Do I need BiPAP?

[jwalsh126]

Hi Everyone,

I am 28 years old, started CPAP about 4 years ago after doing an at-home sleep test which showed I have severe OSA. I never did the full in-lab study. After starting CPAP, this forum (shoutout to Pugsy) was IMMEASURABLE in helping me get acclimated to my treatment. I felt reborn after starting. I also want to shoutout LankyLefty on Youtube.

At this point, I now think I need to go back to the sleep Dr. and am considering requesting a BiPAP. I use an APAP with fixed pressure of 9.4 cm, and EPR on 2. I spent many months fine-tuning the settings to arrive at this point. If i increase to 9.6 cm water pressure, I experience general bloating and more frequently experience severe aerophagia. If I use fixed pressure without EPR, I experience severe bloating - so I need EPR. I am aware that the EPR software operates differently than a bilevel machine, which may cause other breathing issues. I religiously study my OSCAR data and am now at a loss for how I can further optimize from here.

The "problem" is that on 9.4 cm pressure, I still seem to have 1-2 OAs here and there (on a weekly basis), and likely have other lesser restrictions like hypopneas or RERAs in REM sleep. However, I also notice that i'm having what appear to be true central apneas (don't have EEG, but can see that I stop breathing w/o an arousal preceding the event, nor a "recovery'" gasping breathe after the event). I am aware that too high of a pressure, or perhaps EPR, can cause CAs. Overall my "AHI" score is always less than 3, and almost always under 2.0, so I expect a doctor would just say "you're doing great"! without actually interpreting the sleep data.

I'm attaching several screenshots from the past 1-2 weeks with examples of what I am talking about. THe attachment names will contain details on pressure settings and what I am flagging. My concern is that I am seeing both OAs (and other arousals/events indicating higher pressure may help), CAs, but i'm still getting aerophagia symptoms even at 9.4 cm, so cannot go higher on pressure. I would sincerely appreciate advice here. I am heavily considering visiting my sleep dr. who I have not seen in 3 years to discuss and possibly request Bilevel.

Let me know if you need different screenshots. Thank you so much!

[jwalsh126]

Screenshots that wouldn't let me post in original.

[Pugsy]

Lose the calendar please. It's in the way.

More pressure isn't going to help with those CAs/centrals.
I don't see enough OAs/hyponeas happening to warrant more pressure (especially since more pressure causes aerophagia) so I don't see the need for more pressure at this time.

I guess you missed this.
viewtopic/t172378/StickyIf-you-want-CPA ... Gquot.html
and the links inside it.

Please don't do snippets without giving us at least the overall report to start with.

[Dog Slobber]

Allegedly, the EPR algorithm is different than the PS algorithm.

And the PS algorithm is configurable, you *might* do better with your aerophagia.


I think you're fixating on numbers, unnecessarily.

*EDIT* - Removed comment about bilevel not helping some with Aerophagia.

[jwalsh126]

Apologies about the bad screenshots. It's been about 2 more weeks, so I wanted to post 2 more "typical" nights of data. I don't feel bad by any stretch, but I get mild aerophagia symptoms (diarrhea, bloating). I'm afraid to lower pressure because I still have infrequent OAs at this pressure, and some hypopneas (looks like during REM sleep). However, I'm seeing a number of CAs that do not just appear to be position-change related (e.g., take a deep breathe, roll over, then don't breathe despite no obstruction).

Given I don't feel particularly low energy/exhausted, do you think this is the best i'm going to be able to do as far as controlling my apneas? I try to sleep on my side but i'm a back sleeper and always revert to my back. I also mouth tape to try to help prevent leaks. Please let me know if you have any advice for optimizing my treatment. Thank you very much.

[robysue1]

First,

Your data actually looks quite good.

The goal of CPAP/APAP/bilevel is NOT to achieve a perfect 0.0 AHI every single night. It's to wake up feeling decent and to have enough energy to get through the day because the vast majority of obstructive events are prevented from happening.

And even with the centrals, your treated AHI is quite a bit lower than 5.0, the threshold below which sleep docs are going to say things are fine.

