advice/thoughts on improving settings?

Hi everybody!

After some reports saying that many people can reduce their events with a brand change, and the doctor recommended ResMed machines as well, and said that a bipap would probably help both with aerophagia and centrals, I bought a new used machine from the wonderful folks at secondwindcpap (thank you again for the impressive service if one of you reads this!)
So I used the same settings as the previous machine, opened up a bit the bottom and the top, and set the pressure support on 4 (as the previous EPR was giving me awful aerophagia)
This is clearly just one night, but... would you recommend any changes?

Shnorky wrote: ↑

Tue Jun 12, 2018 2:50 am

Hi everybody!

After some reports saying that many people can reduce their events with a brand change, and the doctor recommended ResMed machines as well, and said that a bipap would probably help both with aerophagia and centrals, I bought a new used machine from the wonderful folks at secondwindcpap (thank you again for the impressive service if one of you reads this!)
So I used the same settings as the previous machine, opened up a bit the bottom and the top, and set the pressure support on 4 (as the previous EPR was giving me awful aerophagia)
This is clearly just one night, but... would you recommend any changes?
sh.png

Looks like a PS of 4 is too much for you... and is causing centrals. I'd say give it another day or two, and see if they get better, if not you'll likely need to reduce the PS.

palerider wrote: ↑

Tue Jun 12, 2018 2:57 am

Shnorky wrote: ↑

Tue Jun 12, 2018 2:50 am

Hi everybody!

After some reports saying that many people can reduce their events with a brand change, and the doctor recommended ResMed machines as well, and said that a bipap would probably help both with aerophagia and centrals, I bought a new used machine from the wonderful folks at secondwindcpap (thank you again for the impressive service if one of you reads this!)
So I used the same settings as the previous machine, opened up a bit the bottom and the top, and set the pressure support on 4 (as the previous EPR was giving me awful aerophagia)
This is clearly just one night, but... would you recommend any changes?
sh.png

Looks like a PS of 4 is too much for you... and is causing centrals. I'd say give it another day or two, and see if they get better, if not you'll likely need to reduce the PS.

Thank you, I was not aware that higher PS could trigger centrals!

Shnorky wrote: ↑

Tue Jun 12, 2018 3:44 am

Thank you, I was not aware that higher PS could trigger centrals!

It can in some people..and a very small number of some people at that. Sometimes any pressure support will do it in some people.

I know a woman who gets an AHI of about 16 per hour with 95% centrals when she uses PS of 4 on the same machine you are now using...and with the PS of 3 she maybe might see 3 centrals for the total night.
She needs the PS because of her pressure needs being in the upper teens. Just doesn't sleep so great without the exhale relief that PS offers. So with a bit of time and experimenting we figured out that PS of 4 was too much and PS of 1 or 2 she slept badly due to problems exhaling but with PS of 3 everything lined up. Central numbers were no more than normal...she was comfortable...slept good and her AHI is consistently less than 2.0 and often less than 1.0.

I think if it were me I would not only play with PS by reducing it...I would also try lowering minimum EPAP and see how things go.
Not necessarily at the same time but eventually try a little lower EPAP and see what happens with the OA stuff.
If you reduce PS and the centrals don't reduce...for sure try lower EPAP.
While PS can trigger centrals in some people it isn't the only culprit known to trigger centrals.

All this is assuming those are real centrals and you were for sure asleep when those centrals were flagged.
Do you know how to zoom in on the flow rate to look for awake vs asleep breathing flagging?
If not...watch the videos here especially the last one.
http://freecpapadvice.com/sleepyhead-free-software

Pugsy wrote: ↑

Tue Jun 12, 2018 6:41 am

I think if it were me I would not only play with PS by reducing it...I would also try lowering minimum EPAP and see how things go.
Not necessarily at the same time but eventually try a little lower EPAP and see what happens with the OA stuff.
If you reduce PS and the centrals don't reduce...for sure try lower EPAP.
While PS can trigger centrals in some people it isn't the only culprit known to trigger centrals.

All this is assuming those are real centrals and you were for sure asleep when those centrals were flagged.
Do you know how to zoom in on the flow rate to look for awake vs asleep breathing flagging?
If not...watch the videos here especially the last one.
http://freecpapadvice.com/sleepyhead-free-software

Thank you for the advice and for the videos!
You just made me realize that I thought the lower pressure was 9, whereas it would be 9+4, so 13, and thus 2 more than on the previous machine instead of 2 less. Oops!

