Could use some guidance regarding results

[Zenthar]

Hi everyone,

I've had a CPAP for probably close to 6 years now (might be due to change machine soon actually) with somehow "mild" success and I wouldn't even know where to start looking for things to talk to my doctor about.

First off, my AHI usually oscillates between 5 and 12, with no clear pattern I could find in the spikes; one thing I did notice however is that when I turn CFLEX off, it usually reduces my AHI by a good 3-6 points, unfortunately if I do this at my current pressure, I get horrible aerophagia to the point it wakes me up with stomach cramps and I'm even able to burp while using the CPAP, but I did try it for almost 5 months before re-enabling CFLEX; during that time my AHI would barely ever go past 5 and I'd get to 2-3 often. Another thing I noticed is that while CFLEX is disabled, my CA index accounted for only 0-15% of my AHI while it's more like 20-50% with it enabled.

Asking many of those questions now because I'd be due to change PAP machine soon and wondering if a BiPAP or an APAP could solve some of my problems and/or if I might have some abnormal breathing issue (I feel I have very shallow breath even when awake). I also have a slightly deviated septum which could be causing swollen turbinates and chronic congestion issue (which is why I use a full face mask, mostly a mouth breather); anyone ever had apnea improvements from septum/turbinate surgery?

I'd be very interested in having people help me interpret all the numbers from OSCAR, thank you in advance and let me know if there are any additional data you'd like me to provide.

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[Julie]

Hi - any reason you're on plain cpap vs auto? If you had a range, you'd have more options to try to deal with the apneas that are too high and more options for the aerophagia which could be addressed then.

Turbinate surgery does work for many people but won't fix your apnea by itself.

The newest machines are ResMed Airsense 10 Autoset (and a 'For Her' model which is actually not 'for Her' alone - silly name) and Phillips Dreamstations, but the former are much more popular. Don't worry about your CAs right now they may not be much of a factor if you have a newer machine.

[Zenthar]

Hi, on a plain cpap just because that is what my Dr prescribed after the brief at-home test and titrations; moreover insurance won't cover BiPAP or APAP unless justified by a doctor. Perhaps just letting him know about aerophagia would be enough, I'll have to call him this week.

Regarding the surgery, I really wasn't expecting it would cure me especially since my case was very severe to start with (46 AHI I believe), mostly looking for something that works improve the overall efficiency of the apnea treatment and this my quality of life.

[Pugsy]

Bilevel machine might open up some options so you could use more pressure and not have the aerophagia issues.
It does appear that you need more pressure...that's why the AHI reduces when you use CFlex exhale relief....with CFlex reduced your overall pressure is a bit higher so it does a better job preventing the airway collapse.

At your needed pressures....I would be pushing for bilevel...it will allow for higher pressures and more exhale relief to help battle the aerophagia issues.

[Miss Emerita]

Pugsy, I wonder about this: “Another thing I noticed is that while CFLEX is disabled, my CA index accounted for only 0-15% of my AHI while it's more like 20-50% with it enabled.” Could this suggest bilevel would jack the CAs up? Or maybe that’s a reasonable trade off?

Zenthar, there’s a lot of clustering in you OAs and snores. Did you go to sleep on your back last night?

[Pugsy]

Pugsy, I wonder about this: “Another thing I noticed is that while CFLEX is disabled, my CA index accounted for only 0-15% of my AHI while it's more like 20-50% with it enabled.” Could this suggest bilevel would jack the CAs up? Or maybe that’s a reasonable trade off?

Yep...this might be one of those times that we have to make one of those compromises that I talk about.
Have to weigh centrals vs belly pain and feeling miserable or even being ill the next day.

In the report above though...centrals aren't as numerous as the obstructives are and Flex at 3 is being used which means 2 cm drop at most (which you can clearly see on the pressure graph). We don't know that having more PS would make a horrible difference in centrals at this point but we do know this number of obstructives is far from optimal and at this point the OAs/hyponeas could be causing arousal false positive centrals. Meaning the slight increase with Flex off better deals with the obstructives and the obstructives might be causing false positive centrals. See where I am going here...maybe the less centrals with Flex off has nothing to do with the bilevel thing and more to do with better therapy leading to less arousals and less chance of false positives.

