OSA on exhale?

[Albacore]

Alright so it would appear that I'm not crazy, and not the only one to have OSA upon exhale. On another note, I did in fact switch my machine to auto BiPAP mode. I set the minimum epap to 11 and the max ipap at 20 with PS set to 8. I will say I think I had better quality sleep, although my AHI only decreased to 9.2. Still any decrease to my AHI is an improvement, and I honestly didn't notice the pressure at all. Breathing felt very natural in auto mode. I didn't even notice the pressure increase. Detailed report this morning showed that my 90 percent ipap was 17, and my 90 percent epap was 14. Those are higher numbers than I have been using, but I never noticed! And that was without using the ramp function. I think I'm going to stick with auto mode at this point considering how comfortable it is. I slept my first 5 hours straight through without any interruption and woke up in the exact same position. I don't do that very often, but when I do it feels pretty darn good. Now I need to figure out how to get my AHI down below 5. I will probably need to get a week or two of data off my card and analyze it in order to make effective adjustments.

[Pugsy]

If the AHI stays higher than you want...look at EPAP increase..1 cm or maybe 2 cm...leave everything else the same since it is comfortable and you are sleeping well.
You can do the increase in 0.5 cm increments if you wish.

[Albacore]

Thanks Pugsy, I will try that. Do I still leave the PS setting at 8? I imagine that's probably where I would have to leave it, since it's maxed. I'm starting to think the sleep study tech wasn't that far off with his numbers of 20 / 16. I guess with a sleep study AHI of 97, I am pretty severe. It obviously takes a lot more pressure to manage my OSA than I thought. I guess I'm still breaking through my own denial and coming to terms with this, and just how severe it really is. At least the auto function makes those presures very comfortable. It definitely makes a giant difference in my quality of sleep. Quality sleep + low AHI = bliss. Can't wait.

[Pugsy]

Do I still leave the PS setting at 8? I imagine that's probably where I would have to leave it, since it's maxed.

I don't know that I would leave it at 8 if I was using fixed pressures but since you are using auto mode that means PS default of 2 is where you start out and PS can range up to 8. I would need to see the reports to be sure but I doubt you are utilizing the entire max PS.

M series machine and the "older" PR S1 BiPaps ..in auto mode had a default PS of 2 that the machine does without any input from you and the maximum PS of 8 (or whatever) just means that is what it CAN go to but doesn't mean it will go there.
It all depends on what your body does and what the machine senses it can do.
If you were using the latest 60 series BiPap then it has a specific setting for minimum PS and maximum PS available..your M series machine doesn't. When you start out the night before going to sleep your EPAP is going to be 2 cm less than IPAP and IPAP or EPAP won't increase until the machine senses a need and then it decides what PS is best used...2 to 8 (in this situation).
The most commonly used PS (when in fixed pressure mode) is 4 which is what they came up with to start you with the 16 EPAP and 20 IPAP....20 minus 16 is 4...and that's what PS is...difference between IPAP and EPAP.
It's the difference in the two that offers the comfort on inhale and exhale.
When PS is too high it can cause some breathing instability issues in some people. Sort of like hyperventilating and that's why I wouldn't use it (high PS) in fixed bilevel mode. I would probably go with the usual 4 cm PS if I was using fixed bilevel mode but since you are using auto mode then you are for all purposes using a roaming 2 cm PS up to 8...I doubt it goes there so it doesn't really matter especially if you are more comfortable and sleeping better.

EPAP of 11 with the default 2 cm PS..means IPAP is 13 while awake and that's going to be sooooo much easier to adjust to than 20/16.
Then let the machine decide what is needed and do its job. So it really isn't that big of a deal what max PS is set at since by default the machine is going to start at 2 cm anyway and then go where it thinks it needs to go depending on what it senses.

I doubt the machine wants to give you PS of 8...but if it did and you sleep well and your reports look good...who cares?

[Albacore]

Update:
Only got one really good night of sleep on auto mode. Pressures are high and I cannot stop the mask from leaking. I've been frustrated and unable to use it for the last few nights. The pressure requires the mask to be so tight it destroys the bridge of my nose. I'm fighting with a DME for a different mask. Will update again if I don't quit this crap all together. My frustration levels are so high right now I feel like just walking away from the whole #@*% business.

[SleepWrangler]

EPAP is probably too low if you are seeing more OAs.
Generally EPAP for OAs and IPAP for hyponeas but I have found that often with hyponeas...if EPAP does better with the OAs then the hyponeas also reduce as a by product. So I tend to look at EPAP minimum as a starting setting to try to optimize first.

I notice when I am awake that my breathing gets into a strange feedback with S9 AutoSet in CPAP mode where I feel I have to overcome the continuous pressure and breathe forcefully, then the resistance to exhale becomes less so I ease my breath, then pressure feels harder again. This repeats in a cycle. I can imagine this happens in my sleep too and have a suspicion that it triggers clear airway / hypopnea events. For some reason I imagine it is related to EPR, hence OSA on exhale. Have not experimented with EPR as recommended yet ... will soon.

[djhall]

Update:
Only got one really good night of sleep on auto mode. Pressures are high and I cannot stop the mask from leaking. I've been frustrated and unable to use it for the last few nights. The pressure requires the mask to be so tight it destroys the bridge of my nose. I'm fighting with a DME for a different mask. Will update again if I don't quit this crap all together. My frustration levels are so high right now I feel like just walking away from the whole #@*% business.

