AHI still too high

[TedVPAP]

Hey guys...did you read this part?

Doc decided I should try just CPAP at 10. My AHI did actually improve some, but I was freakin' miserable. My sleep was even more fragmented than usual, and the aerophagia made me feel sick most of the time.

We already know more pressure is needed but more pressure comes with a whole new set of problems.
If fixed at 10 causes bad aerophagia and bad sleep...just what do you think will happen with a range of 10 to 15????

To nightwatch..... can you please refresh my memory on a few things since it has been a while and I don't remember what we may have talked about in the past.

What position do you normally start the night in and do you pretty much stay in that position most of the night or do you move around all over the place when it comes to position?

Have you tried a cervical collar at all?

What is the status on the bilevel? Do you know if it will be Respironics or ResMed? Any idea when you will get it?

What range of pressures gives you the best AHI without causing aerophagia and sleep issues...I know it won't be a great AHI and not what you want but what max pressure can you use without causing bad sleep and bad aerophagia?

My suggestion...use the range that lets you at least sleep and not have belly issues...it does you no good at all to kill all the apnea events with more pressure and make yourself sick and not get any sleep doing it.
And take ajack's advice if you haven't already...get a cheap cervical collar and wear it and at least see if it helps or not.

We know you need more pressure but along with more pressure you get a host of new problems that is making you miserable and trashing what little sleep quality you had. You need a bilevel machine to stand the greatest chance of finally getting to be able to use the higher pressures and not cause more belly issues. Even then it might take some real fine tuning and compromise.

Yes I understand.
Tuning between 7 and 8.5 may help the tummy but not much for the OSA.
The fixed 10 was with FLEX off. That makes no sense.
While waiting for a bilevel, thinking that will save the day, I suggest maximizing FLEX and turn the pressure up. The fact that treatment causes issues is true with most people - time to adjust is often needed.

[USMCVet]

https://www.sleepapnea.org/treat/cpap-t ... solutions/

So it's good he is using FFM. Is aerophagia happening when awake or sleeping? How slow did night watch ramp up go higher pressures? Is night watch using ramp feature? Has night watch tried epr or flex or whatever it's called of 3?

Any other anatomical issues we don't know about?

Can you is dental mouth piece with CPAP?

Personally if aerophagia was my issue I would be looking at causes and solutions to it. I would slowly build up pressures and try new ideas during naps to reduce unpleasantness.

[USMCVet]

https://blog.easybreathe.com/cpap-aerop ... -bloating/
Can you use strap to keep mouth closed with FFM?

Also anything you try write it down. What makes things worse or doesn't help or helps a little could be helpful to some here or your doctor in correcting this issue for you.

[NightWatch23]

Wow. Thanks all for the help. I really appreciate it. I'll start with answering Pugsy's questions:

Positioning: I start on my left side generally, but I tend to move around. I tried constructing elaborate and firm wedges out of folded blankets, and I found it very comfortable, but it didn't help with aerophagia. I have also tried two tennis balls in a sock, attempting to force me to stay on my side, but a) I didn't see any improvement in the numbers, and b) I often woke up on my back, having a dream about something harming my back.

Cervical collar: I just got one yesterday, and tried it last night. It was surprisingly comfortable (although it might be a bit warm in summer). Alas, I didn't get a lot of data last night. My wife was snoring so I slept on the couch for a while. But I was able to sleep with the collar, and will make better sleeping arrangements tonight.

Bilevel status: yesterday was day 11 of the promised 14 business days, so I expect it middle of next week. I don't know the brand yet.

Best pressure range: Good question. Looking at my efforts since the doc gave up, I see that searching for good results has probably prevented me from doing what's needed to find the best available results. I'm guessing something like 7 to 9. I tried steady pressure at 10 with the flex on 3, and that felt bad, so I tried several nights at 8.5, and it wasn't good. Seemed like the longer I slept, the higher my CA went.

So for the next 4 days or so til the Bilevel arrives, I'll try 7 to 9 with the collar and see what happens. I'm wondering if I should get an oximeter, or try video taping myself to see if I can learn anything about positioning.

