New CPAP User, Long time sufferer...

Hello everyone, my name is Justin or Bosh if you prefer. I've been reading up on cpap life quite a bit lately and all roads lead back to the cpaptalk forum. Thought I should go ahead and introduce myself, don't think I'll be leaving anytime soon .

I was diagnosed with OSA officially back in 2009. Had a split-night study done early that year. Been suffering from sleep apnea for most if not all of my adult life from what I can tell (I'll be 36 yrs old soon). Back at the time of my sleep study, I was given a machine and all the accompanying goodies. In truth, I didn't know what I was in for and I wasn't prepared to follow the therapy through. With the BiPAP I had back then and the mask options available, compliance was very difficult. I gave up therapy completely after a couple of months.

Fast forward to Oct. and I find myself at a sleep clinic again. This time with a different attitude. Determined to see the therapy through however difficult it is. Within a few days I've got a new Philips Respironics DreamStation Auto BiPAP. Started out with an Amara View mask, moved to the DreamWear Nasal mask. That nasal mask is so much better than anything I knew existed back in 2009. I coupled it with a single strap Resmed Chin Strap and honestly, sometimes I don't even realize I still have it on. Needless to say, therapy compliance has been 100% since day one. I'm right at the 60 day mark and I honestly look forward to putting it on every night before I go to bed, there is something strangely comforting about it. I feel like that statement probably sounds weird to 90% of CPAP users out there.

Initial sleep study clocked my AHI at 25 with only 2-3 hours of sleep. Right now my AHI as measured by the DreamStation is 4.18 (Last 30 day avg.) (2.38 CA / 1.42 OA). I've already downloaded SleepyHead (v1.0.0-beta-2) and am getting pretty familiar with the interface and the charts. Sadly in real world practice, I don't feel any better at all. It's very likely that I fall asleep 4-5 times while driving to work (26 minute trip). Usually by noon I get it together and don't feel too groggy until around 9:30pm - 10pm at which point I instantly feel like I could fall asleep standing up.

After reading the newbie suggestions post, I figure I'll be using this thread as a sounding board for the first little while to get most of my beginner questions out of the way. In advance I appreciate anyone's time who is willing to help my transition into the world of human forced induction.

I'll go ahead and post some sleepyhead screenshots of my journey thus far:

First night 10/15/2018
10/22/2018
10/31/2018

Welcome to the forum.

Can you post last night's results please?

On the right side graphs...only need
Events
Flow rate
Pressure
Leak

don't need anything else...the snores are flagged on the events graph and the respiration rate really isn't needed.

You can hide the calendar and turn off the pie chart (preferences/appearance tab) and then your setting information will move up into the viewing area.

Do you take any medications of any kind? If so what?

How often do you wake up during the night....approximately?

Hi Pugsy,

I have some additional screenshots I intended to include in the first post, but ran out of space and had to wait for the thread to be approved before I could continue. Also, thanks for the hints on how best to post the screenshots. I'll edit my original images if possible. Otherwise from now on I will post with your recommendations in mind.

To answer your questions, the only medications I take are Flonase and a daily allergy pill (Cetirizine).

Sometimes I don't remember waking up at all. Sometimes I fight my pillow setup. Still haven't gotten that situation handled. Yesterday I had my first followup appointment with my sleep specialist (who is also a neurologist and a pulmonologist). He recommended that I bump my pressures (I was already thinking of doing it anyway). I raised the EPAP to 10 (from 7) and left the pressure support the same (5.0-8.0). I will post last night's data as well.

Data from last night after the pressure increase.

Here is the additional data. Sorry things are a bit out of order.

11/14/2018
11/30/2018
12/03/2018

12/11/2018
12/12/2018

Overview and Statistics (as of 12/12/2018)

That's the end of the wall of images. Thought it might be useful to have some background data posted ahead of time. Not sure how useful the Overview and Statistics are, figured more info is better than less. Also, on my most recent images, I included the Session Information. If that's not very relevant, I can leave it out in the future as well.

Only idea I might add at this time...restrict PS. It could possibly be a factor in some of those CAs/centrals.
Maybe PS minimum of 4 and max of 5.

Maybe run with the new setting the doctor made for a week or so. Watch the CA/central index and if they are still running 2 ish per hour....then restrict PS.
I wouldn't make the change right now so soon after changing minimum EPAP. Give your body some time to adjust to the new settings first and then see if maybe another change is needed. There is some truth to the "give it time" thing.

