New to BiPAP: Clear-Airway Flags, Pressure Titration, Secondary Settings, and Unexpected Naps

[at_switchback]

After about two months on CPAP, I finally switched to BiPAP and now have one night of data. I am trying to stay disciplined while dialing in the settings, but I would appreciate the community’s perspective on three areas:

1.       how much weight to give the clear-airway events flagged by my ResMed machine;

2.       whether to leave the AirCurve 10’s secondary settings alone while I first optimize IPAP and EPAP; and

3.       two unexpected changes involving naps since I began PAP therapy.

AirwayLab share link to my data: https://airwaylab.app/shared/72d0e019-d ... 92eeaaae39

Clear-Airway Events 

An experienced respiratory therapist reviewed my CPAP data and advised me not to react to most of the machine-flagged clear-airway events. Much of the data was affected by substantial mouth leak, which can distort the machine’s event classification. In the cleaner segments, he saw obstructive recovery breathing, arousals, and brief post-arousal pauses rather than a pattern suggestive of true central sleep apnea. His explanation was that recovery breaths after an arousal can temporarily reduce respiratory drive as a person returns to sleep, creating a pause that the machine labels as a clear-airway event. He also noted that true central periodic breathing would generally show a smooth waxing-and-waning pattern, which he did not see in my data. 

In the cleaner, non-leak portions of my data, he saw flattened or concave inspiratory waveforms leading into arousals. He interpreted those waveforms as evidence of residual obstruction and inadequate effective pressure, rather than central instability. I trust his judgment, but I would appreciate hearing what experienced users examine in OSCAR to distinguish false or post-arousal clear-airway flags from events that merit closer attention.

So I trust his analysis, and yet I am scared about the number of clear airway events flagged by ResMed during a 30 minute sofa trial of BiPAP 13/9. I think my fear is not rationale.

First Night on BiPAP

For my first BiPAP night, I conservatively retained the IPAP and EPAP values from my most recent CPAP trial rather than increasing pressure immediately. The clearest improvement was leak control: I continued using nasal pillows and combined horizontal and vertical mouth tape with my mandibular advancement device. I also have a soft 4-inch cervical collar on order.

Between the switch to BiPAP, continued use of nasal pillows, and better leak control, I am wondering whether the same nominal IPAP/EPAP levels may now be more effective than they were on CPAP. The respiratory therapist’s expectation is that I will probably need an IPAP in the 13–15 cm H₂O range. The planned progression is 13/9 tonight (30 minutes of this setting while sitting on the couch produced a lot of Central Airway events), then 14/10, and then 15/11 if tolerated and still indicated, while reviewing leak-controlled data at each step.

Secondary AirCurve 10 Settings

The secondary settings I understand to be relevant are:

·       Mode: S versus VAuto (I have it set on S, not trusting the algorithm)

·       Easy-Breathe: on or off (I have it set on)

·       Trigger sensitivity: how readily the device initiates IPAP when inspiratory effort begins

·       Cycle sensitivity: how readily the device returns from IPAP to EPAP as expiration begins

·       Ti Min: minimum inspiratory time

·       Ti Max: maximum inspiratory time

·       Rise time: how quickly pressure increases from EPAP to IPAP when Easy-Breathe is not governing the waveform

The initial recommendation I received was fixed S mode, pressure support of 4, Easy-Breathe on, Trigger High, Cycle Medium, Ti Min 0.3 seconds, and Ti Max 2.0 seconds, without using a faster rise time.

ResMed describes TiControl as setting minimum and maximum inspiratory-time limits and identifies adjustable trigger and cycle as tools for optimizing patient-device synchrony. My gut tells me that along with pressure settings, that dialing in these secondary settings will also be important to finding my therapy sweet spot. 

Short of a WELL ADMINISTERED BiPAP titration study, what is the best approach to dial in these secondary settings?

Unexpected Nap Changes Since Starting PAP

Since starting PAP, I have also noticed two changes involving naps. First, several naps lasting only 5–10 minutes have felt inexplicably deep—much deeper than I would expect from such a short period of sleep. Have others experienced unusually deep or restorative-feeling short naps after beginning PAP therapy?