When you get a chance be sure to update your equipment profile to reflect your new machine to avoid potential confusion later.

Shnorky wrote: ↑

Tue Jun 12, 2018 2:50 am

So I used the same settings as the previous machine, opened up a bit the bottom and the top, and set the pressure support on 4 (as the previous EPR was giving me awful aerophagia)

Shnorky wrote: ↑

Tue Jun 12, 2018 7:40 am

You just made me realize that I thought the lower pressure was 9, whereas it would be 9+4, so 13, and thus 2 more than on the previous machine instead of 2 less. Oops!

The statements you've made make me suspect you're a bit confused about how bilevels work, maybe it's just the way I'm reading what you've said.

What were your previous machine's settings?

EPR works by lowering pressure when exhaling, PS works by raising pressure during inhale. They end up doing the exact same thing in the end, but they go about it in opposite ways the way they're set.

Your realization on the 'lower pressure' seems to be flawed... in this instance, your lower pressure is actually 9, and then when you inhale, it rises to 13 (epap +ps = ipap).

That would be the same as having a regular cpap (elite/autoset) pressure of 13, with EPR of 4 (which, of course, can't be done since EPR only goes to 3)

Also, just noticed you previously had a respironics, they don't even have EPR... they have flex.. which sort of works somewhat like EPR, but with less pressure changes... so your current setup would be like a respironics with a pressure of 13 and a flex setting of 8-10 (which, also isn't possible since flex only goes to 3).

Thank you for the kind explanations!
It makes sense, just I'm confused sometimes (been known to wear tshirts the wrong way round, etc, too )

Shnorky wrote: ↑

Wed Jun 13, 2018 1:33 am

Thank you for the kind explanations!
It makes sense, just I'm confused sometimes (been known to wear tshirts the wrong way round, etc, too )

No worries, there's a lot of changes between your previous machine and the one you have now.

I quite like the one you've got now,

Just for the record, the following two nights, after making the suggested changes.

As per our chat on irc... your old pressures were 11.5-14 with flex 3, that equates to about a minepap 9.6 ps 1.8, maxipap 14.

I'd suggest reducing your PS another notch.

Are you are on any medications? If so, what?
I assume you felt you slept soundly those nights? Or do you think it was fragmented with a lot of wake up?

Can you zoom in on the 2:20 cluster of Centrals on the Wed report? Make sure to include the OA that was flagged right before the centrals.

I think we probably need to do some looking and see if we are worrying about real centrals or not.
Watch the videos here especially the last one.
http://freecpapadvice.com/sleepyhead-free-software

Thank you, I changed the settings yesterday as you suggested, apart from the large leaks it seems to have gotten better (will leave the settings like this for a few nights to check, unless you have any advice?) Pugsy, no medications apart from methsomethingsomething (PPI) against GERD. And yes, no conscious waking up at all, or none that would have stayed in memory. According to the video this looks like some kind of awake-CA, right? weird.

Yeah, to me it looks like post arousal....see the irregular breathing prior to the start of the first OA (which I am not so sure is real either) at around 16:30...that's an arousal and the rest of the breathing doesn't look like asleep breathing.

At some point I would like for you to at least try a night with no PS. Set it to 0 and let's see if the whatever those central flags are (real or not) reduce. If you get the leaks fixed and the centrals return in excessive numbers.

Even if none of this stuff is "real" it bothers me that you might be having so many arousals from something.
You don't necessarily remember all arousals either. You only remember them if you are awake long enough to remember it...if the awakening is very brief you won't remember it.
So if those aren't real it still means crappy sleep quality and if real...well means crappy sleep and a worry about centrals in numbers that we don't like to see.

When you have such massive leaks we don't know if the absence of anything is real or not. So this "good" night might not have been so good if the leaks weren't so bad. Did a lot of stuff happen but the machine just couldn't sense it....maybe.
The big block of leak starting at 3:45 is the one that really concerns me. When excess leak gets that bad we can't trust the data for that time and since it was quite prolonged it could have impacted the good appearing AHI.

For now work on leak management and see what your reports look like with the leaks managed better.
Short periods of large leak not a big deal except it might be a factor in some arousals. But anything over say 45 for very long we just can't trust the blank spots to mean nothing happened.

Thank you for taking the time to look at this data!
It's an awesome help, and very much appreciated!
(I'll follow your advice, a few days without leaks, probably after the weekend as sleeping in usually creates CAs as well, or at least used to on the other machine, and then reducing the PS slowly down to 0 and see what happens.)