Now you write:

I am 28 years old, started CPAP about 4 years ago after doing an at-home sleep test which showed I have severe OSA. I never did the full in-lab study. After starting CPAP, this forum (shoutout to Pugsy) was IMMEASURABLE in helping me get acclimated to my treatment. I felt reborn after starting. I also want to shoutout LankyLefty on Youtube.

How are you actually feeling these days? In reading between the lines of what you've written, I would suppose that you are worried about something (other than just the residual AHI), but it is not clear what you are worried about, except maybe for the aerophagia you seem to be experiencing.

You also write:

At this point, I now think I need to go back to the sleep Dr. and am considering requesting a BiPAP.

Given what you write later on, it is not clear at all why you think requesting a bilevel machine is going to make a difference. What problems are you currently expecting that you think a bilevel might help?

And when you say BiPAP, do you mean any (generic) bi-level machine or do you mean a Philips Respirionics BiPAP Auto or a Resmed AirCurve VPAPAuto?

I use an APAP with fixed pressure of 9.4 cm, and EPR on 2. I spent many months fine-tuning the settings to arrive at this point. If i increase to 9.6 cm water pressure, I experience general bloating and more frequently experience severe aerophagia. If I use fixed pressure without EPR, I experience severe bloating - so I need EPR.

There's nothing in your data that screams you need to increase the pressure beyond 9.4cm. And there's nothing in the data that screams you need to turn EPR off.

If bloating is still a problem at 9.4cm with EPR = 2, then you ought to consider turning EPR up to 3. Alternatively, you could decrease the pressure to 9.0cm and leave EPR = 2. Just make one change at a time. More on these ideas a bit later.

I am aware that the EPR software operates differently than a bilevel machine, which may cause other breathing issues.

The most significant difference between the way a bi-level machine works and the way EPR on your current machine works is this: On a bi-level machine the pressure relief on exhalation is not restricted to less than or equal to 3 cm.

That's really the biggest difference between the EPR algorithm on a Resmed AirSense CPAP/APAP and a Resmed AirCurve VPAP. On the bilevel AirCurve VPAP, the PS setting is essentially the same as the EPR setting on the AirSense APAP, but PS can be set to 4, 5, 6, or higher. There are other settings (Ti_Min, Ti_Max, Trigger, and Cycle) that give some additional control over how the pressure adjustments are done, but for most people, the differences those settings make are so subtle that they can't really tell any difference.

So what exactly do you want the bi-level machine to fix? If you think you need more pressure relief on exhalation, the first thing to do is to try EPR = 3 on your current machine. What happens if you use EPR = 3? Does that help the bloating at all? Does it affect the number of CAs that you see in your data?

I religiously study my OSCAR data and am now at a loss for how I can further optimize from here.

The data you post makes it clear that your current settings are basically optimized in terms of the obstructive sleep apnea events.

The "problem" is that on 9.4 cm pressure, I still seem to have 1-2 OAs here and there (on a weekly basis), and likely have other lesser restrictions like hypopneas or RERAs in REM sleep.

CPAP is not going to eliminate every single OA and every single hypopnea. And if hypopneas, RERAs and flow limitations were a significant issue in REM, we'd see some clusters of hypopneas and RERAs being scored during time periods when you were likely in REM along with a lot more activity in the flow limitation graph, along with flow limitations hitting the 0.5 level.

Now you report that you have "severe bloating" if you increase the pressure at all or if you turn EPR off. So aerophagia is an issue that you are dealing with. But aerophagia doesn't show up in the Oscar data, except perhaps if the aerophagia triggers an excessive number of spontaneous arousals. Now switching from CPAP/APAP to bilevel can help some people deal with or overcome issues caused by severe aerophagia. (I am one of those people.) But the usual way bi-level helps with aerophagia is that you can use PS = 4, i.e. you can have 4 cm of pressure relief on each exhalation. And that can lead to less swallowing of air.

