Help with evaluating data

[jwalsh126]

My recent nights have been looking somewhat similar with AHI between 4-5 usually around 4.0. Large leak % has varied daily, but has been alarmingly high for me (as high as 38% recently, varies from 15-30% of night). I really don't want to change any settings on the machine until I get the leaking under control so that I can be sure why events or arousals are happening. I'm waking up with slighter symptoms of aerophagia now, and I suspect it is from those periods of the night where the APAP increases to around 8 or 9. I probably need this higher pressure for REM sleep, but I also have a feeling that the mask starts leaking maybe when I move my head, and the machine responds to the leaking by increasing when I don't really need the pressure increase per se.

Next resupply with insurance I think i'm going to try the Resmed Airfit F20 due to the great reviews especially with leaking issues. I want to see if my therapy looks/feels any different simply by changing out a mask and obtaining better leak numbers.

Question: I posted a couple specific events that happened last night and i'm wondering what your thoughts are on each. Specifically, i'm looking at what the pressure is and what the leak rate is doing (spiking upward, flat-lined at high leak, or flat low). To me, the machine seems to mix what may look like an OA for a CA, or vice versa, or simply a Hypopnea. How will I know what adjustments I need to make regarding treatment? I have other screenshots from last night and a total night view that I can post if that helps as well!

P.S. I use an F+P Simplus medium FFM with cervical collar and sleep supine on slight wedge (attempt to keep neck neutral). I was placed immediately on the Simplus FFM and have never tried any other mask, but I noticed my "mouth drop" was ruining my therapy within the first month or two of being placed on CPAP so I have used a soft cervical collar ever since and feel like i'm becoming dependent on it. I've never tried a nasal cushion.

[Pugsy]

post a detailed report not zoomed in on anything please.

Go to Preferences then cpap tab and tell me what it says for red line threshold.

Those events you zoomed in on look more like arousal breathing false positives to me and don't need any adjustments.

[jwalsh126]

Leak threshold in cpap tab is set to 70.0 L/min. I similarly think many events are post-arousal and can be disregarded, but I notice that my AHI is consistently at 4 as opposed to 2 or lower. I don't think I actually need that high of a pressure, but it's hard to make an assessment with false events and leaking. Also, i'm starting to think I show signs of "positional apnea" where chin tucking and supine sleeping results in clusters of events when the breathing gets shallow.

[Pugsy]

When you evaluate your AHI you have to subtract any awake/arousal flagged events from the AHI to get a real asleep AHI.
PITA I know but you have to do it if you want real evaluation.
Last summer I had a night with AHI of 9.4....on the face of it horrible but I went through all the flagged events and 95% of them were arousal/awake related. I had a really bad night pain wise. Had over done things working outside in the garden and paid for it with lots of back pain that night. Slept horrible.
The real asleep flagged events amounted to less than 1.0 AHI.

Looks like your 70 L/min threshold number is a bit too generous but it is so hard to come up with a line in the sand with Respironics machines because the line in the sand varies so much.
I see large leaks on that report yet the statistics show 0 percent over red line.
The machine's LL gray blocks trump the statistics.

Your pressure graph box is weird looking....you might reset the parameters so it more accurately reflects the pressure movement.
Not sure how to do that but you don't need max of 25 scale.

For real asleep events...probably just a little more minimum pressure will help.

[jwalsh126]

Thank you Pugsy! You are a savior to everyone on this forum and just talking through treatment with someone helps immensely from a mental health perspective, while also learning new things every time I come on here.