USMCVet suggested a dental piece and/or a chinstrap. Ever since I can remember I've never been able to breathe only through my nose for more than a minute. It just doesn't work somehow, so I'm thinking a chinstrap or mouth-taping is not going to work for me. Doc said a custom-made mandibular advancement device might help, but he's seen lots of cases where folks have spent tons of money for no benefit. I've tried boil and bite's in the past for bruxism, and hated them. I actually find the mask more comfortable. If I can't get the air machines to work, though, I suppose that's the next thing to try. And if that fails, perhaps both at the same time.

[TedVPAP]

Wow. Thanks all for the help. I really appreciate it. I'll start with answering Pugsy's questions:

Positioning: I start on my left side generally, but I tend to move around. I tried constructing elaborate and firm wedges out of folded blankets, and I found it very comfortable, but it didn't help with aerophagia. I have also tried two tennis balls in a sock, attempting to force me to stay on my side, but a) I didn't see any improvement in the numbers, and b) I often woke up on my back, having a dream about something harming my back.

Cervical collar: I just got one yesterday, and tried it last night. It was surprisingly comfortable (although it might be a bit warm in summer). Alas, I didn't get a lot of data last night. My wife was snoring so I slept on the couch for a while. But I was able to sleep with the collar, and will make better sleeping arrangements tonight.

Bilevel status: yesterday was day 11 of the promised 14 business days, so I expect it middle of next week. I don't know the brand yet.

Best pressure range: Good question. Looking at my efforts since the doc gave up, I see that searching for good results has probably prevented me from doing what's needed to find the best available results. I'm guessing something like 7 to 9. I tried steady pressure at 10 with the flex on 3, and that felt bad, so I tried several nights at 8.5, and it wasn't good. Seemed like the longer I slept, the higher my CA went.

So for the next 4 days or so til the Bilevel arrives, I'll try 7 to 9 with the collar and see what happens. I'm wondering if I should get an oximeter, or try video taping myself to see if I can learn anything about positioning.

USMCVet suggested a dental piece and/or a chinstrap. Ever since I can remember I've never been able to breathe only through my nose for more than a minute. It just doesn't work somehow, so I'm thinking a chinstrap or mouth-taping is not going to work for me. Doc said a custom-made mandibular advancement device might help, but he's seen lots of cases where folks have spent tons of money for no benefit. I've tried boil and bite's in the past for bruxism, and hated them. I actually find the mask more comfortable. If I can't get the air machines to work, though, I suppose that's the next thing to try. And if that fails, perhaps both at the same time.

Are you sure you had FLEX set to 3? The chart you posted shows that it was off. Maybe you tried both???

[ajack]

it will be interesting to see a chart using the collar and a flat pillow, hopefully it is going to help a lot.

as to the air bloating, I had GERD and real trouble at the start, but it did get a lot better. The body seems to adjust.
do you have heartburn/reflux/GERD? take antacids etc? This can inflame the valve on top of the stomach and make the air bloat worse. You could raise the head of your bed 4-6" about the size of a house brick under each leg at the head of the bed. This will put the bed on a slope, keep the contents of your stomach where it belongs. Google : gerd LCHF ..as a change of diet cured mine.

If you wife is snoring, she should get checked for sleep apnea too. funnily enough, there is a spare machine in the house that she could use, or is it going back?

[NightWatch23]

In the several nights I had left waiting for the BiPAP, I found I felt better when I didn't use the CPAP, so I stopped. The collar didn't change my numbers during the one night I had it and the machine on at the same time, but I did notice that I felt a bit better on the days after I had it on. Small sample size, but I've been wearing it since.
So then my BiPAP arrived. I've had some trouble with aerophagia, but it's bearable, and seemed to improve when I extended the ramp time. Here are the charts:

2/14
2/15

After these first two nights I called the DME to report the dramatic change from OSA to Central, but I didn't get any response, and I took that night off from the machine.

2/17

After this night I woke up tired as usual, and the kids were at a friend's house, so I lay down for a moment and fell asleep for 2 more hours without the machine. The un-papped nap helped my tummy, but I was still tired. About 5 pm today I finally was able to shake the fog enough to do some tasks.

