12 months use - no idea WTH I'm doing - need help - CSR/CA

[AHMF]

Hi all,

I've been using my Resmed Airsense 10 Elite with a full face mask and no water tank since diagnosis after home sleep study of OSA. I've tried different masks, but I've found them problematic due to nasal congestion, and I feel like it's really the only effective one (though you may be able to point me in a different direction), although I have a nightmare with swallowing air which I'd really appreciate advice on.

I've just found out about Oscar, and this forum and Youtube channel. Evidentially, I have no clue what I'm doing with my CPAP and have had zero follow up from health services since starting.

I've been acutely unwell since a run of virus and bacterial infections on Feb-April '23, but looking back at my CPAP data (which seems to indicate it's poorly managed) I'm wondering how much of the chronic fatigue and other debilitating symptoms that I won't bore you with could be related.

Oscar has caught lots of CA events, and some CSR. Naturally I'm worried about it, and want to make sure I'm doing everything I can to fully optimise my therapy.

I should add that I nap during the day with my CPAP, in the lead up to my nap I meditate (with CPAP on) and invariably end up falling asleep supine. My data seems much worse when I'm in this position. At night I'm generally on my side.

I'll post my stats from Oscar, and an example of CSR and CA. But perhaps you guys would be better at asking me for what might be useful for you to see and perhaps be able to give me some advice about.

Thanks so much. Any help greatly appreciated.

[vandownbytheriver]

Thanks so much. Any help greatly appreciated.

From what I can see you have a leaking problem. You complain of sinus but are not using humidifier.

Your second night shows Cheyne-Stokes of 5%. Even under therapy your AHI is over 5 after years of treatment.

Some experimentation is warranted! I believe you're in the right place.

'Nightmare of aerophagia'? Do you get it, or are you just worried about it? Your pressure is/are low-medium range, you're on EPR2, the Elite is a non-APAP machine... seems criminal that you were given an Elite after a home sleep study with no titration. Those leaks need to be tamed, perhaps tighten your mask some... most full-face masks want to be tighter at the bottom and looser at the top... the cushion should be able to 'balloon' to create the seal. We don't know what mask, exactly... perhaps fill out your profile with machine and mask so they're at the bottom of every post, like I do.

I'm going to recommend you start using humidification and see if that helps your sinus... many of us here do something to try and tame those passages e.g. neti pot, nasal spray etc. I couldn't sleep with blocked sinus I can tell you that.

You probably need more pressure but you're complaining (we're not sure) of aerophagia. The V-COM device is supposed to help with it... it's pretty cheap to try anyway, about 30USD.

The gold standard would be a sleep lab titration, where you wear the mask and a technician monitors your vital signs and adjusts the therapy to find the best fit. You may also find that you're on the wrong machine... I paid 2500USD for the privilege of a lab titration and was found to need a bi-level at higher pressures... my sleep has improved dramatically. I'm not sure where you are but here in USA we have to use insurance... the 2500USD out of pocket meant my deductible was satisfied for the year, so they bought me the Aircurve (mostly) and are buying my supplies (until the end of the year, mostly). Normally folks with home sleep studies are given an APAP machine like the Autoset, this at least allows you to find your own good pressure fairly quickly.

In the meantime I'd suggest you raise your pressure and try to adjust. You have 1cm of EPR left to use... try going up 2cm and turn EPR to 3, that would give 1cm of effective therapy increase. Your CA's are not alarming... that cyclic episode you zoomed in on the second night is obstructive, more pressure is required.

In addition, while Oscar is great for home use, SleepHQ is better for sharing info here... with one link we can see your entire night in hi-res. It's a free website a lot like Oscar, you start a free account then upload your SD card data. For a year's worth it will take some time to upload but after the first one the next ones go quick... here's last night of mine, for example:

https://sleephq.com/public/ea278381-e06 ... 0a6e0d891c

Note how you can zoom in with the mouse just like Oscar. Use the 'r' key to reset the graphs.

Anyway, welcome to the Forum. Plenty of help available here. Please let us know how it goes.

[Pugsy]

In lab titration studies aren't the end all and be all solutions to finding optimal pressures. They can be wrong and often are....it's one night in a foreign environment.

