Help with Latest Sleep Numbers, Could it be Leaks?

[LookingEast]

I'm uploading jpgs of my latest SleepyHead data results. (I'm three weeks new to BiPap therapy)
I've been wearing the ResMed Swift For Her with my PR Auto BiPap machine with heated Humidifier and using it every night.
But --- when I wake up, the mask is OFF and I have NO MEMORY of removing it.
Most nights, I'm in bed about 2 hours more than these results measure, but again, have no memory of the mask came off during the session.

1. Am I having more than "OK" levels of LEAKS?
2. Also, I still see the groups of events vs. throughout the night. Does this signify anything in particular?
3. What's up with my Resp Rate? It seems erratic or am I misguided by the jaggedness of the graph?
4. Results of 6/10 with AHI of 12.8: shows A LOT of activity in spurts -- but looks like mask was off/leaking? YET --
the results on 6/14 have an AHI of only 3.79 but also have a strong marks in the leak action in the graph.

I'm not sure how to read the Leak results.
Can someone help out?

I'm getting a new mask-the one I have, the velcro head strap broke. I'm getting an AirFit P10; I don't like the rubberiness of the Swift straps and think I'll prefer the cottony ones.

I posted most nights since last posting but left out some of the shorter nights.
Thanks in advance,
Sue

[LookingEast]

One good thing I wanted to mention is I've not been waking up everyday with headaches since I began using the BiPap.

[Pugsy]

There's a setting in the clinical menu called Auto Off....this setting will either let the machine turn itself off when you remove the mask without knowing it...that setting is "On".
If it is set to "Off" the machine should keep blowing if you remove the mask until you manually turn the machine off.
From the looks of your graphs it looks like you were at least wearing the mask for at least this entire reporting period meaning leaks aren't from the mask being off if that is what you were asking.
You can confirm by going into the clinical menu and look for that Auto Off feature and see if it says "On" or "Off" as a choice. If the mask is off and the machine is blowing the leak will be very large and flat line probably up around 100 L/min. This doesn't look like a mask leak that comes from the mask being off...it looks like a mask being used leak rate.

SleepyHead makes mountains out of molehills when looking at the leaks at this scale level. Large leak territory is somewhere around 80 to 90 L/min with your machine and your mask at your pressures. You rarely even come close to that large leak territory boundary line.

Ignore the ragged respiration graph line. It's nothing to worry about. You should see mine sometimes.

On June 9....were you awake and using the machine at that 10:30 or so time frame where things are ugly? Tossing and turning or half awake by chance?
Same question for June 11 but around the 12:00 time right before the machine was turned off?

Did you take your mask off without knowing it 2 hours prior to waking up on each one of these nights posted?
Have you tried a little taping of the straps to the cheeks so that when you attempt to remove the mask in your sleep the discomfort of the tape pulling on the skin would wake you enough to stop the unwanted behavior?

What about the leak report do you have trouble understanding?

You have some good reports and some ugly reports. Makes me wonder what changed to cause the difference.
Any idea? Did you get "better" or "worse" quality sleep with the good or the bad night? Change in sleeping position?
Do you spend much time awake with mask and machine on?

[LookingEast]

There's a setting in the clinical menu called Auto Off....this setting will either let the machine turn itself off when you remove the mask without knowing it...that setting is "On".
If it is set to "Off" the machine should keep blowing if you remove the mask until you manually turn the machine off.

Mine was set to off, I changed it to on.

Back to my original question, then, could it be that the mask was off and still blowing when things got "ugly" with the data?
I don't remember any "more unusual than usual" sleep or awake events on any of the given days.

I'll try the taping idea, thanks for the suggestion.

Overall, sleep quality feels better. I say this because of the cessation of horrible awakening headaches and also, my memory is improving a teeny tiny bit; but I'll take what I can get.

What I don't understand about the leak report was answered, I think, by the auto-off feature you mentioned. Meaning now that I have it "on" it will stop blowing AND stop measuring if the mask comes off, as I understand it...?

Today's Graph:

I'm guessing I had the mask off (and blowing) after 9 am -- I have no recollection. I actually woke at 10:15. I thought I took the mask off when I woke up but it could have just been on my head and face and not under my nose. (Swift for her).

I had fallen asleep without it (unintentionally) at about 2 am and put it on at 6 when I woke and then went back to sleep.

The graphs look really good until the 9:00 time and then goes crazy.

I felt I got good sleep. (The Hs are tapering off overall as well.)
Sue

[Pugsy]

No, you didn't remove the mask at 9 AM. If you did the machine couldn't record all the other stuff that you see like respiration, etc. It got ugly but it wasn't because the mask was off.

When a mask is removed and the machine continues to blow (like with the Auto Off feature turned Off) the machine will show pressure but nothing else...no events, no leak, no respiration and if using Encore it would show "machine on but not used" time.