However, I also notice that i'm having what appear to be true central apneas (don't have EEG, but can see that I stop breathing w/o an arousal preceding the event, nor a "recovery'" gasping breathe after the event). I am aware that too high of a pressure, or perhaps EPR, can cause CAs. Overall my "AHI" score is always less than 3, and almost always under 2.0, so I expect a doctor would just say "you're doing great"! without actually interpreting the sleep data.

You are right, a sleep doc looking at this data will say, "You're doing great! in terms of the sleep apnea being treated." But it's on you to bring up the bloating issue, particularly if the aerophagia itself is causing you to not sleep as well as you feel like you should be sleeping.

You don't have enough CAs for sleep docs to start thinking about treatment emergent central sleep apnea problems or complex sleep apnea problems, even if every single one of those scored CAs is a real CA.

Now, the question again is: What do you think a bi-level machine is going to do in terms of those CAs? Or do you want to try bi-level because of the aerophagia problems?

You don't need any additional pressure to treat the obstructive stuff. So one option is to reduce your pressure setting a bit. What happens if you only use 9cm of pressure instead of 9.4cm? Does that help with the bloating issue? Does the number of OAs and hypopneas significantly increase? Do you start seeing clusters of events?

If EPR = 2 is triggering your CAs, then effectively increasing EPR to 4 or more by using a PS setting on a AirCurve VPAP that is greater than the largest EPR setting currently available just might make your CAs worse.

But increasing the pressure support (i.e. turning EPR up to 3) is a common suggestion for folks fighting aerophagia.

Now, if bloating is your biggest problem and additional pressure relief helps with the bloating issues, then you might just be able to make a case for switching to an AirCurve VPAP so you could use PS = 4 (or 5) to see if the bloating can be eliminated or minimized. But any PS greater than 4 or 5 is much more likely to cause problems with CAs than an EPR = 2 or 3 does.

I'm attaching several screenshots from the past 1-2 weeks with examples of what I am talking about. THe attachment names will contain details on pressure settings and what I am flagging. My concern is that I am seeing both OAs (and other arousals/events indicating higher pressure may help), CAs, but i'm still getting aerophagia symptoms even at 9.4 cm, so cannot go higher on pressure. I would sincerely appreciate advice here. I am heavily considering visiting my sleep dr. who I have not seen in 3 years to discuss and possibly request Bilevel.

As I've said before:

You clearly do not need any more baseline pressure: At 9.4cm, the obstructive stuff is exceptionally well controlled.

Since aerophagia is an issue and the obstructive stuff is well controlled, you can try experimenting with the following ideas:

1) Lower the pressure setting to 9.0cm and keep EPR = 2 for at least 3 or 4 days. And see what happens to the number of OAs and hypopneas, along with RERAs and flow limitations. If the obstructive part of the AHI stays below 2 and the aerophagia is better, you clearly know that reducing the pressure to 9cm is ok.

2) Keep the pressure setting at 9.4cm and turn EPR = 3 for at least 3 or 4 days. And see what happens to the aerophagia and the AHI as well as the CAI. If aerophagia is better and the number of CAs doesn't increase, then I think you can probably conclude that EPR = 3 is not a serious problem in terms of the CAs.

It's important to NOT change both the pressure setting and the EPR setting at the same time: When you change two variables and the results change, you can't figure out which of the two setting changes is responsible for the change in the results.

[robysue1]

Apologies about the bad screenshots. It's been about 2 more weeks, so I wanted to post 2 more "typical" nights of data.

Again, there's nothing in this data that indicates a need to change the therapeutic settings.

I don't feel bad by any stretch, but I get mild aerophagia symptoms (diarrhea, bloating). I'm afraid to lower pressure because I still have infrequent OAs at this pressure, and some hypopneas (looks like during REM sleep).

Given the aerophagia issues and the exceptionally low obstructive AHI---i.e. the AHI minus the CAI---, you can afford to experiment with decreasing the pressure by a bit. Try using 9.0cm for a few days and see whether the number of OAs and Hs goes up significantly and whether the aerophagia symptoms get any better.

