Help for Bipap newbie

Hi all. My name is Chris, and I'm new to the notion of talking about this stuff.

I was diagnosed with moderate OSA almost a year ago. Since then, I've been on a cpap and recently upgraded to a bipap.
My AHI has never been below 8 for more than a single night, usually < 4 hours use. On the cpap, all of my apneas were "clear airway" (it was a ResMed AirSense 10.)

I've upgraded to the bipap to see if that would help with the mixed apneas. It has made them much worse. My AHI most nights is between 14-20.
I did a second sleep study to see about getting a bipap asv, but they were able to get my apneas under control using only a cpap setting of ~10cmH2O. That said, I found the second sleep study to be significantly less restful than the first.

In other words, I seem to have a large number of central apneas whenever I'm at home, but they don't happen (or happen far less frequently, anyway) in the lab. My doctor is under the impression that my insurance wouldn't cover a bipap asv as a result.

I'm interested in why the centrals happen, sure, but the biggest problem is that this treatment isn't working.
I don't know what to do, and I need help.

This is my latest sleepyhead data, and I'm happy to provide any extra information I might have left out. I'm up for any suggestions that might help, however outlandish, and thanks for reading either way.

https://photos.app.goo.gl/lu1QTjM3XrEziwr52

Wow...that's a mess.

First thing I would suggest...change PS to 1 minimum and 1 maximum. Don't want so much PS and don't want it roaming around either.
There are a few people who will actually have centrals pop up as a result of pressure support. So let's limit the PS significantly and see what happens with the centrals/clear airway apneas.

Do this first and see what happens. Probably will need more minimum EPAP than the 10 cm but I don't want to make 2 changes at one time...so limit PS first and let's see what happens and then decide what to do with EPAP minimum.

Leave everything else the same for the time being.

Thanks for the reply! So that change seems to have dropped the centrals pretty substantially, percentage wise. Here's the data from last night.

https://photos.app.goo.gl/uxVrJpoExuyrsJvr1

Still an ugly report.

The obstructive stuff isn't well prevented and maybe some of those remaining centrals are post arousal centrals.

All I know to do is try to better clean up the obstructive stuff and cross our fingers that the centrals will reduce as the obstructive stuff reduces. It wouldn't be impossible and worth trying. If they don't then we have a different discussion about a different machine.

But for now let's try to do what we can with your machine to better prevent the obstructive stuff from happening because that's all we can fix with this machine.

You need more EPAP and I am suspecting quite a bit more EPAP and will suggest a bigger jump in EPAP minimum than I would normally suggest to someone. If the jump is simply not comfortable and you can't fall asleep...then we back up and move the EPAP up a bit slower.

Minimum EPAP of 15 keep PS min and max to 1...turn BiFlex off if you have it on and instead use rise time to modify the inhale/exhale response if you aren't comfortable with the timing. Rise Time becomes available only when Flex is turned off.

If EPAP min of 15 is just too uncomfortable to start with split the difference and try 12.5....
And in your situation I am not going to give you the usual "give it 4 to 7 days" advice before changes....right now you are so far out of optimal therapy that big changes are actually needed quickly. No sense in wasting time with an obvious way sub optimal setting. Now once we get close to optimal settings then we take more time and make smaller changes.

I am not ignoring the centrals...they are always on the back burner but not much we can about centrals with your machine.
Instead I am more about trying to fix what is obviously needing fixing and can be fixed with your machine and once that is fixed then we see what might remain in terms of the centrals and worry about that later.

Now if the big jump in EPAP turns around and we see a huge increase in centrals....we have a different discussion about a different machine and seeing your doctor.

Short night last night, mostly because I worked an opening shift today. Seemed to hit way higher pressures than usual, which is...good?

https://photos.app.goo.gl/FSfleaxAazPUlrTR2

I turned bi-flex off as soon as I learned what it was and how to get into the therapy settings on my machine. Rise time is at 2...can't say I notice much difference with those. I've been afraid until recently to mess with the therapy settings, but you've seen what my data looked like.

15 was a bit high, but I set a ramp and fell asleep without much fuss. I'm not sure if the pressure woke me before my alarm or not, I'll have to get a longer night to find out.

By the way, thank you -so much- for your help. I had been seriously losing hope, and you've been great.

Actually even though the AHI is still high...it's mainly hyponeas and only a couple of centrals which is nothing to worry about....so a substantial improvement.

