How to handle leak and other questions

[Pugsy]

If you ever want to go poking around in the clinical menu setup area just to see what's in there or maybe to change something....it's easy to learn the secret handshake. Just a couple of little button pushing combinations.

The manual explains it.

https://www.respshop.com/manuals/ResMed ... %20her.pdf

This stuff isn't rocket science. Not hard to learn at all.

How are you sleeping and feeling the next day?

[st8728]

Thank you, I figured out how to get into it last time to change my EPR to 1. I was wondering if I should raise my low pressure slightly to something like 9 perhaps what do you think?

Still feel exhausted really. I wake up and feel like going back to sleep, most of the day I think about how far it is until I can sleep again haha.

[Pugsy]

You could try increasing the minimum to 9 cm but in all honesty I doubt it would be the miracle fix.
More pressure won't fix central apneas and your AHI is primarily composed of central apneas. Your flow limitation graph isn't horrible which is what we might look at for more pressure.
I think you don't feel rested because the bulk of your central apneas point to fragmented sleep and it's the fragmented sleep itself that is causing poor sleep quality and non restorative sleep or not as restorative as you need or want.

If it were me I would try turning off EPR first and see if the centrals reduce any at all with EPR off. I have my doubts but there is a slim chance it might. There is a remote chance that EPR is a factor in the centrals popping up and the centrals could be contributing to the poor sleep.

If you find you need EPR for comfort so you can fall asleep you can set EPR for ramp only and then choose a ramp time that gives you enough time to fall asleep.

It's hard to know for sure if the centrals are the cause of the poor sleep or just a symptom of poor sleep.

[st8728]

Thank you. I will try turn off EPR. I set ramp to 15 minutes with a start pressure of 8.0 cmH2O and will leave my pressure at 8-20 for now. I set EPR to ramp only.

The flow limitation you can tell if the start pressure is enough? Last night was not great I think the mask kept sitting funny and leaking as I turned my head side to side I might upload that one tomorrow perhaps.

I realised today that my stomach is rather sore it just feels full and sore since I woke for the whole day. I went for a bike ride and it was painfully sore. It has felt full and annoying for a week or two but today it was sore full also.

I asked the sleep shop lady what what a bipap machine does and she said it’s for central apnea is that correct?

[Pugsy]

I asked the sleep shop lady what what a bipap machine does and she said it’s for central apnea is that correct?

Well.....there are several types of bipap/bilevel machines and some are indeed for central apnea but there are some types that are nothing more than apaps with more options available for pressure or comfort than the machine you are using now.
So the idiot was partially correct but I suspect she thinks that bilevel is only for centrals and that simply is not the case. I use a bilevel auto adjusting machine and it won't treat centrals and I don't have a problem with centrals so I don't need it to.

Now are your centrals numerous enough to maybe need addressing??? At this point we don't know for sure as the number is borderline.
First of all you need to be asleep for them to be a problem and secondly numerous enough while asleep. An occasional for sure asleep central apnea isn't a big deal but a truckload of them (while asleep) is a problem.

Lets see what happens with turning EPR off. With EPR off you are effectively increasing that overall average pressure a little bit. Not a lot but a little.

[st8728]

Ah thank you she said I would need to wait for the sleep doc if I needed a bipap or not anyway. The machines here I think still require a prescription to get from the sleep doc. I don’t actually know if she can read the reports or she just doesn’t care what else are bipap machines used for?

I slept with EPR off last night (had ramp on but seemed pointless so I have turned it off again). I had a really bad sleep but I think it was because it was hot, it felt like it took hours to fall asleep but maybe I was drifting in and out. My AHI was lower (around 3 something) but I will try to stick to it for at least 3 days but hopefully a week to see how it goes.

My stomach still hurts and it ends up being sore the whole day, I am going to see if I can fall asleep with my head in different positions to see if that helps or not. It hurt less today that yesterday but it’s painful enough to be really annoying.

Also I don’t know if I mentioned but my PLMS was just over 20 an hour when I did my study, does this get treated via the cpap or something else? He didn’t say much about it other than it was “noted” and I had a lot of suspect leg movements.