I posted 2 previous nights from earlier this week to show how bad the leaking was. The AHI is lower probably because the machine can't tell what's going on during those gray boxes so it can't measure any events that are taking place. I know what you mean with the AHI variations on bad nights, but now mine seems to be consistent at this 4-5 AHI. I think you are right about needing a slightly higher minimum pressure, but am I wrong to think the leaking is problemo numero uno to address because of the potential to mess with accuracy of the data? I also noticed aerophagia creeping back slowly, so I may want to try A-Flex 1 again, but as I learned, 1 change at a time and get multiple nights or a week of sample size to see how the changes impact both my "feel" and the OSCAR data. Do these other nightly charts suggest anything different in your opinion? I also copied 1 specific OA that happened last night that seems to be legitimate as opposed to the others I showed. I just want to make sure I know what I am looking for.

[Pugsy]

I don't think your leaks are bad enough to totally miss events. Usually total leak has to be in excess of 100 L/min (that top leak line) for the machine to just be clueless. So I doubt you are missing all that many events during times of large leak. Historically Respironics machines can still do a fairly decent job up to around 100 L/min total leak or above.

Remember the machine won't do anything for a CA/central event....nor will it do anything during a flagged event (awake or asleep).

The most recent zoomed in flagged event....I think that is arousal related because of the flow rate or breathing just prior to the flag...asleep breathing isn't irregular like that. Asleep breathing is boring and with no variations like these.



Use whatever Flex setting is simply most comfortable to you. I firmly believe that comfort equals better sleep.

Your leaking could very well be contributing to arousals even if you don't remember fully waking up and might be a factor in some of the false positive arousal related flagging.
I would concentrate on sleep quality and fixing leaks and not zero in on the AHI so much.
An AHI of 0.0 can still mean crappy sleep and feeling like crap during the day.....been there and done that myself.

Pressure increases...like the time on the recent Mar 11 at around 04:00....either REM related or supine related or maybe chin tuck.
We can't do much about REM at all but I always have felt that sometimes it's best to just get a good minimum and let the machine sort it out if at all possible. Anytime we start doing weird crap to modify sleep position we potentially affect sleep quality and since we don't know for sure if REM related or position related...I let the machine sort it out. That time frame is ripe for REM related.

[jwalsh126]

Thank you so much Pugsy! I have an inclination that you are right on the money in terms of leaking causing arousals which I don't consciously remember waking up to, but maybe causes me to shift positions or move. Any disruptions in sleep continuity will cause me to feel crappier the next day.

I won't change any settings, but will instead focus on trying to secure a better mask seal to prevent leaking and I certainly think comfort is the other big component to mitigating arousals. I find when I force myself to sleep in any weird position, I get back pain or something else that causes me to wake up or toss and turn. Like you said, an AHI of 0 isn't the best if we simply aren't sleeping due to any comfort issues. If for some reason I can't seem to get the leak rate under control again with this mask, I may try a trial in 3 months of the Airfit F20 silicone FFM which I hear through reviews is recommended for people struggling with mouth leaks. But for now, I will focus on sleep etiquette and comfort as you said and try to go by how I feel. If I notice an increase in aerophagia symptoms, I may try A-Flex 1 again, but for now I will keep this setting off.

Thanks again Pugsy, and hopefully I can report back soon with good news.

[jwalsh126]

I forgot to include this screenshot, but it was about 3 weeks ago when I had minimum pressure of 7 and A-flex 1. I distinctly recorded that I felt really good compared to any other night recently when I woke up. The starkest difference to me is that there was no leaking that night as opposed to these recent nights. I'm not sure if this adds anything, but I figured it might be evidence that the leaking is causing arousals and that itself is irritating my sleep, separate from events that are still occurring.

[Pugsy]

When we have arousals or full awakenings we simply don't have a chance to cycle through the normal sleep cycles and get the needed percentage in each sleep stage so we don't have a chance for the restorative powers of sleep to work their magic.
Doesn't matter what causes the arousals either....and we don't always remember arousals either but if you remember a sizable number then I would bet my last dollar that you had more than you remember.

Here's a good article that explains the need for each sleep stage...and while it talks about alcohol and its affect on sleep you can substitute anything for alcohol and it still means the same.

https://www.sleepfoundation.org/nutriti ... -and-sleep

Doesn't matter if it is alcohol, medication side effects, pain, dog, leaks or whatever....the end result is the same.