Second, on some mornings after a relatively better night of sleep, I have unexpectedly wanted to nap after my morning coffee. On at least one occasion, that urge turned into a long nap. Has anyone else noticed greater morning sleepiness—or a stronger urge to nap—after a comparatively better PAP night? If so, did it seem like part of an adjustment period, repayment of accumulated sleep debt, or something else?

Where I Could Use Input

I know the usual advice is not to change too much at once. Part of me wants someone experienced to weigh in immediately on all of the secondary settings, but I suspect the better approach is to leave them stable, follow the planned 13/9 → 14/10 → 15/11 progression, and evaluate one pressure step at a time using nights with controlled leak.

For those experienced with bilevel titration, would you first complete the planned 13/9 → 14/10 → 15/11 sequence while leaving Trigger, Cycle, Ti Min, Ti Max, Easy-Breathe, and rise time unchanged? When comparing nights in OSCAR, which findings would you prioritize for example, leak shape, flow-waveform quality, arousal patterns, event timing, or patient-device synchrony to decide whether pressure is helping or a secondary setting deserves attention?

I waited a long time to obtain the BiPAP, so I am finding it difficult to be patient with the process of dialing it in. I would especially value responses from people who have titrated an AirCurve 10/11 methodically: how long did you hold each pressure before evaluating it, and what evidence told you that it was time to change pressure or address a secondary setting?

Thank you,
Dan

[Pugsy]

For those experienced with bilevel titration, would you first complete the planned 13/9 → 14/10 → 15/11 sequence while leaving Trigger, Cycle, Ti Min, Ti Max, Easy-Breathe, and rise time unchanged? When comparing nights in OSCAR, which findings would you prioritize for example, leak shape, flow-waveform quality, arousal patterns, event timing, or patient-device synchrony to decide whether pressure is helping or a secondary setting deserves attention?

I highlighted the default settings that I suggest you leave alone for right now. The majority of people will do quite while at those default settings once you get used to bilevel therapy. Give your body and mind some time to adjust.

how much weight to give the clear-airway events flagged by my ResMed machine;

Depends on how many and were you awake or asleep when they were flagged.
I tend you agree with the RT you spoke with unless you are having a truckload of them while you are asleep and any flagged while awake can be totally ignored. Anything flagged while awake doesn't account for much except to point to crappy sleeping quality and bad sleep can be from a multitude of causes and the fix depends on the cause.
It is normal to have an occasional central sleep apnea so no need to panic when you see an occasional central flag.
If more than 4 or 5 per hour then we dig deeper.

As far as naps....are you on any medications of any kind? Even OTC?

I am not familiar with the report your link went to so I can't comment on it.
I am familiar with OSCAR and SleepHQ reports. SleepHQ reports let us zoom in on the flow rate/Breathing to evaluate asleep vs awake/arousal breathing.

See this thread to understand more on what I am talking about when I say asleep vs awake/arousal.
viewtopic.php?f=1&t=187767&p=1451526#p1451526

[Pugsy]

Oh.....the auto adjusting algorithm is pretty darn good. I use it myself.
My OSA is much worse in REM sleep but not so horrible in the other stages of sleep (or sleep position). It's much easier to let the machine increase for what I might need in REM and then go back down when not needed. REM amounts to maybe 20% of the night.
Much easier to use 4 EPAP and 8 IPAP for 80% if the night instead of 12 EPAP and 16 IPAP all night long just to cover my 20% of the time in REM.
Same sort of thing if side sleeping vs supine (on your back) and more pressure is need when on your back.

Just a thought.

[at_switchback]

Pugsy: thank you very much for your two replies. I will read them more carefully when I return. In the meantime here is a share link from SleepHQ:

https://sleephq.com/public/teams/share_ ... /dashboard

Looking forward to hearing your thoughts.

Dan

[Pugsy]

I reviewed the SleepHQ report.