That's an ideal world scenario. I had an in lab titration study (separate night after in lab diagnostic study) and they sure as hell didn't find the "perfect" pressures for me.
Too many potential problems with in lab sleep study and the big one is that often there is considerable trouble actually sleeping (both falling asleep and staying asleep) in the foreign environment.

Besides....some sleep lab techs are just friggin idiots. I know I had one. He also lied to me (bold face lied) about some stuff that I knew he was being an idiot on. Wasn't a big surprise that he got the pressure wrong.

[Pugsy]

To the OP.....you got some serious work to do on those leaks.
Until the leaks are better manage the results you are getting don't mean much because the leaks are so bad that the machine ability to record or sense anything is greatly in question.

[AHMF]

Please see my replies below in bold, hopefully this makes it a quick read

From what I can see you have a leaking problem. I think I may be on the way to solving that, I have a Resmed F20 with the foam cushion now. The night I supplied was also not a typical example of leak status, but it had the CSR example in. You complain of sinus but are not using humidifier. - I wasn't aware a humidifier would help with the sinus issue, which is a believe allergy related. I thought the humidifiers were more for dry mouth. So, on the shopping list for sure.

Your second night shows Cheyne-Stokes of 5%. Is this 100% CSR? It doesn't look like the typical patterns of more gentle waxing and waining I've seen examples, and of course can the machine accurately diagnose this when the leak is so bad? Few people on Reddit before I found this forum where quite adamant it wasn't CSR due to the pattern not being typical Even under therapy your AHI is over 5 after years of treatment. Yep, I haven't really taken it seriously, more fool me.

Some experimentation is warranted! I believe you're in the right place. I have experimented a little the last couple of nights after some advice, I'll post, but it looks like improvement.

'Nightmare of aerophagia'? Do you get it, or are you just worried about it? Your pressure is/are low-medium range, you're on EPR2, the Elite is a non-APAP machine... seems criminal that you were given an Elite after a home sleep study with no titration. Those leaks need to be tamed, perhaps tighten your mask some... most full-face masks want to be tighter at the bottom and looser at the top... the cushion should be able to 'balloon' to create the seal. We don't know what mask, exactly... perhaps fill out your profile with machine and mask so they're at the bottom of every post, like I do. Absolutely getting aerophagia, get it pretty bad every night. Belching, passing wind which follows all the next morning. I also have gastritis which makes it very painful

I'm going to recommend you start using humidification and see if that helps your sinus... many of us here do something to try and tame those passages e.g. neti pot, nasal spray etc. I couldn't sleep with blocked sinus I can tell you that.

You probably need more pressure but you're complaining (we're not sure) of aerophagia. The V-COM device is supposed to help with it... it's pretty cheap to try anyway, about 30USD. Looking into this and it's suitability

The gold standard would be a sleep lab titration, where you wear the mask and a technician monitors your vital signs and adjusts the therapy to find the best fit. You may also find that you're on the wrong machine... I paid 2500USD for the privilege of a lab titration and was found to need a bi-level at higher pressures... my sleep has improved dramatically. I'm not sure where you are but here in USA we have to use insurance... the 2500USD out of pocket meant my deductible was satisfied for the year, so they bought me the Aircurve (mostly) and are buying my supplies (until the end of the year, mostly). Normally folks with home sleep studies are given an APAP machine like the Autoset, this at least allows you to find your own good pressure fairly quickly. I'm prepared to do and spend whatever is needed, but like you say some experimentation is probably warranted first, I'm considering a consult with AXG Sleep Diagnostics

In the meantime I'd suggest you raise your pressure and try to adjust. You have 1cm of EPR left to use... try going up 2cm and turn EPR to 3, that would give 1cm of effective therapy increase. Your CA's are not alarming... that cyclic episode you zoomed in on the second night is obstructive, more pressure is required. Given the new night I've uploaded what do you think?

In addition, while Oscar is great for home use, SleepHQ is better for sharing info here... with one link we can see your entire night in hi-res. It's a free website a lot like Oscar, you start a free account then upload your SD card data. For a year's worth it will take some time to upload but after the first one the next ones go quick... here's last night of mine, for example: Will get SleepHQ now an upload tonight's results tomorrow using that.

You can see the daytime naps after meditation and falling asleep on my back are a problem. The second night I'd upped the pressure to 12 and EPR at 3, maybe that's too much given how my previous night at 11 looked??? The zoomed in one is of the night with pressure at 12

[Pugsy]

Is this 100% CSR?

