Help with Therapy after Dr said he didn't know what to do

[jwhjwh54]

Hello!
I've been lurking for a bit and have been learning a lot. I've had more success from this site than the sleep Dr.

Quick history

Initial sleep study 2013. The second sleep test when I slept with the machine was terrible and the tech ended up being fired a couple days later for just being terrible apparently.

Was sent home with a bipap machine for some reason. Wasn't compliant in 30 days because I'd take the mask off. Couple Dr appointments and reading charts, the AHI was around 15 or so when I would keep it on and the DR eventually said I don't know what to do. Try a oral appliance. Got an oral appliance 1500 later and started to sleep all night with it and feel a bit better. Slept with the appliance for several years and felt like I could sleep better. Did an at home sleep test with the appliance and the Dr said the appliance wasn't helping that much either. Decided to stop wasting my time at the DR and not go back until I was sleeping with the Cpap machine on. After about 2 months I'm consistently sleeping with the mask and taking it off maybe once a week . Also finding sleepy head was awesome and has been great to see that things are starting to improve.

I'm 29, 209 pounds, athletic build. Probably going to find a new DR and new sleep test so I can get back on insurance but I want to get in the sleep study and nail it!

Machine Respironics Remstar bipap auto with biflex. Full face mask

Was wondering if someone could read these charts and offer any tips on what was going on with me. If you need to see any chart not in the screen shots I'll get it.

Thank ya'll for any help and after 5 years, I'm ready to get this sleepy stuff over and done with!

[Pugsy]

Welcome to the forum.

Please review this thread which includes the format of the graphs.
viewtopic/t158560/How-to-post-images-for-review.html
In your effort to include so many graphs you've made them pretty tiny and hard to evaluate and most we don't need anyway.
And you omitted the Events graphs which is kinda more important.

No need to redo these images though. I can see well enough what I think part of your problem is.
If you post again after making some changes...refer to how I show it in that thread above.

I think you need more minimum EPAP pressure.
8 to 9 cm Minimum EPAP instead of the current 6. Maybe a little more but that's when I really need to see the graphs in the better format to decide.

You have a bilevel machine but have it set up working like a non bilevel machine. Any special reason?

[jwhjwh54]

Thanks for the reply and the info. I went ahead and reposted but will make the changes and come back in a few days!

I'm not sure why it's not set at bi level. I guess they set it like that so It would be more like a cpap? I've set it before for CPAP mode and was able to sleep with the mask on all night but only tried it for 2 nights and the AHI was around 10.

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Cpap night

[Julie]

I suggest you raise your min. pressure by 1-2 cm for now and later on depending on how things go, you might even want a bit more. You're at quite a low rate so far and it may not be therapeutic for you. Leave the max one high... it's not going to matter much here.

I also wonder if you've ever tried a soft cervical collar - could help your flow rate if you tend to sleep with your head down.

[Pugsy]

Some nights you need more minimum pressure all night and some nights not so much.
Some nights you need even more than 12.5 at some times during the night. The May 6 night with fixed cpap mode of 12.5 shows a couple little clusters with the worst at around 3:30.

The primary reasons for when we see reports like this where the pressure works fine for the bulk of the night and not so great for part of the night is either supine sleeping or REM stage sleep causing greater pressure needs. It's quite common for OSA to worse when on our backs or during REM and for us to have significantly higher pressure needs when the OSA worsens.
Given the time frame of the clusters on that May 6 report...I suspect REM stage sleep.

I don't know why they decided to have the machine function more like apap/cpap by eliminating the pressure support feature.
It's the PS of 0.0 that is doing that.
Pressure support is the difference between inhale and exhale and when it is at 0.0 there is no difference...that's why you just see the single pressure line instead of 2 pressure lines.

I have a couple of ideas but let's see what happens with just changing the minimum EPAP to 8 or 9 first and how your comfort level ends up being at that pressure minimum and how well you sleep (or don't).
If you aren't comfortable with starting minimum of 8 or 9 and it just seems too difficult we can add in some PS to help you out...like change minimum PS to 3...though if you slept with fixed cpap pressures of 12.5 then I doubt you will have significant problems with 8 or 9 minimum EPAP.

Report back tomorrow please.

[prodigyplace]

Personally, I find I sleep better with a minimum pressure around 5. It appears to be a very personal preference. Somebody here claims they need their minimum at 15.

[LSAT]

Personally, I find I sleep better with a minimum pressure around 5. It appears to be a very personal preference. Somebody here claims they need their minimum at 15.

My minimum pressure is 12...I don't think that is unusual.

[Pugsy]

Personally, I find I sleep better with a minimum pressure around 5. It appears to be a very personal preference. Somebody here claims they need their minimum at 15.

