Please help- No Improvement w/ BI-PAP

[AHItoohigh]

Thanks in advance for any advice that can be given!

I believe I have had sleep apnea my entire life, but just began treatment four years ago. My first sleep study showed around 150 events per hour. After my second study I was given a Philips Respironics System One. Tried a few different masks and settled on the Swift nasal pillows. Things were better than with no treatment at all, but my AHI was still averaging 12-14. Various pressures between 6 and 15 were tried. After a third sleep study I was given a Dreamstation Auto BI-PAP in February 2017. Things have been straight downhill from there. The first couple months my AHI was averaging around 19. The last month or so however, my AHI is averaging nearly 30, and is sometimes into the 40's and 50's. Looking at the data it seems obvious I have complex sleep apnea, and this machine is not going to solve my issue. Events are often split nearly 50/50. Pressure on auto is 8-15. Some nights it goes all the way to 15, sometimes it only goes to 9 or 10.

I have tried many things to rule out what the problem is, including:

Mask- mask seal is usual 100%

Sleep position- AHI is same or even higher sleeping on my side rather than on my back propped up w/ four pillows

-Sinus/congestion- been on allergy shots for six months. Use saline spray and take a Zyrtec Evey night. In February had turbinate reduction, nasal spur removed, concha bullosa repair, and sinuplasty.

-Iron deficiency and Thyroid test came back negative

-I use a chinstrap

I'm a 40 year old male with no other health problems. I don't understand what is going on here. How does my AHI triple on Auto BI-PAP over CPAP?

Have an MRI tomorrow to check for a Chiari malformation. At this point I think the doctor is just taking shots in the dark.

Here is a typical night for me lately:

http://imgur.com/a/lXK8v

[Pugsy]

Turn off the pie chart...it's hiding some potentially useful statistics.
Preferences/Appearance tab...remove check mark for show Pie Chart.

Omit Snore and Respiration charts. They aren't particularly useful and by having them the other more important graphs are so small they are hard to evaluate.

As to why worse with BiPap than cpap...dunno because we don't know what settings were used on cpap.

If you really do have complex sleep apnea then you may need one of those special bilevel machines called ASV machine.
https://www.youtube.com/watch?v=CU-XTcf ... e=youtu.be

It appears that your settings aren't getting the job done in terms of OA and hyponea prevention....the machine is machine out for long periods at IPAP max of 15.5....it wants to go higher but it can't.

The ClearAirway/Central events...they could be real or they could be post arousal SWJ centrals.
If they are real you probably need that ASV machine.
If they are post arousal SWJ (sleep/wake/junk) then better preventing that obstructive stuff could maybe reduce those centrals to a less alarming number.
You need to figure out if they are real or not which isn't always so easy to do.
viewtopic.php?f=1&t=114600&p=1110933#p1110933

You need to look at the flow rate zoomed way in in those green PB flagged areas to see if the flow rate looks like this or not.

[AHItoohigh]

Thank you for your reply!

Sorry, I'm new to Sleeyhead. I'll cleanup my data and re-post. How do I zoom in on the Flow Rate graph?

Thanks again!

[Goofproof]

The more complex the XPAP System, the more setting you have that you can set incorrectly. K.I.S.S. Then after you get one XPAP System set correctly, and there is a know reason other than incorrect set-up, feel free to try a more complex treatment keeping in mind it will be harder to set up.

Personally I'd get a APAP, the Software to read the full data, a Full Face mask that fit, and go from there, using No RAMP, and a Pressure range of 3 cm that can control your Apnea. Jim

[AHItoohigh]

How do I omit the unnecessary graphs?

CPAP settings were 10.5 with c-flex set to 3

THANK YOU!

[Pugsy]

How to organize the graphs.
3 pages so be sure to read all
https://sleep.tnet.com/resources/sleepyhead/shorganize
You can turn graphs off or resize if you wish.

How to zoom in...
Click on the Events tab over under where the pie chart is. You will see each category of event. Click on Clear Airway/Central and then you will get a long list of all the centrals/CAs flagged.
Click on one of them and the graphs on the right will automatically zoom in for you at the level of zooming in that is needed for optimal flow rate evaluation.

[Pugsy]

The more complex the XPAP System, the more setting you have that you can set incorrectly. K.I.S.S. Then after you get one XPAP System set correctly, and there is a know reason other than incorrect set-up, feel free to try a more complex treatment keeping in mind it will be harder to set up.

Personally I'd get a APAP, the Software to read the full data, a Full Face mask that fit, and go from there, using No RAMP, and a Pressure range of 3 cm that can control your Apnea. Jim

Sometimes the situation is complicated and needs a complicated fix.
APAP is not necessarily the best choice for complex sleep apnea. Right now the BiPap is pretty much functioning like an apap with a variable exhale relief...going to apap is unlikely to change the results.

