going on too many more days weeks months years kaput

Because at this point there is no option but to play the hand that has been dealt. Simple as that. Just because you think they should go directly to ASV isn't going to make it happen. News flash...Canadian medical doesn't give a rats ass what you or anyone else in the US thinks they should do.
And again...we don't know if the centrals predate cpap or not. You are assuming facts not in evidence. This is one of the things you do that doesn't help anyone. You assume facts not in evidence and go off on a tangent that really hasn't been proven to be needed.

We have no choice but to play the cards dealt...there's no other option at the moment unless you want to go buy an ASV machine and send it to her.

And...about the

suffer them needlessly hoping to get used to them or hoping they go away

who said anything about suffering and waiting for years? Again you are assuming facts not in evidence.