I firmly believe in at least trying to fix what we can with our machines and in this situation about all we have any chance of fixing is going to be the obstructive stuff. Reduce those and then see if centrals are a problem or not. Fix the known problem first and then worry about later if/when we cross that bridge.

Unless bilevel (if that should even be a central trigger) causes a truckload of centrals....I think better dealing with aerophagia with more bilevel is at least worth trying. We know bilevel will help aerophagia but at this point we don't know for sure if bilevel would cause more centrals.

IMHO anyone who needs at least 15 cm for OSA....needs bilevel for sure if they have any hint of aerophagia issues.
Besides...you never know where the line might be for PS if it did cause centrals. I have a friend who gets about 15 per hour average with a PS of 4 but with a PS of 3 the centrals are rare. Go figure that one but I thought for sure she was going to need ASV but all we did was drop PS to 3 and they all but went totally away. Her starting pressures needed for her OSA...around 17 and having some sort of exhale relief at that pressure is absolutely critical to her sleep.

So in this situation....fix the known fixable problem first and then see if other problems remain.
It wouldn't be impossible for the OAs to be causing arousals and false positive central flagging and if we better reduced the OA stuff the centrals might also reduce....and if it didn't then we talk about how bad the centrals might be to let a few slide or do they warrant another type of therapy.

The OP here...using the DreamStation Pro which does have a trial of auto mode available. That's where I would go here and see just how high the machine needs to go to deal with the obstructive stuff and what happens to the belly issues.
I don't know if the OP is comfortable going that way though.

[Zenthar]

Zenthar, there’s a lot of clustering in you OAs and snores. Did you go to sleep on your back last night?

I probably did yes, and I know I move during my sleep as I sometimes wakeup on one side, sometimes on the other and sometimes on my back. I think the aerophagia might have made it worst as I think I get more bloated on the side than on the back, but get more apnea on my back (and sometime lower back pain or my legs just feel weird on my back, I think my quads might be too stiff/tight).

[Zenthar]

The OP here...using the DreamStation Pro which does have a trial of auto mode available. That's where I would go here and see just how high the machine needs to go to deal with the obstructive stuff and what happens to the belly issues.
I don't know if the OP is comfortable going that way though.

I was able to get an appointment with my doctor next Tuesday, I'll talk to him about that and see if we can use that as a test for my aerophagia and see if pressure really is set properly. I played with some of the setting a bit, only going in the clinical menu to disable CFLEX (since impossible from normal menu), never changing the PS.

Here is the high level stats if anyone interested in seeing how I played with the settings (I blanked some of the sensitive info ):

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[Pugsy]

Your machine doesn't have an official PS setting (only available on bilevel machines) but PS (pressure support) is really nothing more than the difference between inhale and exhale so when you use the Flex exhale relief you are essentially creating a bilevel pressure situation since the pressure drops a little on exhale. With a bilevel machine you have greater choices in the amount of PS you can use and more PS usually means people can get by with higher pressures needed to deal with the obstructive stuff and not have the aerophagia be such a problem.

With Flex...the most PS you can get is 2 cm and that's only if you breathe rather forcefully which you apparently do judging by your pressure graph lines.

In general we look at IPAP (inhale pressure) to help better prevent OAs...and using more PS lets people use a little higher IPAP and the drop with more PS keeps the aerophagia monster away. You need more IPAP (at times) than the 15 cm you are getting now.
If you increase the IPAP you most likely will open the door more for the aerophagia monster......at least with the current machine and the limitations that Flex exhale relief give us to deal with which is 2 cm PS.
If you could maybe use 17 IPAP and have PS of 4....I think your OAs would reduce and hopefully still keep the aerophagia monster away because of the drop to 13 during exhale.

I don't know for sure about bilevel....but I think the option should at least be available for you to try in an effort to better optimize the OSA therapy and try to keep the aerophagia monster away at the same time.
Bilevel machines are simply more versatile.

[Miss Emerita]

Many thanks, Pugsy, for sharing your reasoning!

Zenthar, it sounds as though lying on your back leads to OAs and snores. You don't want to make yourself miserable trying to stay on your sides, but it's worth asking yourself how difficult that would be. Some people do manage it without too much trouble. You might also want to keep some notes about when the aerophagia is worst/best vis-a-vis back/sides. Oh, and if you use a fat pillow, or several pillows, try using a single fairly flat and firm pillow instead.