I sympathize. I've been on BiPAP for about nine months, and I just got my average AHI under 1.0 at pressures of 19 EPAP and 22 IPAP. Everything gets tougher as the pressures get higher and I wen't through a lot of mask changes looking for something that could take the pressure, wouldn't destroy my face, wouldn't blow in my eyes, and wouldn't make the bridge of my nose turn into hamburger!

The only way I was able to do it was by accepting that getting sleep was more important than getting numbers. I had to settle for worse numbers at pressures I could handle and sleep at, and then slowly increase the pressure a little at a time over half a year before I could finally make it work at the pressures where I wanted to be. The masks and the ingested air were the two biggest challenges I faced by far. You may need to do the same. Getting some treatment and reducing your OSA from severe levels to mild levels for several months while you work your way toward better effectiveness is vastly preferable to getting so frustrated and sleep deprived that you throw the thing out the window and quit!

[Albacore]

I would never throw my mask out the window. It's much more satisfying to throw it against the wall (which I did Sat. night ). I know, I know, bad form. I would say "You don't know how frustrating this is," but it sounds as though you do. Thanks for the encouragement. I was actually considering the very thing you're talking about. I was thinking about reducing both my EPAP and IPAP pressures to tolerable levels, and settle for reduced AHI's rather than looking for that magic under 5 mark. My sleep study showed an AHI of 97, so if I had 15 or so it wouldn't be all that bad, would it?

[djhall]

My sleep study showed an AHI of 97, so if I had 15 or so it wouldn't be all that bad, would it?

The clinical guidelines classify < 5 as normal, 5 - 15 a mild, 15 - 30 as moderate, and > 30 as severe.

I look at is like this: If the alternatives are not sleeping (or sleeping like crap, or having a bloody nose bridge, etc), or giving up and living with an AHI of 97, or sleeping comfortably with an AHI of 10 - 20 while I work on getting it lower.... I know where I want to be.

[Albacore]

I look at is like this: If the alternatives are not sleeping (or sleeping like crap, or having a bloody nose bridge, etc), or giving up and living with an AHI of 97, or sleeping comfortably with an AHI of 10 - 20 while I work on getting it lower.... I know where I want to be.

I agree. I slept fairly comfortably the last two nights with reduced pressures. My average AHI for the last two nights was right around 9. I'm not saying I'm giving up, but if I did have to live with an average AHI of 9 on a regular basis would it really be all that bad? It's still a whole lot better than 97. I imagine my risk for heart attacks and strokes would be greatly reduced. I'm still working with the DME on getting a Resmed Quattro mask.

[djhall]

I look at is like this: If the alternatives are not sleeping (or sleeping like crap, or having a bloody nose bridge, etc), or giving up and living with an AHI of 97, or sleeping comfortably with an AHI of 10 - 20 while I work on getting it lower.... I know where I want to be.

I agree. I slept fairly comfortably the last two nights with reduced pressures. My average AHI for the last two nights was right around 9. I'm not saying I'm giving up, but if I did have to live with an average AHI of 9 on a regular basis would it really be all that bad? It's still a whole lot better than 97. I imagine my risk for heart attacks and strokes would be greatly reduced. I'm still working with the DME on getting a Resmed Quattro mask.

I think we all want to maximize our sleep quality, but if it makes you feel any better, Medicare only covers CPAP for AHI < 15 if there is also documented daytime sleepiness or associated medical conditions AND those conditions show improvement after a 3 month trial on CPAP.

[Albacore]

Interesting. I know human reasoning and medical science don't always match up, so...am I correct in assuming that a significant reduction in my AHI
greatly reduces my chances of heart attack and stroke? Am I thinking it through correctly?

[djhall]

Interesting. I know human reasoning and medical science don't always match up, so...am I correct in assuming that a significant reduction in my AHI
greatly reduces my chances of heart attack and stroke? Am I thinking it through correctly?

It is believed so. See below:

Sleep apnea may be an important risk factor in the development of hypertension (high blood pressure), especially for those with moderate to severe sleep apnea. Treatment of sleep apnea has been shown to improve blood pressure.

There is growing evidence that sleep apnea contributes to the development of coronary artery disease.

Untreated severe sleep apnea is associated with a high risk of both non-fatal and fatal heart attacks and stroke. Sleep apnea may also worsen pre-existing coronary artery disease. A study from the Mayo Clinic found that sleep apnea increases the chance of having a heart attack during sleep. Treatment of sleep apnea may reduce the risk of heart attack or stroke.

Sleep apnea is a well-established cause of abnormal heart rhythms (arrythmias). Approximately 50% of patients with atrial fibrillation are found to have sleep apnea, and treating sleep apnea in these patients greatly improves the chance of successfully treating the heart arrhythmia.

Sleep apnea may weaken the heart muscle’s pumping ability, leading to congestive heart failure. Studies have shown that treating underlying sleep apnea in patients with this condition can significantly strengthen the heart muscle.

Clearly, sleep apnea is an important risk factor in the development of cardiovascular disease. Patients with cardiovascular disease should be screened by their doctor for underlying sleep apnea.