No....I don't believe it is but with the large leak also occurring at the same time it's hard to say with 100% certainty.

You haven't zoomed in enough on the CSR flagged events...and with the large leak present it is flagging UAs or unclassified apneas because with that amount of leak the machine simply doesn't know what to call the flagged events....and real CSR needs both for sure asleep central apneas meeting a certain pattern (I don't think yours does) before we call it Cheyne Stokes Respiration.
It could simply be Periodic Breathing which is a waxing and waning breathing pattern. CSR is one form of PB but it isn't the only form. '

This person has real for sure CSR


This person doesn't have CSR...it's just periodic breathing (barely)


and ResMed's own example

[AHMF]

Thanks Pugsy

So, a better night last night with these settings (apart from having to get up a couple times with the kids), but I had terrible aerophagia again.

I use a Resmed F20 full face mask with a foam cushion now, I've tried pillows and no joy with that, my sinus congestion is just a too bad. I've had issues with my sinus' since breaking my nose as a young athlete, so I think firstly there is a physical issue with my sinus breathing, but also I suffer from just stuffy sinus related issues. I wear a nasal strip at night which does help and I'm thinking of trying one of the magnetised ones, have you seen them? Looks like they would help even more. I also use a sinus spray before bed, which helps as well.

I've looked into the V-COM device which looks like it could really help, but there does seem to be some controversy around it's approval by manufacturers and if the CPAP machines can still properly read what's going with the V-Com device being used. What's the latest on that view point, has there been any official testing to approval by manufacturers of the CPAP machines or however would be relevant?

I've included below the charts from last night. For the last period after the long break, I turned the EPR off (it was on 3) to see how it would work after watching a couple of Lanky Lefty videos. Looks to my untrained eye that it was better with it on. I also made as much effort as one can to sleep on my side only last night, my left side in particular, I definitely have a big problem in the supine position - does that tell me anything in particular I need to know about?

I've zoomed in on a couple of CA's, would I be right in thinking the first one is likely related to the quick leak or a yawn or a combination of both? Sometimes actually if I have an itch I scratch under the mask, could it be that?

After last night I felt so much better this morning, even with having to get up in the night. Wow!

I'd be really grateful for any further advice on how to optimise my therapy. I'm also open to new equipment suggestions etc, I'm quite prepared to spend whatever it takes to get the best therapy. If there are any further or more useful images you'd like to see just let me know and I'll upload them. Thanks so much.

Oh, maybe just to let you know I'm a 44 year old male, 5ft 11" and weight is 79kg so not overweight.

[vandownbytheriver]

I've included below the charts from last night. For the last period after the long break, I turned the EPR off (it was on 3) to see how it would work after watching a couple of Lanky Lefty videos. Looks to my untrained eye that it was better with it on. I also made as much effort as one can to sleep on my side only last night, my left side in particular, I definitely have a big problem in the supine position - does that tell me anything in particular I need to know about?

Your OSA is positional. When you turned off EPR you went down in pressure... the FL's went up. The higher pressure with EPR on seemed better... whatever you have to do to tolerate the higher pressure. V-COM looks like it would help you, it's Lanky Recommended(tm)!

I've zoomed in on a couple of CA's, would I be right in thinking the first one is likely related to the quick leak or a yawn or a combination of both? Sometimes actually if I have an itch I scratch under the mask, could it be that?

Your leaks are stellar. By all means scratch your nose. Your events are a distinct improvement. Any event when awake or aroused is not sleep apnea.

After last night I felt so much better this morning, even with having to get up in the night. Wow!

Yep, you're doing the right things. Now get a V-COM.

[Pugsy]

Please hide the calendar. It is causing some useful information on the left side to be hidden.
We don't need the calendar....the report has the date on it.

EPR is your best friend in the whole world when it comes to fighting aerophagia. I strongly urge you to use it.
Jason (LankyLefty) doesn't like it but it has its place in the cpap world for several good reasons. This is one of the reasons I don't always agree with Jason.

Your zoomed in on central apnea flag at 04:05 shows a very definite arousal immediately preceding the flagged event.
You weren't asleep...so all that central means is you weren't totally awake. As to why??? If that is when you scratched an itch then you for sure were awake because you know you scratched an itch.
Otherwise we don't really know why the arousal happened.