Now as to why it got ugly. I don't think we can blame it on leaks.

The centrals could be a response to the increased pressure. The machine's wanting to increase the pressure could be in response to that truck load of Obstructive apneas. Why so late in the sleep session? I don't know unless maybe related to sleep position meaning your OSA is worse with supine sleeping and maybe you were on your back during that time so the machine needs to use more pressure to deal with the OAs and the centrals pop up because of the higher pressures.

When is your follow up visit scheduled with your sleep doctor? If you don't have one you probably should make one.
Did you have an in lab sleep study where they actually titrated you to a specific pressure range? Were there any centrals mentioned in that report? Did you have centrals mentioned in the diagnostic sleep study without the machine? Do you even have copies of your sleep study reports? If not...get them.

The leak graph...part of that increase in leak is a reflection of the increase in pressure...more pressure means more intentional mask venting which is included in that top line on your leak graph. It's not all venting though...there's some excess leak in there too. Most likely because the mask is just difficult to keep sealed at the higher pressure.
It's not enough leak to invalidate the results though...the machine could still sense that something is going on.
That ugliness is real and needs to be looked into.

[LookingEast]

Could the mask have been "on" but smashed into my face or something? I'm a very "active" sleeper - covers are in a pile and/or on floor most mornings.

I agree the mask (Swift for her nasal pillows) doesn't seal well in response to the a pressure increase. One of the side strap did break and I'm waiting for a new mask, different brand.

What are centrals?

I was told to have a follow up 60 days after start of biPap treatment so that's not until july 21.

I don't like the doctor who ordered the study, he's had little contact with me and is unresponsive to calls, etc. in a timely fashion. There's still a call into him from the Resp Therapist with my first 2 weeks of usage data and my concerns, but no call back so far.

I'm going to make an appt for follow up with another, sooner than July 21 if numbers get crazy like last night's. That graph just went bonkers at 9 am - I'm not sleeping on my back as far as I can tell - never wake up that way. I love side sleeping, curled up, etc. Thinking the mask must be sliding around too much...

Sue

[Pugsy]

Centrals are open airway cessation of breathing. Hold your breath for 10 seconds. That's an open airway cessation of breathing but you did it on purpose. A few centrals here and there is no cause for alarm but you are having more than a few and they may be related to the higher pressures that the machine wants to go to. If you told me you were awake tossing and turning during that time period we could maybe explain away some of those centrals as awake breathing flags but you think you slept soundly so we can't easily explain them away and when we see this many we have to look harder.

Can you zoom in on a few of those centrals and get me a screen shot of what the breath by breath flow rate looks like?
To do it easily go to the events tab...then to the Clear Airway category and click on it...it will then open up so you see all the Clear airway events you had during the night with the times you had them. Click on one of group of CAs....sort of in the middle of a short time frame. When you click on the individual event the flow rate graph will automatically zoom in on that event and hopefully include 3 or 4 of them on either side.

If you are a very "active" sleeper don't count out rolling onto your back at times.
Those OAs that likely caused the pressure increase could also maybe be happening during REM stage sleep.
Something is making the machine want to go with the higher pressures and it isn't the centrals because the machine doesn't respond to centrals with more pressure.
I know you want to blame the leaks but I think the leaks are a by product and not the cause of the ugliness.

[LookingEast]

Attached is a screen shot of what I think you asked for, let me know if you need something else.

I see a rise in the Leak graph same time as everything got "ugly" which is why I was wondering if that was a factor/cause/anything...?


Thanks,
Sue

[Pugsy]

Can you do one more zoomed in image for me? This time choose the CA group that coincides with the green PB bar. I can't tell exactly what time but maybe # 41 at around 10:09.

The ugliness started at 9:00AM before the leak showed the big increases. Remember a good bit of that increase in leak is a byproduct of increased intentional leak rate that comes with the pressure increases and is normal venting.
With this first zoomed in image take a look at that leak line zoomed in....not bad at all...in fact actually probably normal..see the gradual increase in leak coincide with the increase in EPAP pressure?

Is your machine's LCD screen showing any time spent in large leak? It should show a % of time in large leak if it thinks you went into large leak territory per its calculations.
Do you have Encore software? I forget. What operating system is on your computer?

[LookingEast]

Is this the correct zoomed-in spot?
My machine info shows 0% leaks in the "info" window. Is there another place I can check?

I don't know if I have Encore software - how do I find that out?

I'm on a Mac using OS10.6.8.

(not to confuse things but I only used the machine about an hour last night. It kept doing that thing where I could feel the pressure abruptly halt only 3/4 of the way through my inhalation. It was so frustrating I couldn't get to sleep. At this point I don't know what to say to a doctor.)

