BiPAP was working amazingly and then stopped

I started using my BiPAP around the end of October and noticed a huge difference in how I felt. More energy, concentration, memory, all that good stuff. Then just before Thanksgiving I start feeling like crap again. Sometimes even worse than before I started BiPAP. Occasionally I would have a few nights where it seemed like things were getting better after I changed the cushion on my F&P Evora full face mask but it never lasted more than three days. I've done a ton of research and analysis of my data in OSCAR and tweaked my settings several times but haven't been able to figure out how to replicate those nights where I felt well rested the next day. I've only been at this for a week and some change so forgive me if I have no clue what I'm talking about but the "events" I'm having don't really look like true events at all. It looks more like I'm waking up and shifting position and the machine is tagging it as an event (hence why I turned auto off). I'm also having a lot of what look like just straight up arousals like the one in the picture that isn't tagged as an event. Between what's being tagged as an event and what's not I'm having anywhere from 15-20 of these spiky changes to my flow rate on any given night. On my good nights I've had less than 10. I've tried raising my EPAP and lowering my IPAP but I'm not 100% I'm operating on accurate information, and even if I am I'm at a loss as to what to try next, so I could use some help. Here are some screenshots of a good night (lower AHI), a bad night (higher AHI), and some of the supposed events I've been having.

https://imgur.com/a/V6J9Uqm

Bump

Welcome! Can you think of changes that happened around the time your response to PAP therapy started to flag? More stress, changes in your sleep environment, new meds or off old ones, new health problems? Changes in timing or quantity of food, drink, exercise, daylight exposure?

A couple of pieces of advice: try to go to bed and get up at the same time each night, and try to leave enough time for a solid eight hours of sleep. Stay off your screens for at least 30 minutes before you go to bed.

About your charts. Yes, you are experiencing arousals during the night. That's actually fairly normal and not necessarily a problem. Arousals become problematic when you frequently wake all the way up or stay awake for longer period of time. Do you have a sense for how often you wake up and how often you stay awake for more than, say, three minutes?

Arousals, which often involve deeper breathing, can be followed by pauses between breaths or breathing that is more shallow. This can lead to flags for CAs or Hs. Those CAs and Hs can be discounted; they're not your problem, but the arousals can be (see above). You also show an OA flagged after arousal breathing. You may have held your breath as you changed your sleep position. Again, you can discount this.

Do you have any Oscar charts from the time when you were doing well?

And why are you using a VAuto rather than a regular PAP machine?

Somehow I totally missed this response. Ironically I've learned a lot what you said here in the past month and things have improved. Not as good as I was doing in the beginning, that was the OSCAR chart with the 0.69 AHI I had initially posted, but better. I was on BiPAP because I wasn't able to tolerate CPAP during my study. I'm not clear on why they set it to VAuto to be honest and the doctors office and respiratory therapist don't really care enough to help since my AHI is under 5.

What I ended up doing was switching to a set pressure on VAuto mode so I could still see flow limitations and starting at 4-8 and increasing every night. That went great until I got up to around 7.8-11.8 and started having a big increase in CA flags. I definitely notice feeling worse too so I assume at least some are legitimate. Not sure where to go from here so I'm hoping someone can provide some insight based on my charts from the past few days

https://imgur.com/a/rLhEx5X

LordofthStrings wrote: ↑

Thu Feb 22, 2024 2:21 pm

Somehow I totally missed this response. Ironically I've learned a lot what you said here in the past month and things have improved. Not as good as I was doing in the beginning, that was the OSCAR chart with the 0.69 AHI I had initially posted, but better. I was on BiPAP because I wasn't able to tolerate CPAP during my study. I'm not clear on why they set it to VAuto to be honest and the doctors office and respiratory therapist don't really care enough to help since my AHI is under 5.

What I ended up doing was switching to a set pressure on VAuto mode so I could still see flow limitations and starting at 4-8 and increasing every night. That went great until I got up to around 7.8-11.8 and started having a big increase in CA flags. I definitely notice feeling worse too so I assume at least some are legitimate. Not sure where to go from here so I'm hoping someone can provide some insight based on my charts from the past few days

https://imgur.com/a/rLhEx5X

I believe you're inducing CA's due to low blood CO2... that starts up a cyclic breathing thing when you're starved, then saturated, with O2. Your blood CO2 regulates your breathing drive... without enough CO2 you quit breathing for a while... then the cycle can start.

Perhaps reduce PS? You might benefit by taking it down slowly, increasing your tolerance for CPAP, building up some muscles. Here's some Lanky Jason for you:

https://www.youtube.com/watch?v=GE5zpwi75yo

I'm not seeing the value of increasing your EPAP pressure. In your place, I'd go back to 8, which seemed to work well for you.

It's hard to say why you're feeling worse. I doubt whether it's the CAs themselves, though perhaps for some reason you're experiencing more arousals during the night -- and arousals are sometimes followed by CAs. Can you think of reasons why you'd be having more arousals? New stress in your life? Change in your sleep environment or eating and drinking habits? New medication?

Just FYI. Arousal breathing tends to be deeper than regular asleep breathing, and there are two theories about why arousal breathing is sometimes followed by a CA. One is that you've blown off enough CO2 to cause a pause in your breathing; the other is that something called the Hering-Breuer reflex is at work. (This reflex is a response to greater-than-normal inflation of your rib cage.)

I notice that you're going to bed at fairly different times from night to night and not using the machine long enough to be getting 7 or 8 hours of sleep. I think you'd really benefit from sticking to a regular bed-time and making sure you can get AT LEAST 7 hours of actual sleep each night, which would probably mean at least 7.5 hours on the machine.

Let us know how it goes if you return to 8. Stick with it for a week before considering any additional changes.

Some thoughts based on the feedback you guys have given:

Bedtime definitely isn't an issue. My bedtime varies by 20 minutes or so typically. Sometimes I put the mask on at different times but my bedtime is definitely regular and these days I consistently get 8-9 total hours of sleep with roughly 7 of those on the machine.

Lowering PS was something that was mentioned elsewhere as well and I'm keeping that in my back pocket as something to try.

In the meantime it was suggested in another forum that I go back to the pressure right before the CA flags started showing up so that's what I've been doing for the past few days and I got 7 hours with an AHI of 1.1 which is the lowest I've gotten since I started adjusting my settings myself and I felt pretty darn good this weekend. I was also advised to go slower with the pressure increases so I'm going to stick where I am at 7.8 - 11.8 and if all continues to go well just stay here. If not I'll increase a little and give myself a good few days to adjust. I appreciate all the advice and I'll let you know how it goes

I stuck with 7.8-11.8 for a few days and the CA flags did go back to their usual 1-1.5 range but the obstructive apneas also got worse again. Tried bumping up to 8-12 and the CA flags increased again :/. After learning more about how to read the flow chart and examining a lot of nights worth of data I'm certain these flags are arousals and my guess is the sleep fragmentation is what is causing me to still feel so tired. I'm still not sure why I was having the occasional fantastic night where I had so few events and arousals in the beginning though and am kind of at a loss about what to try next.


Reducing PS doesn't seem like a good idea now because I'm not actually having central apneas. I thought about starting all over at 4-8 and titrating slower to see if my body gets used to sleeping with the machine but it's been nearly 5 months using it and I don't feel uncomfortable going to sleep with it. It just feels natural. Any ideas, input, feedback, advice, etc. is appreciated as always