APAPs and CPAPs work great for obstructive sleep apnea...not always so great for centrals and in fact can be contraindicated and potentially cause more problems.
At this point we don't know if the centrals are real (and if they are there is a problem) or if they are post arousal centrals.

[AHItoohigh]

I think I did this correctly...

http://imgur.com/a/GOGB9

[Pugsy]

CPAP settings were 10.5 with c-flex set to 3

Doesn't really tell me much without seeing the reports and even then doesn't tell us much because not comparing apples to apples with the way Flex works vs PS and the settings are so different.

For some people adding PS (pressure support which is the difference between inhale and exhale) can trigger centrals but you must have had a lot of centrals on the cpap for them to try BiPap.

There's a lot of information needed in your situation that we don't have available.
Like has your doctor said you have complex sleep apnea? If he has then has he discussed something maybe after this bipap?
When was your last sleep study both with and without any sort of cpap/bipap therapy?....do you have a copy of those results and do they mention centrals?
What other settings have been tried? What were the results?
When was the last time you saw your sleep doctor?

Do you wake often during the night? Spend a lot of time awake with the mask on and machine on?
Do you take any medications of any kind that might suppress respiration...specifically opiates or synthetic opiates?

It's painfully obvious that this isn't working like it is...now what to do about it...that's a really big question but to fix a problem one has to know for sure what the problem is and is it fixable with what is at hand.
Sometimes central apneas can be fixed with regular bipaps like you have now...sometimes they need one of those special high dollar bilevel machines.
For both obstructive and central apnea...that high dollar machine is the ASV machine. It can auto adjust as needed for the obstructive stuff and breath for you when you have a central and don't breathe on your own.

Your Obstructive apnea stuff is still too high...so you need more pressure.
Is the pressure the cause of the centrals...maybe...but those centrals might be simply post arousal centrals caused by the OAs/hyponeas causing arousals.
My suggestion would be concentrate on what is known to need to be fixed and is fixable with your machine...the obstructive stuff...
Get the obstructive stuff handled and then see if the centrals remain numerous or not and then if they do cross the ASV bridge if needed.

[Pugsy]

Let's fix the Statistic pertaining to the % of time over the red line.
SleepyHead default is for a ResMed leak number and it's 24 L/min for large leak territory to begin...
you are using a Respironics machine so your large leak territory number isn't 24 L/min and in fact is quite a bit higher. Respironics never gives us an exact number because it can vary so much with pressures used...so you can use an "about" number or turn that statistic off.
Go to Preferences CPAP tab and on the right remove the check mark for the red line threshold to turn it off or change it to something that is more in line with your machine at your pressures and that would be maybe 70 L/min. You see the one brief time in large leak shown on the events flag...no way is that 24% of the night and in fact it's such a short period of time I wouldn't dwell on it.

Yes, thank you for the redoing of the image. It shows me better what I was wanting to wee which was what PS was trying to do...the most it went to was 1.5...so your inhale and exhale are staying real close together and not widely apart. When widely apart centrals can be triggered.
I don't think that PS is a big factor in your centrals.

Are you comfortable making changes to your pressures on your own or do you prefer to have the doctor/DME do it?

Can you get me a zoomed in picture of 3 or 4 of those centrals/CAs flagged in the PB green? Pick one that is in the middle of 3 or 4 closely together and you should see 3 or 4 in one image. Don't zoom way out...I need it zoomed in at the level I mentioned above from the individual timed event.
Similar to this one.

[AHItoohigh]

I followed exactly what you said but it did not zoom in the graph

[Pugsy]

The graphs on the right will change if you click on one specific timed event...not on the category but you have to go into the category where there should be tons of individual CA timed events.

[AHItoohigh]

hmm that's what I did, and just tried again, but it doesn't zoom in at all

[Pugsy]

Hmmm....
Get me a screen shot of what you are doing showing the events tab being opened and the graphs on the right.

Make sure the you highlight and click on one specific timed event...

[AHItoohigh]

Last sleep study in 2016 the first thing the sleep tech said in the morning was, "you seem like you have central apnea".

Doctor said she "thinks" I have complex sleep apnea, but that's about it. I got the auto bipap in February 2017 and she hasn't discussed anymore options.

Just called to get copies of all three sleep studies. First one with no PAP my events were 150 per hour. No mention of centrals at that time.

I know how to adjust the setting myself. I have tried EVERYTHING! I saw my sleep doctor two weeks ago, when she requested the MRI to check for Chiari.

I don't wake up often at night. Usually once or twice. Spend virtually no time with mask and machine on but lying there awake.

I don't take any medication, or use any illicit drugs.

Here is the Flow Rate graph. Hopefully this is what you meant.

http://imgur.com/a/65llh