Thanks,
Sue

[Pugsy]

You don't have Encore...it won't work on a Mac anyway.
That's okay I was just wanting to see if it flagged any of those borderline up around 80 L/min leaks as large and if it says 0% on the LCD screen then it didn't.
Yes, that is the correct zoomed in spot. I just wanted to see what it was calling PB and what I see is what I pretty much expected to see. Not sure if we are looking at CSR Cheyene Stokes Respiration here but it surely is suspicious for it.

I don't understand what you are describing about the machine and what it is wanting to do or what you are sensing it is doing but it sounds like it is related to the BiFlex settings in some fashion. Did you ever try the different BiFlex settings to see if one would feel better than the other or even turn it off?

What it looks like when things get ugly is CompSA. Now please understand that I am not saying that this is for sure what is going on but it is surely suspicious. See this video
https://www.youtube.com/watch?v=CU-XTcf ... e=youtu.be
If it is CompSA it seems to be related to when your pressures go up trying to chase what it thinks are OAs...maybe they are and maybe the machine has it wrong.

Ideally your doctor needs to be actively helping you here and not some fly by night dial a winger on an internet forum . So let me just say that right now. Your doctor needs to get on the ball and evaluate your data. He's the one that should be helping you sort all this out but sounds like your doc has dropped the ball. I can give you some ideas but please don't mistake them for more than what they are...ideas and maybe.

That said....IF (and I am saying a big IF) this is CompSA there is a possibility that it could be manage by simply not allowing the machine to go to those upper pressures IF the pressure itself is the trigger for the instability.
Sometimes there is a fine line where the Obstructive sleep apnea can be well controlled with so and so pressure and by not going above a fine line in pressure the centrals don't rear their ugly heads. Now we don't know IF for sure it can be and we don't know where that fine line might be.

Idea number one...limit the maximum IPAP to maybe 10 or 11 and see what happens...see if the CAs reduce and aren't replaced by a bunch of OAs.

[palerider]

not to be alarmist, but the last time I saw a breathing pattern like that, it was the result of congestive heart failure... in a 39 year old.... he's currently doing much better after a lot of time at a cardiologist and time in a heart failure clinic... as well as supplemental oxygen at night.

It won't hurt to run that by your doctor and see if a visit to a heart doc to rule that out.

[LookingEast]

not to be alarmist, but the last time I saw a breathing pattern like that, it was the result of congestive heart failure... in a 39 year old.... he's currently doing much better after a lot of time at a cardiologist and time in a heart failure clinic... as well as supplemental oxygen at night.

I just had a very thorough physical and that included tests and scans from head to toe. Only "remarkable" findings were same as usual: familial high cholesterol and BP, both treated and long-standing hypthyroidism and Hashis, also treated. Last test to have is a barium swallow due to longstanding difficulty swallowing but an endoscopy already ruled out anything GI.

My sleep study itself showed an AHI of 10, mild apnea. It's just that one night just went really wacko for some reason and, ironically, I woke up the most rested.

I talked to my doctor's office today, they are going to have the DME resend them the data from my BiPap therapy results and will get back to me in the next day or two, phew!

[LookingEast]

So let me just say that right now. Your doctor needs to get on the ball and evaluate your data. He's the one that should be helping you sort all this out but sounds like your doc has dropped the ball.

Yes, understood.

I talked with his nurse today and she said they didn't receive the fax from my Resp Therapist at the DME so I put in a call to her to re-fax. I'm also in process of finding a new doctor that my insurance accepts.
I want to stay on top of this.

So very frustrating when I was told I have such mild AHI to begin with, at 10, and the BiPap could help get it to under 5.

I've also requested my sleep study reports so hopefully I'll get those soon as well.

Sue

[Pugsy]

There's a small % of people who start cpap/apap/bipap therapy that will see centrals develop as a result of the therapy where there weren't any centrals before. It's a breathing instability brought on by an imbalance in the oxygen/carbon dioxide levels in the blood and the CO20 gets washed out too soon before it gets high enough for the brain to say "OMG too much CO20 & I need to tell the diaphragm to breathe" and if this happens the person gets into a nasty little cycle that sort of feeds itself. You might be one of those people. Funny thing is that when this happens and a person in on cpap/apap the usual next machine to try is the bilevel like you have and if that fails then the high dollar bilevel ASV type of machine.
Also sometimes when this happens the body can sort it out on its own and the centrals can go away with just some time. So some docs prefer to adopt a wait and see approach before bringing out the high dollar machine just in case the instability clears up on its own.

At any rate since you have an active (hopefully) doctor already on board it just makes sense to let him do his job if at all possible. I think I saw where in one of your reports you had a truckload of centrals and didn't have much of a pressure increase at all so I am not sure at all if pressure alone is the trigger in your situation.
While increasing pressure can cause centrals they aren't the only cause...so best to have the doctor on board in situation like this whenever possible.
I have seen people have a boatload of centrals with a pressure as little as 6 cm...so sometimes it isn't higher pressure...it any pressure.

Keep us posted. We do care.