[Pugsy]

First of all the term "bipap" has sort of become a generic term for bilevel cpap machine but it actually is only a marketing term for Respironics bilevel machines. So I prefer to call them bilevel machines as other brands use different marketing terms. Example I am using a ResMed bilevel auto machine and ResMed calls it a VAuto...no mention as to "bipap" anywhere in its literature. They do talk about bilevel though.

Bilevel just means there are 2 distinct pressures being used. One for inhale and one for exhale and the difference between those pressures is referred to a pressure support (PS for short). When you use your AutoSet and EPR....you are using it as a bilevel machine because EPR creates a bilevel pressure situation. EPR creates a pressure support situation but it is limited to 3 cm difference between inhale and exhale. This is true with any form of exhale relief...exhale relief creates a bilevel pressure situation and why we often refer to exhale relief as a "poor man's bipap/bilevel". The real bilevel machines like I use aren't limited with the pressure support available.
They can go higher than 3 cm and sometimes that higher PS is needed for various reasons. Maybe it's comfort or aerophagia issues or maybe a much higher PS is needed just to help ventilate the lungs. Like maybe someone has COPD issues or some sort of neuromuscular problem where the lungs need some extra help. Sometimes with central apneas the machine has to kick in with a high PS to force the person to breathe because they aren't breathing on their own.

So sometimes the bilevel machines are nothing more than glorified apap machines with a higher PS being available...sometimes they can force a person to breathe like with ASV machines. Mine is nothing more than a glorified apap machine. That's okay....I like PS of 4 better than PS of 3 which is what I get with EPR at 3. Personal comfort...and comfort is important. If we are more comfortable we simply sleep better and sleep is probably a primary goal. Without sleep none of this stuff matters much.

Now for some people (very small minority) using bilevel of any kind creates a situation where there is an imbalance of gas exchanges during respiration and people end up with more central apneas popping up just from bilevel pressures. When that happens obviously spending the money for going from apap to bilevel isn't going to help much unless they end up needing ASV bilevel.
At this point we don't know for sure if you are one of those people or not.

The usual fix for aerophagia issues....bilevel pressures but if you happen to be one of those people who find that bilevel makes central apneas worse...not a viable option. It's why I have been trying to figure out if your EPR is a factor in your centrals or not.
Your experiencing the belly issues...really complicates your OSA therapy because you get in a situation where X amount of pressure is needed to hold the airway open but that amount of pressure might create belly issues so you trade one sleep disturbing problem for another and that's not good. We might have to compromise in your situation and use a lower pressure to avoid belly issues for now and allow a few events to happen as a trade off for solid sleep. Maybe revisit higher pressures later and go up in very small increments if we do.

So for right now...no urgent need for bilevel in your situation and there is the remote possibility that bilevel might be a factor in your centrals and if that's the case....waste of money if you can't utilize the bilevel features very much.
You might end up doing better on a fixed or very tight apap pressure range without EPR. We just don't know right now.

As for the PLMD....sometimes it does resolve itself with optimal cpap therapy which is why cpap is often the first go to therapy for it.
The thinking being that it is the apnea events causing the arousals which cause the limb movements.
If that doesn't help much then there are medications which can be used as well as other treatments. So you end up treating the PLMD as a separate sleep problem. Sometimes it can be fixed with cpap and sometimes it can't. So if a person knows they need cpap anyway then they try cpap first and see what happens.

If you continue to have belly issues...reduce your pressure 1 cm and leave EPR off for now and try to sleep solidly enough for us to try to evaluate the data reported. If you know you didn't sleep well and woke up a lot then we don't know how much faith to put in that AHI of 3.0 that is likely primarily centrals anyway. I would also restrict the maximum to a tight range to try to help reduce the chance that the aerophagia is related to short periods of time at higher pressures.

[st8728]

I see thank you. I am just going to see if I can last a week with no EPR to see what sort of results I get over that period. It’s definitely more comfortable with EPR on 3 than any other setting. One think I realised now when ramp was on originally it almost felt like I was suffocating or something, like I wasn’t getting enough air. Although I turn it off now so that’s not an issue. Is a CPAP with EPR of 3 and a bipap with PS of 3 the same or do they work completely differently? I think the most annoying thing now is this painful bloating feeling. Initially it was just bloating with no pain and now it’s painful and doesn’t go away. I had a look around and it seems like like of people who get it can get rid of it in a few hours? (Temporarily get rid of it as it would come back the following night). It’s almost like mine gets worse throughout the day which is odd.