While abdominal bloating can be attributed to aerophagia related to CPAP, I'm not sure that diarrhea can be. If the diarrhea is new or if it's happening on regular basis or is more than very mild, you ought to report it to your primary care doctor. Not all our medical problems are related to OSA and CPAP.

However, I'm seeing a number of CAs that do not just appear to be position-change related (e.g., take a deep breathe, roll over, then don't breathe despite no obstruction).

The number of your CAs is not alarming, even if they are all real. A small decrease in pressure might make them a bit less likely to happen.

Given I don't feel particularly low energy/exhausted, do you think this is the best i'm going to be able to do as far as controlling my apneas?

Your obstructive apneas and hypopneas are exceptionally well controlled at this point. You don't feel low energy or exhausted. Further tweaking of the settings is not likely to make you feel much better---except if you can eliminate the aerophagia issues.

In other words, your CPAP therapy is currently doing a near perfect job of controlling the obstructive sleep apnea. If you are worried about the CAs, you may have to accept a little less control of the OSA stuff. If the aerophagia is enough of a problem that you want to troubleshoot it, you may have to accept a little less control of the OSA stuff to feel a bit less bloated.

I try to sleep on my side but i'm a back sleeper and always revert to my back. I also mouth tape to try to help prevent leaks. Please let me know if you have any advice for optimizing my treatment. Thank you very much.

Your CPAP therapy is already "optimized" in the sense of controlling your OSA. Your current settings seem to be enough to allow for back sleeping. So if you prefer sleeping on your back, allow yourself to sleep on your back. As for side sleeping: Sleeping on your left side is usually a bit better for all kinds of stomach issues, including aerophagia. Your leaks are decently controlled and if you are comfortable with mouth taping, there's no need to change what you are doing.

So at this point, I would suggest that you focus on comfort (minimize the aerophagia and sleep in your preferred position) and just let yourself sleep instead of worrying about the small number of events that are making it through the CPAP defenses.

[jwalsh126]

Thank you all for your help with this journey. I have studied extensively and am checking back in to see if anyone has dealt with a similar conundrum. In short, my sleep has mostly been good, but I have weeks at a time where my subjective test tells me I am not feeling well-rested (only okay). I welcome any thoughts others have on whether I should make any changes.

I'm trying to fine tune my settings, given I am tending to sleep in more and not feel as rested as I have previously while using these settings. I notice I enter REM sleep and recall starting dreams, but feel I am getting fragmented sleep. Specifically, I tend to have a strong urge to sleep past my alarm and continue whatever dream I was having right before waking. Second, I notice that right at the start of sleep, my breathing looks more flow-limited. The breaths are not "rounded" like they are later in the night. I believe this is causing arousals, but am looking for advice given what I describe below.

Is this evidence that I have treatment-emergent central apneas? My IPAP has been fine-tuned to be high enough to prevent OAs and Hypopneas, but low enough to prevent the aerophagia I was experiencing. At 9.6 or above, I notice significant increase in aerophagia. Yet, I can never eliminate the 1-2 clusters of CAs I get per night. Sometimes I feel good, sometimes I feel not rested.

But there seems to be a tradeoff. At EPR 2 (which helps with my aerophagia), I am now getting several clusters of CAs per night. Not enough to conclude that it is worse than a lower pressure (which would cause OAs + hypopneas). But I wake up not feeling the most rested. This night in particular was a "good" night where I felt rested. The next night was not. Am I just stuck in the bucket of "complex" apnea, where I have no further adjustments I can make to my settings - this is the best I can do?

Screenshot 1 - Full Night
Screenshot 2 - Central Apnea
Screenshot 3 - Wave forms indicating flow limitation

Sleep Setup: Wedge + cervical pillow; Mouth Tape; N20 nasal mask.

[jwalsh126]

Different Night where I clearly feel more tired - Legitimate Obstructive Apnea at same settings.

Given occasional OAs and some flow limitation on nights without OAs, is it worth trying a higher pressure of 9.6 again? My concern is the aerophagia boogeyman that stopped me last time I tried. Sue may be correct that I have optimized nearly as much as possible given my circumstances. But I'm curious if there is anything else I can really try (sleep hygiene-wise, for example).