[jwalsh126]

Hi all:

Upon taking a closer look at my nightly data and each breathe, it looks like i'm having so many of these "arousals" prior to an OA or CA being flagged. I'm confident that these arousals are happening frequently and that my sleep is being horribly disrupted. I wake up with headaches, etc even though my AHI "looks decent." I'm starting to think my body might actually be reacting to pressure changes that are happening where I don't see a viable explanation why they should be. For example, i'm at 7.50 IPAP and breathing looks consistent and flat, but then the machine ramps up to 8.50 and back down to 7.50 quickly, then I see staggered breathing indicating an arousal, followed by a marked Hypopnea, OA, or even CA. I'm not sure if I am even having full blown OAs at this point which makes me wonder what other variables are at play.

I do think I need a minimum IPAP somewhere in the 6-8 range, but I was even having aerophagia symptoms as low as 6.0 IPAP without flex settings. Turning A-flex to 1 for comfort worked for purposes of aerophagia, but then i'm in this feedback loop where the pressure doesn't feel high enough and I think I may be allowing for more potential hypopneas. It also adds another variable to my breathing which I don't necessarily have a problem with, but my body may be reacting to with arousals. I'm even seeing subsets of the night at a little higher pressure (9.0) where I get that CSR-look of "waxing and waning" indicating that the pressure may be too high for me. This is only for select 20-30ish minute increments of the night though.

I'm wondering if you all think it would be a good experiment to try to narrow the maximum a lot more and keep myself within a fixed pressure range that is even tighter, or even try fixed CPAP just to see what the result is. I did find that I had trouble sleeping on my back so much last night (this is rare, my body usually prefers supine) that I woke up on my right side in the middle of an intense dream. shifting positions makes me weary of a fixed pressure due to the potential for increased pressure need on back.

I think I may be a case of a more "complex apnea" and simultaneously my body may be reacting negatively to certain aspects of the CPAP therapy. I am at the 2 steps back stage and would love to get your help if possible specifically if you could help analyze my data more to confirm/deny my intuitions. I think i'm closer to figuring out what is happening, but it is frustrating. I am also planning on running a side-sleeping experiment in a few weeks because I am young and want to see if I could possibly train my body to sleep on side (not banking on it as Pugsy discussed). Also, if my pressure needs are too high to tolerate supine, then side sleeping could be the proposed solution if viable. If not, I guess we will have to go from there.

[Pugsy]

You don't have complex sleep apnea...not enough real asleep centrals to make that diagnosis which requires at least 5 centrals per hour average and you must be asleep first. It is entirely normal to have a few central apneas here and there throughout the night and they are real asleep centrals...it's normal and no big deal. You would need a lot more centrals than you are seeing to earn that diagnosis

Those spiky saw tooth pressure increases of about 1 cm...they aren't nearly as fast as you might think they are. Those are test pressure probes where the machine is just sort of testing the waters kind of thing.
This is explained in the provider manual...did you ever get it and read it?

Or my explanation here....it's old but basics are the same.
viewtopic/t80875/Respironics-APAP-press ... se-up.html

If you need more pressure to reduce the OAs and hyponeas but more pressure causes aerophagia issues then you play with Flex to see how much it can help you out or not. Sometimes we just have to compromise and let a few events slide by the defenses so that we aren't miserable with belly pain.

I would bet my last dollar that the pressure changes during the spiky sawtooth probes aren't the cause of the arousals but instead airway issues from the airway trying to collapse are causing the arousals....but if you want to eliminate the pressure probes...set minimum to equal maximum and Flex that feels the best to you and see what happens.