[Pugsy]

You need to get back with your doctor sooner than later.
Way too many centrals and your doctor has already slapped your hands for changing the settings.
He/she may just want to watch them but the doctor needs to be aware of them and their progression.

[ajack]

yep, it was worth a try, but the collar was a fail, along with the bpap. The ca will need to be investigated seeing you have been on the machine since nov. It can take up to 12 weeks for ca to settle, but they aren't in your case. You may need another sleep study, to be titrated to another machine.

[NightWatch23]

yep, I need a new sleep study to be titrated to an ASV. I was surprised the doc went there so quickly, but he says tinkering with the BiPAP won't help with Complex Apnea, so on we go to the next step. I've checked all the local sleep clinics, and they all wake you at 5 am, so I'm going to try UW Medical Center, and see what they have in Portland. Since last summer, my delayed sleep phase disorder has gotten worse, and worse again since starting CPAP in November. So lately I've been falling asleep anywhere between 3 am and 5 am. It used to be pretty regular at 2 am.

So, between now and my next test, can anyone send me the procedure for changing settings on the AirCurve, and suggest things to try? The doc is getting to know me. He said I can do what I want with the settings now. Or is it really a lost cause, and I should return this rented BiPAP and just wait for an ASV?

The thing is, the last few mornings I've felt a bit more lucid in the mornings. My energy is still unavailable, but it seems like the fog has thinned somewhat. And my AHIs have dropped some:

2/18
2/19
2/20
2/21

[Pugsy]

You can request the manual here along with how to get into the clinical setup menu area.
https://www.apneaboard.com/adjust-cpap- ... tup-manual

Looks like your settings are pretty much factory defaults.

Reduce PS....I would try PS of 2 ...and even turn it off so set to 0 to see if PS is a factor in those centrals.
Change minimum EPAP to 6 and max IPAP to 15.
It's a wild as guess...but it's better than the factory defaults.
Probably won't help but it's something to try while waiting to jump through all the hoops for the new sleep study with ASV.

[ajack]

It must have been a timezone thing and I was drinking, when I posted? That OA/H on your chart shows that the collar was working for you. the OA/H events were greatly reduced to 1 from up to 10, so I would think it was a lot of positional apnea by that chart.

The CA rose probably because of the flex. I would think the bpap will do the same thing. Your first charts without flex had CA at 1.8 together that will give an AHI of under 3, if you are lucky.
I'd go back to no flex and use the collar, till you can work out a pillow to keep your airway straight.

[palerider]

It must have been ...I was drinking, when I posted?

More drinking, less posting.

...I'd go back to no flex

Easy, since the OP's machine *doesn't have flex*.

[NightWatch23]

Thanks for the suggestions Pugsy, it seems like things are moving in the right direction. I set the machine with the settings you recommended, but felt like I wasn't getting enough air, so I put the PS at 2. Thursday's was the lowest AHI I've recorded. You might think you refuse to shine, but I'm donning shades all the same.

After 2 nights, I tried lowering the PS to 1, and found that increased my aerophagia, so I'm wondering if setting the PS back to 2 or 4, and turning down the max pressure might help some.

2/22
2/23
2/24

[Pugsy]

Sometimes using PS causes centrals in some people which is why I have been suggesting lowering or turning PS off.
Unfortunately sometimes reducing or turning PS off will cause the aerophagia monster to come for a visit and he's not a particularly welcome house guest.
So sometimes we have to make compromises and figure out which is a worse house guest...the aerophagia monster or a few centrals popping up (assuming that PS is causing the centrals).

The bulk of your AHI is central in nature...whether they are real or SWJ Sleep/Wake/Junk centrals. If real they are of course a concern but if SWJ they are of no concern. Unfortunately it isn't always so easy to figure out if they are real or SWJ from the data shown by the machine.
Since your AHI is made up mainly of centrals you probably have some room to reduce that maximum pressure in an effort to reduce the aerophagia monster's visits. In other words compromise a bit on maybe allowing a couple of OAs slide by if lowering the max helps keep the aerophagia monster for a visit.

If PS does seem to be causing the centrals then you have to try to find a line with PS where the centrals aren't horrible and just above the line they are pretty bad.......and stay below the line.

It's a tightrope to walk keeping everything within the compromise.