To my eye the OA flagged was definitely arousal related....you can safely toss that one out the window.

To CAs/Centrals....there was one maybe sleep onset central flagged which is actually normal to see every now and then when you transition from awake to asleep. There was one "maybe" real central which would have been sleep onset anyway.
All the rest of the centrals were definitely post arousal or awake flagged events. They don't mean much except to point to not sleeping as soundly as we would like. You had a lot of arousal breathing going on (you may or may not remember the arousals)

All this really means at this time is you didn't sleep as soundly as we would like but actually fairly common for someone new to bilevel therapy.
Was it the newness of it all or some other factor like medications or other health issues (like pain) or maybe noise...could be anything.
Not so great sleep quality overall...didn't sleep anywhere near soundly. Doesn't surprise me that you felt the need to nap.
8 hours of crappy sleep is actually worse the 6 hours of sound sleep...that sort of thing. Ideal, of course, is 8 hours of sound sleep but that's not so easily obtained even after being on this therapy even after 15 plus years on the machine....I speak from experience there.

In S mode you have fixed EPAP and fixed IPAP and the difference between the 2 is called pressure support even though you may not see that as an actual setting. I don't know that you need more than 9 EPAP and 11 IPAP since you only had the one not asleep OA flagged...so I see no need into increasing those settings and more pressure won't fix the centrals even if they were real asleep centrals. If anything I would reduce the pressure a bit...maybe go down a bit on the EPAP and IPAP and maybe increase the PS to 3 or 4.

Remember the machine can't tell if you are awake or asleep since it only measures air flow/breathing and has no way to measure sleep itself.
It's good but not perfect. My dream is for a cpap that can actually measure sleep and only respond when something happens and a person is asleep for sure. My own AHI ranges from 1 to 3 and 75% of any of those flagged events are arousal/awake related. I don't sleep so great or soundly myself....I am 74 and eat up with arthritis and the pain wakes me up often so I always have a few arousal related flagged events that I have to ignore.

Your most important metric to measure....how you sleep and how you feel. The numbers don't mean squat if you aren't sleeping well and feeling decent.

Give yourself at least 1 week at a setting change (unless the change was a total disaster which I did early on in my therapy) or with a group of settings. Only one change at a time if at all possible so that you can know what change gave what result. It's kinda bad to have a disaster and you changed 3 or 4 things because you won't know which change caused it. Remember Science 101...keep your variables to a minimum with each experiment.

[at_switchback]

Sorry to hear that pain and discomfort is keeping you up at night. Not a nice confounder on top of your sleep issues. Have you maximized your mattress, mattress topper, bed frame, and pillow situation?

I definitely follow your wider margins with respect to pressure support at 4. I'm not sure that I follow your approach on why you're thinking lower overall pressures. I understand that the lowest effective pressures are optimum therapy, but I've had pretty remarkably fragmented sleep that has not responded to the lower CPAP pressures. The logic that underlies the thinking of going to 13/9 on BIPAP and then trying 14/10 and then 15/11 after each level has had sufficient opportunity to bear out is an approach where the RERAs are targeted.

Your advice about not moving too much all at once is really good for me to hear because less is more, and I'm often too tempted to overthink something such as this, which really requires titrated experimentation.

My doctor ordered a home sleep profiler study where I wore an EEG-like headband while on therapy, and it showed that I was having cortical arousals every 2 and sympathetic activations every 3 minutes.

I've heard such great things about BIPAP. I hope that in time, its effectiveness for me plays out.

[Pugsy]

I'm not sure that I follow your approach on why you're thinking lower overall pressures. I understand that the lowest effective pressures are optimum therapy, but I've had pretty remarkably fragmented sleep that has not responded to the lower CPAP pressures. The logic that underlies the thinking of going to 13/9 on BIPAP and then trying 14/10 and then 15/11 after each level has had sufficient opportunity to bear out is an approach where the RERAs are targeted.