[jwalsh126]

Thank you Pugsy. I actually didn't know that but I just read through your post and this is very informative. I reviewed my data for the last few nights and I think I am right where you insinuated in your last paragraph - I still see 2-3 OAs and mostly Hypopneas each night. Because the PR machine seems biased towards staying at the min pressure (always seems to drop back down quickly), it certainly looks like I need more min pressure. I'm currently using A-flex 1 but if aerophagia remains an issue when I increase to min of 7/7.5/maybe 8, then would you recommend C-Flex? I did a lot of research about both so I am familiar with what A-flex does regarding inhale and exhale, and that C-flex only reduces EPAP (but I have never tried C-Flex, nor a high setting).

Other thoughts - I find that if I stay on my back most of the night, the humidifier tank is always empty in the morning. I'm fairly certain this is from my mouth dropping upon relaxation during deeper sleep which causes some air to escape (even if not classified as "large leak"), thus causing the humidifier to burn faster. I say this because when I notice that i'm on my side for some periods of time, I usually wake up in the morning with a little water left.

I think you are right about the arousals Pugsy (I think this pressure has reduced most OAs that I was having without the machine, but now i'm getting many partial collapses of the airway, resulting in many flagged Hypopneas). The suggested solution is just increased pressure for this. I will have to face the aerophagia monster with trying out different flex settings. I think soon I will also run a side-sleeping experiment with a body pillow to cuddle to see if I can replicate what I am talking about (no leak) and to see if I have a measurable reduction in AHI and good sleep quality.

[Pugsy]

You will just have to try each Flex mode at different settings to figure out what works best for you and feels the best.
I found CFlex was useless to me but that doesn't mean much....everything comes with that YMMV sticker.
AFlex is the newer of the two Flex modes though and supposed to be more "natural".

You may have to compromise a bit and let a few apnea events of whatever kind slide if killing them with more pressure causes sleep problems or daytime unwanted symptoms due to aerophagia. You won't be the first to have to do this. Maybe in 6 months or so revisit a little more pressure and see if you still have the visits from the aerophagia monster.

[jwalsh126]

Thanks Pugsy! That will be the plan for the next few weeks/months until I make up my mind. I will gradually increase min pressure 0.5cm at a time until I start feeling aerophagia problems again. At that point, I will try A-flex 2 and 3 respectively to see if it curbs the aerophagia problems at those higher pressures. I will likely stop at 8.0cm minimum and if the aerophagia is a problem, I will have to do as you say and let some events pass while I wait to revisit a higher pressure, or perhaps find success with side-sleeping.

I will update this thread if there is any good/bad news either way so there is a history of the changes we made. Thank you again.

[jwalsh126]

MASSIVE UPDATE: I am switching to side sleeping! Or anything to avoid supine sleep. These are the results of my home sleep test using PR AliceOne kit. My apnea is more than 2x as bad while supine than in any other position... clearly supine position (for whatever anatomical reason - still don't know what my case is) is causing SO MANY of these events. I didn't even know I slept prone! I can't believe I didn't start from this data in terms of choosing therapy. The doctor shipped an APAP to my house since COVID started and it obviously helped drastically reduce my supine events, but I am still struggling with optimizing it. It seems so obvious to just sleep in any position other than supine and to track if there is a measurable decrease in AHI (i'm willing to bet there will be).

The other aspect of this is comfort. I will change my sleep setup to try to optimize my comfort because, as Pugsy says astutely, comfort allows you to actually sleep. We need to actually sleep to even have "disordered sleep breathing." Presumably I will also need significantly less pressure in any position besides supine, so i'm confident this may help reduce leaking and overall comfort.

Plan of action: Keep settings same for a while, and only change sleep position and setup to avoid supine to best of my ability (still allow APAP to ramp up pressure in case I flip over).

Settings:
-Min: 7.0
-Max: 13.0
-A-flex: 1
-Heated tube: 3
- Humidification: Adaptive (set to 3)

I will collect data over the next few weeks and get back to you with results. I am very optimistic about my prospects here and the chance to get consistently better sleep.