From now on...only the nightly detailed report is probably all we need.
If we need something else we can just ask for it.

When you do post a report...always include your perception of how the night went in terms of your sleep quality and how you feel in general. Numbers don't always tell the whole story and the whole story is kinda important.
How we sleep and feel....that's why we do all this stuff...not to get a good math test score.

Last night's report not so pretty but it's a new setting and you may not have slept well.
How did you sleep last night? Many wake ups? How do you feel this morning?

Thanks again for the tips Pugsy,

As for last night, I felt a little better this morning than I usually do, but I did toss and turn quite a bit trying to get comfortable during the night. I agree with the big picture idea of therapy progress. I feel like I keep having that same conversation with my sleep specialist. He says things like, "Well, with an AHI under 5 your apnea is technically successfully treated". Then I say, "Well... it doesn't 'feel' successfully treated... and isn't that the point?". So yeah, I definitely get what you're saying... I'm going to continue these settings and see how it goes. The weekend will be a good opportunity to test them out. 'If' I can get my wife to let me sleep... lol.

Speaking of the central/clear airway events... I have tried talking to my specialist about an ASV. He seems super against the idea but won't ever give me a straight answer as to why. His first issue was that they are very expensive. They are, however with my insurance, the DreamStation ASV is going to cost me the same in the end as the BiPAP I have, so the cost is a non issue. Then he said that the insurance wouldn't cover it unless I had a titration where it was stated that the ASV was tried and helped me. I pointed out that I had already spoken with my insurance and they said that my 2009 study was acceptable because on the report it was stated that I showed the most improvement while on a BiPAP-ST. So the insurance has already said they are good to go. Then he says, "Well, a lot of patients don't tolerate ASV very well, they say it's very uncomfortable.". To that I said, "Well, isn't the ASV just a BiPAP with an additional feature? If I can't tolerate it or I don't show any improvement using that feature, can't I just turn that feature off and it goes back to being a standard BiPAP like I have now?". He agreed that it worked that way. I basically stated my case that for no additional cost to me, nor any trouble on his part, I could have an additional feature that 'might' help - even if it's only marginally. So why not give it a try? I still could not get him to agree to send an order to my DME company for the ASV.

I figured even if the central events are treatment emergent... if I could reduce the number of events by 50% with an ASV, that would be a significant bump in sleep quality - definitely worth trying I think if it doesn't cost my any additional money and the insurance company has already stated they have what they need. It's almost like he has an ulterior motive for not wanting to recommend an ASV for me. I welcome any comments from you guys/gals on what you think.

At this point there aren't enough centrals to warrant using ASV even if all of them were the real deal.
You would need to be seeing 4 or 5 per hour consistently every night and they would need to be the real deal and not SWJ sleep/wake/junk.

When you have a lot of arousals or awakenings going on the chance of false positive flags increases significantly.
They don't count unless you are asleep but the machine doesn't know if you are asleep or not...it can only measure air flow and our awake/semi awake breathing is very irregular when compared to asleep breathing. The machine can and will flag awake breathing irregularities by mistake.
You probably should go here and watch the videos and learn how to distinguish real events from SWJ flagged events which aren't real and don't count.
http://freecpapadvice.com/sleepyhead-free-software

And we don't always remember arousals...so it can happen even if we don't remember waking up much.

And finally....even if those are all real centrals...they might easily be reduced with a change in PS.
Don't expect to never see one...it's normal to have what is called a sleep onset central during the transition from wake to asleep...those are normal...real and not a big deal. They are only a big deal when present in large numbers, cause desats or keep bouncing you out of sleep. So even an occasional "real" central isn't that big of a deal.

At this point there is no urgent need to do anything about your centrals real or not. That's probably why your doctor didn't want to go down that road at this time.

That comes across as sound advice and I really do appreciate it! I wish he had taken a little more time to explain it the way you did. Maybe he did and I was overly skeptical... that's possible

The thing that really got me treating these centrals more seriously in my mind is things I notice when I'm awake and things my wife has noticed. She said when I am asleep (before therapy) I breathe so shallowly that many times she has to put a hand on my back and watch closely to see if she can detect that I actually am breathing at all. That plus I notice sometimes even when I'm awake that I 'forget' to breathe... it's kind of hard to explain. Or when I'm getting sleepy while driving, I notice that my breathing has become so shallow it's almost stopped. At those times I try to consciously take deep breathes (hoping it will help wake me up). So needless to say I was already concerned about a lack of breathing not related to OSA before starting therapy. When I saw the centrals in sleepyhead it was like, "AH HA! I knew it!".