I suggested maybe lowering pressures because you aren't showing a bunch of OAs that need more pressure to be prevented. I don't see the need but you may or may not need higher for your own comfort.
Be careful...don't exceed 4 PS whatever you do....sometimes PS itself can trigger centrals.
More pressure won't do a darn thing for the Centrals though and in fact higher pressures can trigger centrals.
More pressure can also invite a visit from the aerophagia monster and he is not a pleasant guest. You don't want him. He likes higher pressures.
I just don't believe in using something if it won't help and might hurt....
You would only need higher pressures if you saw a sizable amount of real asleep OAs.

These machines work on the premise that they will try to prevent more obstructive apneas if you have more than the algorithm likes to see.
During an obstructive apnea the machine does absolutely nothing but sit and twiddle its little thumbs because it can't muster up enough pressure to blow through and obstruction. It registers the OA in its memory and depending on what it is sensing in terms of maybe more OAs or Flow Limitations it will decide if more pressure is needed...now that how the auto algorithm works but since you are using fixed pressure mode it can't do anything even if it wanted to. In your situation the machine wouldn't want to go higher anyway. You aren't having a bunch of OAs that are real asleep OAs (you only had the one that was arousal related anyway) and your flow limitations are actually fairly decently low.
So there is no real need to go higher for sure and you could maybe go lower. That's my reasoning for that idea of mine since I tend to be ultra conservative with pressures. Now I know of people using more pressure than they may technically need for OA prevention but it feels better to them and they have ultra low AHI numbers but more importantly they report sleeping great and feeling great so I take the approach of "if it ain't broke I don't go about trying to fix it"

Remember also that these machines can't do a darn thing about real asleep centrals anyway. Even in auto mode it couldn't/wouldn't do anything. There are some specialty machines that do treat centrals and essentially breathe for you but yours can't do the massive and rapid increase that are needed to deal with centrals.

So for OAs....the your machine won't/can't do a darn thing DURING the actual apnea event and instead it hopes to prevent you from having a truckload of more OAs.....one or 2 OAs over the night or even over an hour or two isn't that big of a deal. If you were hoping for AHI of 0.0 don't go down that road. It does happen but it's rare. I can count on 1 hand the number of 0.0 AHIs I have had since 2009.
And sometimes AHIs don't tell the whole truth. I remember one day I woke feeling amazing and slept great...thought for sure I must have had AHI 0.0 but when I checked my data the AHI was around 10.0...I thought "huh, what the hell".....but next night it was back down to around 2 AHI and I felt crappy. This was early in my therapy and because we had all these detailed reports I couldn't put my data under the microscope but now that I know what I know it was probably a night with my usual arousal flagged events but I didn't remember the arousals so I slept better and thus felt better. I have always said if I could feel that good with 10.0 AHI I would happily take that AHI every day of the week.

And yes....I have pretty much done or tried or do all the usual stuff when a person has a lot of pain from something. It's not horrible pain but just enough to wake me up and I can't lay on my back at all without pain. What usually happens is I start out on my side and sometime or other I roll over on my back but after 5 minutes laying on my back causes pain and I wake up and turn back over on my side and go back to sleep (hopefully). Right now I am fight bone on bone knee pain as well as a screwed up back. I need a knee replacement but can't get it done until we get my husband over his current ordeal so he can help me. I am 74 years old...this getting old sure isn't for sissies but it beats the alternative.

[at_switchback]

Have you thought about using a sleep positioner (Night Shift Sleep Positioner) not for the usual avoidance of supine sleep reason (positional supine OSA) but to stay off of your back due to pain? I could see that helping or not helping (just being another annoyance when you are on your back).

[Pugsy]

Have you thought about using a sleep positioner (Night Shift Sleep Positioner) not for the usual avoidance of supine sleep reason (positional supine OSA) but to stay off of your back due to pain? I could see that helping or not helping (just being another annoyance when you are on your back).