Remember these machines only measure air flow or breathing....they have no way in the world to measure sleep status so they just call those awake breathing irregularities as some sort of event (sometimes). I think of those flagged events as false positives. The pause in breathing happened but it wasn't from airway issues....it was from sleep issues. To reduce arousal related flagging one has to try to reduce those awake/arousal times and believe me...I know just how much that is easier said than done. We don't always know just why we have an arousal and it's kinda hard to fix a problem when we don't know what caused the problem.

I also use a sinus spray before bed, which helps as well.

Exactly which "sinus spray" are you using and how long and do you ever use it during the day or is it only at night time?

I wear a nasal strip at night which does help and I'm thinking of trying one of the magnetised ones, have you seen them?

No, I have not seen them but that doesn't mean much. I have no need for nasal strips because I don't really have a congestion problem so I haven't bothered researching (or trying) any of those nasal strips that are supposed to pull open the nasal cavity and allow breathing more freely.

Now I will tell you that I use a really high humidity setting. When I tried a lower setting I did experience considerable nasal congestion and some really ugly allergy like symptoms and I never have allergy symptoms. For some people more humidity actually helps nasal congestion. Some people find that higher humidity causes congestion. This is an area where the humidity needs are highly individualized. You will just have to experiment to see what it is your nasal mucosa needs.
Google "cpap rhinitis"....

I have no opinion about the V-Com device......yet. I may develop an opinion at a later date.

I definitely have a big problem in the supine position - does that tell me anything in particular I need to know about?

All it tells us is that your OSA is likely worse when supine and that's actually quite normal. Supine and REM are prime causes of OSA worsening and/or needing more pressure.
Anything you can do to lower your pressure needs is going to also help keep the aerophagia monster away....so good to know and do.

At this point I don't know if you would do better with a different machine or not. Certainly don't need a machine to deal with centrals....I suspect the bulk of your central flags are related to arousal/awake breathing.
Your pressure needs don't support needing the higher pressures that a bilevel machine can do that would cause a need except that with bilevel you can use more than 3 EPR (that difference between inhale and exhale can be a major factor in battling aerophagia) so even if you don't need the higher pressures bilevel can do for apnea prevention....you might benefit from more pressure support from the aerophagia battling aspect. I know one forum member who had to go to bilevel because of really bad aerophagia and she only needs pressures in the 8 cm ish range.

So....at this point I don't even think that the AutoSet machine (auto adjusting pressures which your Elite can't do) is something that is critical to your success. Yeah, it has some definite advantages but it's not the end of the world if you don't have it. I personally use a bilevel machine (in auto adjusting mode) simply because I happen to like (more comfortable) with the PS of 4 (think EPR at 4 if EPR could go to 4). It's NOT a "fix all your problems" machine though. Bilevel has both advantages and disadvantages.

After last night I felt so much better this morning, even with having to get up in the night. Wow!

Last night's report is actually quite decent...at least on paper. I would be happy with it.

[Pugsy]

I don't normally tell people to avoid supine sleeping unless there is a special need.
I say this because it isn't always so easy to stay off one's back so when people are using an auto adjusting machine, and higher pressures aren't causing problems, so I just let the machine sort it out.

BUT in your situation with the aerophagia monster looming in the background and with having a machine that won't auto adjust .... we don't know for sure that more pressure when supine is going to cause more aerophagia.....it might though so for that reason we are wanting to avoid higher pressures if we can.

Some people will have their OSA worsened significantly when supine....others not so much.
My own OSA isn't positional at all but it definitely worsens significantly when in REM stage sleep. This is very common.
We have zero control over REM so I definitely just have to say "let the machine sort it out" and fortunately the machine sorting it out doesn't cause me any problems. I have had really bad aerophagia maybe twice in over 15 years on cpap so I do at least know what it feels like. It's miserable. It actually made me ill for an entire day.

[AHMF]

Brilliant, thanks guys for the feedback. So helpful!

Just a quick one, had a quick play around with different masks and ended up using the Resmed Nasal Pillows for a quick nap. The graph is attached. I also mouth taped, which I'd never tried before with the pillows.

Ignore the first couple of parts where I was messing with the mask while awake. You can see when I settled down.