[Pugsy]

Given occasional OAs and some flow limitation on nights without OAs, is it worth trying a higher pressure of 9.6 again?

No. Not worth risking the aerophagia issues returning.

feel I am getting fragmented sleep

The CAs/centrals flagged are primarily post arousal events and thus not real asleep events.....so yeah...your sleep is very fragmented. If you remember a dream that means you woke up during it.

Is this evidence that I have treatment-emergent central apneas?

No...you don't have a problem with treatment emergent centrals....the centrals flagged are a symptom of a problem with sleep quality itself.

Now why your sleep quality has gone into the toilet....million dollar question but the usual culprits start with medication side effects or other potential health issues that mess with sleep.
Have you added a new medication or changed dosage? Any health issues that seem to be messing with sleep itself like pain?
Life stressors???

You have a sleep quality problem (trouble staying asleep or also called sleep maintenance insomnia) and not something that is fixable with any machine settings.

[jwalsh126]

Thank you Pugsy for the quick response! I had a feeling those were post-arousal CAs, but needed some confirmation. I definitely need to drill down the reason for my restless sleeping. No new medications, but perhaps it could be an uncomfortable sleep setup with the wedge + cervical pillow. While good for keeping the airway open, maybe it is prompting me to keep tossing/turning in my sleep.

That's the only thing I can think of for now. I work at a desk all day and am constantly tight in neck/shoulders/traps. I had a recent stressful period, but my sleep data has been roughly the same for over a year. Perhaps I need to try a different pillow setup which lets me sleep on a slight incline, but has softer pillows to give more comfort, especially when I turn to my side. I can experiment and see if it makes me feel more rested subjectively.

Plan: I will not be making any changes to my settings. I will tweak sleep setup to attempt to minimize arousals. Perhaps new pillow setup, and blackout shades for windows. I will then check the data and report back after a few weeks.

[Pugsy]

I wish that there was some sort of magical setting available on the cpap machine to help us solve sleep quality problems but there just isn't. Sometimes we just have problems that the machine wasn't designed to fix.
Trust me...if it were there then I would be hopping all over it.
I have sleep maintenance insomnia myself but while I know the cause (in my case good old arthritis pain) it still isn't easily fixable.

Just do the best you can with various experiments to see if something helps the sleep quality.
Remember....when you remember a dream it means you woke up during it and that's not good. It's actually better to not remember any dreams.

[jwalsh126]

Thanks a lot, Pugsy! I get that mixed up a lot on the dreaming... I sometimes think remembering my dreams means I had better sleep, when in fact it is the opposite (awakenings during the dream). I know this happens in the early morning.

Just when we think we have everything figured out, it always seems like there is something else to be "fixed" to improve our sleep. Most recently, my the symptoms that sparked my concern are bouts of dizziness/headaches (not vertigo) that get triggered during the day (noticeably more after bad nights of sleep) from caffeine, loud music, etc. I've seen a cardiologist/neurologist to rule out major issues, so I think it could be from sleep fragmentation, but that rabbit hole is TBD.

I'll keep a positive optimistic attitude and am grateful for the support I've received thus far. The machine has been a life changer and the PAP community is so much more knowledgeable/helpful than any routine doctor visit.

[zonker]

Plan: I will not be making any changes to my settings. I will tweak sleep setup to attempt to minimize arousals. Perhaps new pillow setup, and blackout shades for windows. I will then check the data and report back after a few weeks.

this sounds like a plan. now, on the pillow setup-i'm wondering if you eliminated either the wedge or the collar, it might pinpoint which one is not needed.

we are all of us different. in my case, I never did like the wedge. but I swear by my collar. I know it helps me very much because when approaching 3 months of use, my collar has broken down and needs replacing. and my sleep always improves after replacing the worn one with a new one.

whatever works for you.

[David SC]

Questions for you, is it possible that youre switching from mouth breathing to (blocked) nasal breathing?

Do you have mild asthma? Deviated septum? Mishappen nose airway?

Are you eating before bedtime? Have mild acid reflux??