Over the years I have tried just about everything to help me stay off my back but they are annoying and I had limited success because I actually need to change sides when I sleep. I can't stay on just one side because of both my shoulders being a problem...the side down gets tired and painful so I have to switch sides. I even got a SCS (spinal cord stimulator) a few years ago to help with the back pain. It did help a lot for generalized pain but still doesn't allow very much supine sleeping. It's my SI joints that are the main culprit when it comes to supine sleeping.
I was in a bad car wreck in 1990 and a bunch of things got all broken and then arthritis set in.. I tell you this getting old isn't for sissies.
My pelvis was broke in 8 places...bunch of ribs broken and a punctured lung. I am lucky to be alive.

I worked in the medical field before the accident and I have tried to keep up with stuff so that I can try it if it might work.

[at_switchback]

My second night on BiPAP was way better (subjective feeling upon awakening) but my mountain range leaks were back, which I just don’t get.

Screenshot 2026-09-24 072651.png (20.83 KiB) Viewed 16397 times

Wednesday's night sleep was 13/9 and I feel so much better in the morning despite twice the conscious wakeups.

Leak data terrible again. I flawlessly (so I thought) executed the mouth taping (horizontal no stretch, vertical stretch plus MAD) and tested it throughout the night. Still I have a mountain range of leaks. I have had enough days since my last Afrin use, I could try that tonight — or maybe back to a full face mask? My first night of BiPAP on Beep Eclipse nasal pillows had a pretty decent leak profile. Ugh. Should I try to optimize Beep Eclipse or add in the mask change variable hoping for a better leak profile. Yes, I have a deviated septum, enlarged turbinates and narrow nasal passages.

I definitely had a halo right nostril leak before getting into bed but I added a third halo segment and no longer felt the leak (could a botched halo install cause mountain range leaking — nose leak, not mouth leak)? (New climate line hose, day five of the new Bleep eclipse, no humidity.)

I'd love to see if the existing settings without a leak lead to rounded tops. BiPAP Inhalation and exhalation was easy!

Thank you all.

Dan

[Pugsy]

It is an ugly looking report but it barely goes above 24 L/min which is ResMed's line in the sand for large leak territory.
That 24 L/min is an ultra conservative line in the sand because the machine can compensate for leaks above 24 L/min and therapy isn't compromised. Up to 30 to 35 L/min can occur before therapy might be compromised and then only for the time above the large leak.
So even though a bit ugly....you were below the 24 L/min line for the majority of the night and your therapy itself was still good....and the time above 24 L/min was very brief and barely above 24 at that.

Now with that amount of leak it is very possible that the leaks disrupted your sleep so we don't like that much leak from a sleep disruption standpoint but we know that the therapy itself was doing its job. If you slept through it I would tell you to shrug your shoulders and not worry so much.

If you applied tape to your mouth and the tape was still secure in the morning then you know the leak was at the mask level.
If the tape came loose you don't know for sure if it was mask loosening or movement or mouth breathing.

[michaeldwilson]

Oh.....the auto adjusting algorithm is pretty darn good. I use it myself.
My OSA is much worse in REM sleep but not so horrible in the other stages of sleep (or sleep position). It's much easier to let the machine increase for what I might need in REM and then go back down when not needed. REM amounts to maybe 20% of the night.
Much easier to use 4 EPAP and 8 IPAP for 80% if the night instead of 12 EPAP and 16 IPAP all night long just to cover my 20% of the time in REM.
Same sort of thing if side sleeping vs supine (on your back) and more pressure is need when on your back.

Just a thought.

I’ve always been a back sleeper and avoided side sleeping because it jars my full face mask. But after some night gasping, I tried sleeping on my side with my mask. It worked much better than I thought it would. I wish I would have tried this years ago.

[at_switchback]

If you are not familiar with it checkout the Bleep Eclipse. Nasal Pillows without headgear, so side sleeping presents none of the usual headgear side sleep leak issues.

[michaeldwilson]

If you are not familiar with it checkout the Bleep Eclipse. Nasal Pillows without headgear, so side sleeping presents none of the usual headgear side sleep leak issues.

I am a mouth breather so the full face mask has been most comfortable to me. Thanks.