Help with TECSA with new bilevel user

Hey CPAPTalk Friends,

I am learning how to titrate my newly obtained bilevel machine to treat OSA. I have a few questions for you as you have been so helpful in this journey.

My sleep studies ranged from 5 to 24 AHI, all obstructive. I was started on CPAP for the first 18 days and struggled to fall asleep breathing against pressure, so I was moved to a bilevel (AirCurve 10). It is much much easier now to fall asleep and I can sleep all night.

Analyzing my data, my AHI is low, but it looks like I am having some treatment emergent central sleep apnea. I think there are events that are not being flagged as central apneas that are centrals and that my disturbances are actually higher. You can take a look here:
https://sleephq.com/public/ee58168a-4b7 ... fbf74bb03c

If you would really prefer the OSCAR report, I can upload that too. I am still learning but I think the data from SleepHQ is still helpful.

What do you think? Am I having waxing and waning flow followed by pauses indicating central apneas that are not being flagged by the machine? I am confused by the flow rate that spikes up and down periodically.

Secondly, based on your answers, how should I adjust my IPAP and EPAP settings to accommodate and have more regular breathing? I currently am trying 9 IPAP 5 EPAP with cycle and trigger set to very high. This feels the most comfortable.

If I am missing the forest for the trees here and am off base, please chime in, and thank you for the help!

Welcome to the forum.

How are you feeling during the day?

How's your sleep quality in general? Sleeping soundly or waking frequently?
The bulk of your irregular breathing points to not being sound asleep.
The bulk of the centrals (which aren't numerous enough to worry about) also points to arousal/awake breathing false positive flagging.

I see nothing that points to treatment emergent central sleep apnea. You would need to be seeing a LOT more centrals than you are seeing and you would still have to discount those arousal/awake centrals because you HAVE to be asleep for the centrals to be "real" and matter. Anything flagged when not asleep is just ignored other than make us wonder why a person wasn't sleeping so great.

ATeam91 wrote: ↑

Sat Nov 25, 2023 8:32 pm

Am I having waxing and waning flow followed by pauses indicating central apneas that are not being flagged by the machine?

No...I just don't see it. Mostly what I see is arousal/awake related breathing.

We don't always remember the arousal or awakening.

Pugsy wrote: ↑

Sat Nov 25, 2023 8:46 pm

Welcome to the forum.

How are you feeling during the day?

How's your sleep quality in general? Sleeping soundly or waking frequently?
The bulk of your irregular breathing points to not being sound asleep.
The bulk of the centrals (which aren't numerous enough to worry about) also points to arousal/awake breathing false positive flagging.

I see nothing that points to treatment emergent central sleep apnea. You would need to be seeing a LOT more centrals than you are seeing and you would still have to discount those arousal/awake centrals because you HAVE to be asleep for the centrals to be "real" and matter. Anything flagged when not asleep is just ignored other than make us wonder why a person wasn't sleeping so great.

ATeam91 wrote: ↑

Sat Nov 25, 2023 8:32 pm

Am I having waxing and waning flow followed by pauses indicating central apneas that are not being flagged by the machine?

No...I just don't see it. Mostly what I see is arousal/awake related breathing.

We don't always remember the arousal or awakening.

Pugsy, WOW, thank you for the detailed info and help!!

Answering your questions, I feel somewhat sleepy during the day. I haven't slept as well yet with PAP therapy as without. I think I am still getting used to it. So maybe I am waking up in the middle of the night and that is what is causing this.

Here is one more data point I meant to include that muddies the water. I am also tracking my sleep each night with the Wesper sensors (https://wesper.co/), which you can see in the report here:
https://report.wesper.app/v6.0/breathin ... obile=true

The ResMed report had an AHI of .64, whereas the Wesper system reported an AHI of 23... what gives?

Thanks again for the help.

ATeam91 wrote: ↑

Sat Nov 25, 2023 9:06 pm

The ResMed report had an AHI of .64, whereas the Wesper system reported an AHI of 23... what gives?

I don't have time to dig deep into how Wesper works but the reporting criteria isn't the same as ResMed's because it isn't measuring the same stuff. I just now did a very quick look at their website and how it works.

Resmed flagged events have to meet certain requirements to earn a flag ...certain amount of flow reduction and all flagged events (OAs, centrals, hyponeas) must be at least 10 seconds in duration.
ResMed machines only measure air flow/breathing. They don't know if we are asleep or not. They can and will flag awake/arousal breathing (which can be very irregular compared to asleep breathing) as some sort of apnea event (per the criteria) but they don't really count if we aren't asleep.

From what I can gather about the Wesper...assuming it is fairly accurate but all those devices that say they can tell if we are asleep or not or the sleep stages by measuring movement or heart rate I tend to take with a grain of salt.

I do think that most likely it measures sleep disruptions or non sleep and not necessarily apnea events (per the criteria needed to earn a flag) and what it says is there were 23 sleep disruptions from some cause but I don't think that they were necessarily caused by apnea events. Meaning it can tell you (assuming accuracy) your sleep quality but I don't see how it can measure breathing well enough to say you had some sort of apnea event.

From a quick scroll through your flow rate I don't doubt 23 sleep disruptions or arousals of some sort though.
I looked at the flow rate and the first thought through my mind was "crappy sleep quality"...
I recognize it because I have that problem myself. My problem isn't related to my sleep apnea problem though.
My sleep problem is related to pain causing me to wake often and some other stressors in my life messing with me.
I routinely will see evidence of 20 to 30 arousals (I might remember maybe a half a dozen or so) every night.

So....at this point IMHO you have a sleep quality problem but not necessarily an apnea problem (the machine is doing a great job preventing the airway from collapsing). Now could the sleep quality problem be simply the newness of all this cpap stuff??? Very possible. It took me a full 3 months when I started cpap therapy just to get my brain to accept all this new alien stuff. My first 3 months on cpap I had a gazillion wake ups just from my brain telling me "hey, dudette, do you know you have an alien plastered on your face blowing air up your nose"...

My suggestion for now...give it time and maybe if you can safely take some sort of over the counter sleep aid...take it.

Questions....do you take any medications of any kind? If so, what?
Do you have any other physical or mental health issues that might be messing with your sleep?

I gotta go to bed so this needs to be brief but look at the 2 images below.
This is the flow rate or breathing and there is obvious awake breathing and asleep breathing.

I circled the ASLEEP breathing in red.



and here's the same time frame but not zoomed in so close and I think you can see the obvious asleep breathing...and the other arousal breathing and flagging...not asleep so it doesn't count and I have to mentally removed those flagged events from the calculation for AHI. Obviously the arousal breathing was very prolonged.



We don't take big gulps of air when we are sleeping so whenever you see the big gulp...arousal breath and when it precedes a flagged event like a central that means not a real apnea event...I call them false positives.
Most likely it's a turn over in bed and hold your breath central.
When I was scrolling through your flow rate on sleephq....I saw that with one of your flagged centrals (the second one I think) you had 4 or 5 big gulps of air immediately preceding the flagged event and the first through through my head was tossing and turning in bed so rolled over and held the breath long enough to earn a flag...and I think it was barely 10 seconds.

Pugsy, I can't thank you enough for the detailed thoughts and info here. This is really invaluable to someone starting out.

I don't sleep great with the PAP yet, and the whole diagnosis and coming to reality with the treatment definitely has me rather worked up. I am getting used to that, but it is a process for sure.

I will chill out and try to get used to it so I can sleep more soundly without awakenings, thank you