Your pressure lines look weird and not what I would expect to see though.
Do you by chance have EZ start enabled? I don't even know if your mode offers EZ start but if it does turn it off. You can use regular ramp if you wish but don't use the fancy smart ramp or EZ start thing. Let's keep things simple so we can better evaluate things.

More events in the wee hours of the morning...might be REM related because that's when we typically have more REM. Not unexpected at all. Quite common. It's either REM or you were on your back.

You are going to need more pressure I think but I need to know about EZ start and which ramp you are using.
And you need a bit more time to get used to the 15 cm minimum EPAP and we need a couple more nights of reports with hopefully more hours.

So check out those settings I asked about...and change if needed and don't change anything tonight and let's see what happens after another night.
This is going to take a bit of time to get you dialed in but we are getting much closer.
You are going to be needing some markedly higher pressures and it's going to take a bit of time to work you up to those pressures from a comfort aspect.
At some point we may try to add in a little more pressure support to help you out with the breathing and cross our fingers that the centrals stay away.
It's very possible that those centrals we first saw weren't all related to pressure support but were instead related more to the OAs that were causing arousals. It might also be that PS of 4 caused too many centrals and a PS of 3 wouldn't. I have seen that happen too.

For the hyponeas I would rather try more IPAP but that would mean more PS and at this point I am not sure that more PS is for sure the way to go if your centrals are PS related. So instead we can do more IPAP by increasing EPAP a bit which by default will push IPAP up.

I am not seeing the test pressure probes on the pressure graph that I would expect to see which is why I am wondering about those other settings.
Now maybe the machine didn't want to do them but it is highly irregular for it to not do any.
So look on the machine for the settings and see if Smart Ramp is being used and if EZ start is being used. If they are...turn them off.

Your sleep is extremely broken and you have very bad numbers. So it is hard for me to suggest treatment changes when it appears that your treatment is way off. Or your broken sleep issues is throwing false flags. I would want to see what the events look like on a scale of 5 minutes.
You may want to upload a copy of your SD card and share the location so others can download&import into sleephead and investigate.

EDIT just saw you have been on cpap for 12 months, so that is more than 12 weeks in total. time to go back to doctor and show bpap is no good for you
I have no no real solution, just some what ifs.
I take it this is through insurance and the USA. First, some of these may be from positional apnea/chin to chest and could respond to a $10 foam cervical collar, and is worth trying for one night.
They could be pressure induced CA and will naturally resolve within 12 weeks
as well as PS1 as pugsy suggested, you could have Mim ps 0.0 max ps0.0 to reduce the pressure induced Clear airway apnea, If they are under 20-30sec in time and waiting for the co2 to build back up.
I would bump the pressure up a bit, but min epap 10 and min ps 4 is close enough to give ok results.

If your total time on both the machines have been about 12 weeks, go back to the doctor and show that you have failed bpap. they will titrate you for an ASV. They could be central apnea with O2 drop and need another machine to treat the Central Apnea.

ajack wrote:If your total time on both the machines have been about 12 weeks, go back to the doctor and show that you have failed bpap. they will titrate you for an ASV. They could be central apnea with O2 drop and need another machine to treat the Central Apnea.

He's been "recently upgraded to bilevel" but I am unsure of how recent.
And getting a doctor here in the US to do what you suggest isn't so simple. It can be quite difficult in fact.
They would instead try to do what could be done to make the bipap work (which is what I am suggesting) and they would likely give it a lot more time if there is any chance of the bipap working....and there is a chance that it could work as evidence by the reduction in centrals with the reduction in PS.

I wish it were that easy to get ASV here in the US but it isn't.

For anyone wondering...I am only trying to do what would be done in a one night in a lab titrating the bipap. Once that is done we see what is left and then he goes back to the doctor. Unfortunately we can't do at home what can be done in one night in a lab setting. It takes many nights to get it done.

I am NOT advocating taking the doctor out of the equation here..just suggesting what can be tried until the doctor can be brought in because often it takes a while to get that appointment and there's no sense in continuing something that is obviously not working while waiting for that appointment only to have the doctor end up suggesting what I am suggesting be tried.

Getting an ASV here in the US is difficult enough even for those where it is painfully obvious that is what they need...it's even harder for those where it is a "maybe".
Yeah, ASV would be the quickest simplest fix for the centrals but doctors here in the US won't do it unless nothing else works. Cold hard fact of life.
And then there are the insurance requirements even if the doctor is gung ho for ASV. Just because a doctor says something is needed doesn't mean that insurance will pay for it. It just doesn't work that way with US insurance. Sure wish it did because then I could have my insurance buy me a hot tub for my arthritis. My doc is all for it but my insurance says "wait a minute".