Although short, looking at the graph it seems like the best data I've had. Only thing is, I wore my chest ECG during it just to keep an eye (been having a lot of palps lately, cardiac side all properly checked and all good) and I had a total of nine premature atrial contractions during the sleep which is totally abnormal for me, my burden is less the 0.02%. I felt like maybe there was too much pressure. My wifes and intensive care nurse and said too much interthorasic pressure could have caused them. What do you guys think on that point, and overall, worth trialling it at night with a reduced pressure?

[vandownbytheriver]

My wifes and intensive care nurse and said too much interthorasic pressure could have caused them. What do you guys think on that point, and overall, worth trialling it at night with a reduced pressure?

11cm with EPR 3 is not a drastic increase in pressure. Try the pillows tonight with the mouth tape and EEG at the same pressures and we'll know more. Are you changing the mask setting? If you went from full-face to pillows and did not change the setting then the pressure compensation the machine applied was much less... in effect, like a V-COM. You can treat the mask setting on the machine like EPR, a 'comfort' setting... whichever one feels best use it.

We're still not seeing the full picture... as Pugs noted, the calendar does us no good. I'd actually recommend using SleepHQ for sharing data here, the graphs are fully available in hi-res instead of just a screen-shot. It's free, and anonymous when sharing links. Here's a night of mine:

https://sleephq.com/public/ea278381-e06 ... 0a6e0d891c

[AHMF]

Hi,

Thanks for the info, again, greatly appreciated.

So, last night I used the pillows and mouth taped. I don't feel confident completely occluding my mouth due to my sinus issues, so I just put a fairly thick strip from just under my nose down to a few cm below my bottom lip. I also reduced the pressure to 10.4cm (I felt the 11cm was uncomfortable and could have been responsible for my increased palpitation burden during my nap trial yesterday), but left the EPR at 3. It was also set for nasal pillows.

I struggled with waking up a lot and having a really dry mouth and needing to drink (humidifier on the way!), you'll probably be able to see that. And just after 5 am I'd had enough so swapped to the full face and took the tape off.

Aerophagia was way better, my chart looks better, I think I was obviously having some mouth leaks with the pillows due to not fully taping my mouth. Also when I used the pillows for my nap yesterday (as per previous post) and for the portion of last night pillows, my oxygen levels remained between 95-99%. Previously they were dropping as low as 89% for a few seconds occasionally, but would consistently be ranging between 90-99%, another reason why I feel like I'm maybe on the right track now.

Also, nothing out of the ordinary in the way of palpitations, so that's good news too.

Here's last night's Sleep HQ report, let me know if I haven't done anything correctly. Any comments greatly appreciated.

https://sleephq.com/public/203c39aa-ebd ... e6e2b29194

[vandownbytheriver]

Also, nothing out of the ordinary in the way of palpitations, so that's good news too.

That's good.

Here's last night's Sleep HQ report, let me know if I haven't done anything correctly. Any comments greatly appreciated.

Looks like progress... you could use more pressure, but your aerophagia limits that. You were on FF setting with pillows, so that's kind of a V-COM effect... I believe you'd get more inspiratory pressure relief with a real V-COM, especially when you went back to FF mask at 5am.

The mouth and mask leaking is hurting your therapy... need to get those tamed.

[AHMF]

I don't think I was on FF setting with the pillows, I think I changed it to FF when I swapped masks. I may be wrong though.

I just did another test on a nap with the pillows, should be on the pillows setting.

I reduced the pressure further down to 10cm to see where I'd go with that as with the higher pressures I've been waking up with a sense of respiratory congestion. It's a feeling like I have something to cough up, and it's been lasting most of the morning. Almost makes me feel a little breathless. After today's nap with the lower pressure (though obvs for a short time compared to overnight) I don't have that respiratory congestion feeling. But, oxygen on the oximeter was down to 93% briefly, and for the entire period I was actually asleep it was at 96% flat, which isn't usual.

What's the thinking on normal oxygen saturation levels for someone with OSA that's well managed via CPAP?

I also noticed that my breathing pattern when I'm actually asleep and zoomed in on doesn't look quite right, what's with that? More pressure needed?

I had zero aerophagia during this short test, which was nice. I see there are still some leaks though, are they now within an acceptable level though?

https://sleephq.com/public/d202fd62-8bd ... 767abc4ba0