If I did try to change pressures would it be better to start lowering the lower pressure or lowering the higher pressure first?

Can PLMS be measured somehow not in a sleep study or is that the only way to tell if CPAP resolved it?

[Pugsy]

PS of 3 and EPR of 3 ends up being essentially the same. EPR is pressure support backwards.
Example...on a bilevel machine we might set minimum EPAP to 7 and PS to 3 that will give us 10 IPAP.
on the autoset machine we would set the minimum to 10 and EPR to 3....which ends up still giving us 10 IPAP and 7 EPAP.
Feels and functions the same.

You need to reduce the minimum pressure first in an effort to reduce the aerophagia issues. Maximum pressure settings we don't even know how long you are up near the maximum.
The minimum is the constant pressure and what is constantly putting pressure against the LES (lower esophageal sphincter) and thus pushing air into the stomach. We want to reduce that constant pressure. This is why we also like to add in exhale relief...reduce that constant pressure.

To be honest...if it were me I would use some EPR and just accept a few centrals for now (assuming EPR is a factor in the centrals) because I don't think people should be miserable all day with belly pain. Revisit maybe reducing EPR or adding more minimum pressure later.

I don't know of any way to measure PLMD results except by a sleep study because you need to be able to measure actual sleep and limb movements at the same time. Now some people have set up night vision cameras to watch to see if there is much limb movement happening but it is of course not as accurate...but can be done relatively inexpensively. Might give a person a general idea what is going on.

[st8728]

Thank you. I will try this last night with no EPR to see if it’s still the same tomorrow and if so turn it back on. Recommend would be setting back to 3?

Weird. It is backwards because it can go higher?

I really want this to work I am sick of feeling like a zombie continuously.

[Pugsy]

No, not backwards because it can go higher but backwards because EPR is subtracted from IPAP to give EPAP
and when using PS we add it to EPAP to get IPAP. Subtraction vs addition kind of backwards.
The available higher setting is a moot point (when in auto adjusting mode) because both will allow higher IPAPs which drag up EPAPs by default depending on whatever max setting is being used.

When aerophagia is involved that is significantly uncomfortable and causing problems sometimes we make compromises with both maximum whatever as well as the minimums. Sometimes the machine might want to go higher because of a little flow limitation and just because it wants to go higher doesn't mean we have to let it go higher when the going higher causes a bigger problem than a little flow limitation might cause.
First thing to try though is reducing the minimum and then if we see much range in the pressures then we look at reducing the maximums.

I like to make one change at a time though because that way we can best evaluate the results.

[st8728]

Ah ok I think that makes sense. Here was last 3 nights with EPR off and 8-20 cmH2O

Friday night (Hot kept waking up and couldn't get to sleep):

13112020.PNG (163.74 KiB) Viewed 730 times

Saturday night (woke up just after 8am and realised I had thrown my weighted eye mask across the room so I was moving around trying to find it and went back to sleep):

14112020.PNG (168.4 KiB) Viewed 730 times

Sunday night (someone decided to start banging on the steel fence at around 7:30am):

15112020.PNG (170.46 KiB) Viewed 730 times

Unsure how the aerophagia is currently it usually starts off feeling annoying and gets progressively more painful during the day. Will update if it gets worse today. It's weird the first few weeks I didn't have any of this I don't think but maybe because I was on the default machine APAP pressures it never managed to get that high perhaps? I think I was barely hitting pressures of 10 or above.

[st8728]

Seemingly my aerophagia has been less painful recently perhaps my body is just not used to what’s happening. I am still monitoring. I bumped my start pressure up slightly to 8.4 cmH2O.

I am curious what is the deal with hyponea and EPR? When it’s off I seem to get more of them than when EPR is on. Mine is still off currently it’s just something odd I noticed.

Also I completely forgot to mention in any of these posts previously that I have also been diagnosed with fibromyalgia I don’t know if this complicates everything further than it already is.