More about the ResMed VAuto: I love mine! And with PS of 4.8, CAs and aerophagia are OK; with PS of 5, all hell breaks loose.

[Zenthar]

Zenthar, it sounds as though lying on your back leads to OAs and snores. You don't want to make yourself miserable trying to stay on your sides, but it's worth asking yourself how difficult that would be. Some people do manage it without too much trouble. You might also want to keep some notes about when the aerophagia is worst/best vis-a-vis back/sides. Oh, and if you use a fat pillow, or several pillows, try using a single fairly flat and firm pillow instead.

Ultimately I really don't mind how as sleep as long as I can make myself comfortable (even if I need new/additional pillow to do so), I used to sleep with a latex pillow, but after a while noticed I wasn't that comfortable and switched to a cervical contour memory foam pillow (just a basic one) which aren't that high (maybe 2 inches at the lowest, 3.5 inches highest point) so it does keep my head rather horizontal. Whether or not I'm able to stay in that position during the whole night could be another story as I have no recollection of my nights, I just fall asleep (usually within minutes) and just wake-up 6.5 to 7h later. Any tricks to maintain that position (beside the old tennis ball trick my father used to do) that wouldn't cause worst worst arousals? I even considered purchasing a wedge pillow, but I hadn't had time to look for any sort of review/accounts related to apnea; I do feel as if my guts are pushing a bit on my diaphragm and make breathing harder (BMI of 30.5 which probably doesn't help, but it's getting lower slowly, was 32 1y ago) and it's made even worst if my stomach gets bloated from aerophagia.

I'll talk to my Dr about all this and discuss APAP and BiPAP, here in Quebec we don't just get to choose unfortunately unless we are willing to pay 100% out of pocket.

[Pugsy]

Here's a thought to consider just in case you can't get your doctor on board for bilevel....
You are in Ontario...and I know with the OHIP program getting apap or bilevel just about takes an act of God...they won't pay for anything but cpap...unless God gets involved.

BUT a little known error in the official list of approved machines has the ResMed AirSense 10 AutoSet for Her APAP machine on the CPAP list...so if you request that model...you get OHIP to pay their share and the supplier will do it. Doesn't take an official RX for APAP which is hard to get.

Now the AutoSet for Her does have EPR at full 3 cm reduction available...it isn't as much as Bilevel models that will go above PS of 3...but it is better than the 2 cm PS you are getting now.
Plus the ResMed auto adjusting algorithm responds more quickly both in going up and down meaning you might not end up spending as much time at the higher pressures which could potentially reduce the aerophagia issues.
Meaning maybe you only need higher than 15 pressures when on your back...and the rest of the night maybe you might only need 10 cm...auto adjusting would mean potentially less time at the higher pressures.

So....something to think about. Maybe going for a new ResMed AirSense 10 AutoSet for HER (the for Her part is critical though) and you have what we call a poor man's bilevel. It's limited but better than what you have right now.

Here's the combo manual if you want to look at it.
https://www.respshop.com/manuals/ResMed ... %20her.pdf
It has 3 modes of operation
fixed cpap mode
regular auto adjusting (apap) mode
and a special auto adjusting mode marketed towards women...but I doubt it would be of any great benefit to you if you need pressures in the mid teens. It seems to work best up to around 12 or 13 cm pressure needs. This mode is target marketing for women but in reality there is no reason in the world that men wouldn't benefit from that mode as well if the conditions are just right.

Between the more responsive auto adjusting algorithm...the chance that you might actually end up with less time at higher pressures and the greater PS...it might just work for you. Sure worth considering if you can't get anyone to help you get a full grown bilevel auto machine.

[zonker]

Here's a thought to consider just in case you can't get your doctor on board for bilevel....
You are in Ontario...and I know with the OHIP program getting apap or bilevel just about takes an act of God...they won't pay for anything but cpap...unless God gets involved.

oh, good call, pugsy!

i had forgotten all about that glitch in the ohip program....

[Zenthar]

Thank for the tip, but I'm actually in Quebec, here it's not covered by the public system ever, not even a basic CPAP (kind or ridiculous if you ask me) but I have very decent insurance through work so I believe if I can get my Dr to just write the right explanation as to why it's need a BiPAP or an APAP over a CPAP they'll just cover it.