When my wife was first tested last year, they thought she might need an ASV machine. It took six months to get her machine adjusted to where it is treating her SA. They started her out at a low pressure (IPAP of10) with PS of 4 which cut the number of events she was having in half, with most of them being centrals. Once the centrals settled down to a reasonable number, they would raise the IPAP by two cm, give time to settle down, and then increase again. This went on for six months. Now, her AHI normally stays under 2 with occasional nights around 3. To be truthful, as I tracked her progress, I was pretty sure she was going to need an ASV, but thankfully it has settled down.

It sure seems that pugsy's advice to minimize PS and increase pressure is working.
The OP said that he was successfully titrated using CPAP 10cm-H2O. I would want to study the report to try to understand how that conclusion was reached and how the sleepyhead data compares using those settings. Lab titration data is clean as they know if you are asleep - but sometimes the time at pressure is just too low to draw an accurate conclusion. Machine data is plentiful but the machine assumes you are actually asleep.
If I were the OP I would definitely go back to the doctor but I would also try to learn as much as possible.

TedVPAP wrote:The OP said that he was successfully titrated using CPAP 10cm-H2O. I would want to study the report to try to understand how that conclusion was reached

Yeah, might be helpful to see how they came up with that number but going on my past own experience with an in lab titration...I wouldn't necessarily trust it as far as I could throw the fat lazy ass lying SOB that did my sleep study.
Who knows why...maybe not much REM and what we are seeing is REM related. I would assume they already had him on his back for the titration study to eliminate that variable.
Maybe not much sleep or maybe they caught him on a "good" night for some reason.

I do like what I did with my own...work with the here and now as much as possible. How they came up with 10 cm...beats me. I can't imagine it unless something was off. If it was a "good" study with adequate time and all that then something seems to have changed and we don't know what.
Whatever it was...10 cm isn't going to work unless something changes back ...if it ever really worked in the first place.

Pugsy wrote:

TedVPAP wrote:The OP said that he was successfully titrated using CPAP 10cm-H2O. I would want to study the report to try to understand how that conclusion was reached

Yeah, might be helpful to see how they came up with that number but going on my past own experience with an in lab titration...I wouldn't necessarily trust it as far as I could throw the fat lazy ass lying SOB that did my sleep study.
Who knows why...maybe not much REM and what we are seeing is REM related. I would assume they already had him on his back for the titration study to eliminate that variable.
Maybe not much sleep or maybe they caught him on a "good" night for some reason.

I do like what I did with my own...work with the here and now as much as possible. How they came up with 10 cm...beats me. I can't imagine it unless something was off. If it was a "good" study with adequate time and all that then something seems to have changed and we don't know what.
Whatever it was...10 cm isn't going to work unless something changes back ...if it ever really worked in the first place.

Finally I have learned what gets under your skin - LOL.
From the few experiences I have seen, most of the titrations claim success but were in fact failures.
That is the reason I cringe when I see people going back for more titration with more advanced machines when the past simpler work must be wrong.

That's still nasty, are you tucking your chin to your chest? a $10 foam cervical collar for a night will tell you if that positional apnea is a problem

Thanks for all the suggestions, guys.

A bit more info: I've been on the bipap with mixed (read: zero) actual success for 4-5 months now. The doctor sent me to get titrated for a bipap asv (theoretically) after the first two months didn't work out, but that came back with the 10cm and PS 4 suggestion when I was finally able to go. I can upload that study, but I'm afraid it's not great on the event detail. To say I don't trust it would be a massive understatement...it feels wrong compared to my memory of it. That being said, I was titrated with resmed equipment and I don't think they used bipap settings at all.

The insurance issue is correct. My insurance has no interest in paying for a bipap asv unless I have more than 75% of my AHI as centrals during an in-lab sleep study.

I've got a few more days at the last settings we discussed. I typically fall asleep on my side, chin propped on a pillow. I've tried switching sides to no real effect, but I don't believe my chin falls to my chest at any point. I had wondered if I was getting mouth leakage, but I can't read the leak data on the Respironics machine as well as I could on the old Resmed.

https://photos.app.goo.gl/iud7MyUIXOyYLu9A2

https://photos.app.goo.gl/xB15V76FwAGfXNbY2

https://photos.app.goo.gl/y3QcPWlk5WY2vPBC2

https://photos.app.goo.gl/y3QcPWlk5WY2vPBC2