How effective the minimum is depends on the person and what they need to keep the airway open.
The machine sometimes just needs more of a head start in terms of pressure for some people and you are lucky that your OSA doesn't need that much of a head start.

It also depends on the machine being used and the auto adjusting algorithm.
I have used both brands...ResMed and Respironics and with the ResMed I can get by with a minimum pressure of 7 cm and get good results but with the Respironics auto algorithm I need a minimum pressure of 10 cm to get me the same good results. Anything less and I end up with some nasty OA clusters in REM.

So yeah, lower minimum often makes it easier to sleep and more comfortable but if the therapy delivered is sub optimal with those lower starting points then the overall therapy effectiveness can get reduced and sleep quality can be negatively affected because of apnea events that slip past the defenses so a higher minimum pressure has to be used.

You are lucky that your OSA is well treated with relatively low minimum pressure starting points and your machine can get to where it needs to be quickly enough. Some people aren't so lucky and yeah...they might need 15 cm to hold the airway open. Not a lot of fun but if a person needs it then they have to learn to sleep with it or else have crappy sleep from a truck load of apnea events.

[prodigyplace]

I think I still have the occasional OA. I am trying to optimize things. I really wish my CAs were lower, but I understand APAP can cause them but not treat them.
My home sleep study showed no CA wither because I did not have them ot the system could not detect them.

[JDS74]

Unless you need it, I'd turn off the ramp setting.
If you can tolerate it, increasing the Max IPAP up a couple of cmH2O might also help. Try making it 3 cmH2O higher than the max EPAP setting.
You seem to be topping out a couple of times during the night.

Then incrementally up the EPAP pressure from its current 6.0 cmH2O setting to 7.5 - 8.0 cmH2O to see if the OSA and HYP events could be better controlled.
Try a couple of nights at 6.5, then 7.0, etc. to see if things improve.
As Pugsy suggests, changing the PS from 0.0 to 3.0 might also help.
All of these might take a week or so to dial in.

[JimW159]

I cannot comment regarding the nuances of setting up your BiPAP pressures. The one comment I would like to make: don't change how you fit your mask - your leak rates (if they consistently reflect your results) are stellar. Personally, I have come to believe that leaks contribute an enormous amount to how well PAP therapy feels to you and works for you - keeping them in check is a win in my book.

[CarpeNoctum]

I'm 29, 209 pounds, athletic build.

Hi Dude,
Sorry you're having such difficulty with cpap...but it's all too common. I noticed the above comment about your build and it reminded me of something I read recently. Guys who are very muscular seem to have more of an issue with OSA. I'm talking bodybuilders, football player and the like...guys who have extremely well developed neck muscles.

I just wanted to alert you to this so you can do your own research and relate it to your life. You're young enough that some changes now could reflect on how your cpap evolves over time.
CN

[jwhjwh54]

I'm 29, 209 pounds, athletic build.

Hi Dude,
Sorry you're having such difficulty with cpap...but it's all too common. I noticed the above comment about your build and it reminded me of something I read recently. Guys who are very muscular seem to have more of an issue with OSA. I'm talking bodybuilders, football player and the like...guys who have extremely well developed neck muscles.

I just wanted to alert you to this so you can do your own research and relate it to your life. You're young enough that some changes now could reflect on how your cpap evolves over time.
CN

Thanks! I'm already feeling better about it and am finally seeing the light at the end of the tunnel thanks to this site. My Dad, brother, uncles all have OSA, so combined with the family genetics ( bone structure, small mouth, etc) It doesn't help. I'm not super jacked or anything but have always been thicker/ muscular and have tried when exercising to do more cardio and lean muscle stuff. I'll look into it though. I need to look at sleeping position too maybe. Right now I'm on my back pretty much all night

I've made the changes above on the pressures and will report back tomorrow

[jwhjwh54]

Obstructive is better for sure. CA's are up though. The PS was a little weird feeling. Inhaling the machine would force air and the mask would inflate which was distracting and made me feel out of breath because as as soon as I would inhale, I'd get a blast of air. The ramp feature allowed me to get to sleep so I know I can get used to the PS if it's needed. I could try the same pressures without PS maybe?

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[Pugsy]

Yep, try same pressure but turn PS min to 0 and max to 0. It's a comfort thing and some people like it and some don't.
The IPAP (inhale) pressure of 12 does some work though so stopping any IPAP might mean needing a little more EPAP minimum but we won't know until you try.

The centrals....don't worry about them for now. I am betting some of them aren't real....especially that very first one.
I want you to learn how to zoom in and figure out if they look real or not.
Go here and watch the last video
http://freecpapadvice.com/sleepyhead-free-software
If most of them look real....consider turning off Flex exhale relief or at least reducing it and see if the number of centrals change.
If they aren't real we have to ignore them.