In regards to shallow breathing, it 'seems' counter productive that less pressure support would promote less clear airway apneas. Would you mind to take some time and explain your thinking about how less pressure support would help in this instance. Not because I don't believe you, I genuinely want to understand

I am also going to check out the URL you sent. Thanks for that too.

In some people (relatively small number) PS or exhale relief (because any exhale relief creates a difference between inhale and exhale and that difference is PS) the presence of PS can cause some people to blow off too much carbon dioxide. We call it wash out.

It's actually carbon dioxide levels in the blood stream that are the driving force for the brain to send the "breathe" signals. It's not low oxygen that is the trigger. It's the higher levels of carbon dioxide that is the trigger.
For some people using a higher PS (and sometimes any PS) it simply causes too much wash out and the blood levels for carbon dioxide don't increase to the point of triggering the brain to send the "breathe" signal. So we don't breathe...shallow or not we just don't make the effort.

I know a woman who gets a truckload of centrals with a PS of 4...and none with a PS of 3...go figure that one but I have many reports from her proving it. She needs PS for comfort because she needs pressures in the high teens for the OSA control. We just got lucky that she can do well with 3 PS at her pressures and not have it trigger centrals.
When she was using PS of 4 we thought for sure that she was going to end up on ASV....but once we figured out where the line was for triggering centrals because of too much wash out...piece of cake getting her fixed up.

Why some people and not others...we don't know. Why some people can handle a lot of PS and someone else can't handle even a PS of 1 with a large number of centrals...don't know.

And at this point for you...I don't even know that the PS is the cause of the centrals.
1...we don't even know if they are real or not...if they are arousal related they aren't real and don't count and we just have to ignore them and instead work on what is causing the arousal.
2..if real we don't know if they are related to PS until PS gets reduced or removed
3...at this point it isn't urgent that we figure out exactly why anyway. If you were consistently seeing hourly index for the centrals of 4 or 5 or more...becomes more urgent.

Random bad anythings we have to ignore. I once had 17 centrals in 17 minutes...and the breathing sure looked like it was asleep breathing. Ugly bad report during that time frame but it only happened once....never did figure out why or what caused it and since it never happened again I shrugged my shoulders and moved on. Crap happens.
We base any changes on trends and patterns and not one off random bad nights.

So, to rephrase what you are saying (to ensure I understand)...

PS makes breathing easier... when breathing is too effortless, it can cause someone to breathe 'too' efficiently causing their CO2 levels to drop low enough to the point where their brain doesn't initiate the need to take the next breathe.

So PS is a fine line between 'comfort' and C02 level management.

I increased my PS because I hoped it would help stop me from breathing so shallow (the increase in pressure would 'push' more air in thus increasing the size of the breathe). I can see how there is such a thing as too much given your reasoning above. Last night I didn't feel like the increase from 7 to 10 bothered me. Perhaps I should at least drop the PS from 5 to 4, as long as it isn't uncomfortable and inhibit my ability to sleep, I don't guess it can hurt right?

I assume you get less false positives on obstructive apneas than clear airway apneas. Would it be safe to say that if you were going to 'chase' something, chase the obstructive apneas first? I was surprised to see so many obstructive apneas after raising the pressure last night. I have also noticed that sometimes, before falling asleep, that I can have an obstructive apnea while exhaling... which seems weird, I figured most people would experience obstruction on the inhale... so maybe that further supports the idea of having a higher EPAP...

Boshwash wrote: ↑

Fri Dec 14, 2018 10:13 am

PS makes breathing easier... when breathing is too effortless, it can cause someone to breathe 'too' efficiently causing their CO2 levels to drop low enough to the point where their brain doesn't initiate the need to take the next breathe.

It's not so much efficient vs not efficient as it is just the way a person's body does the exchange of blood gases.

And surprisingly....not everyone thinks PS makes breathing easier...some people don't like it and fight it and think it makes breathing harder.

All this stuff comes with a huge YMMV sticker...everybody is different.

Boshwash wrote: ↑

Fri Dec 14, 2018 10:13 am

So PS is a fine line between 'comfort' and C02 level management.

Sometimes it can be for some people. The majority of people though...no line at all. I can use PS of 6 and not have it trigger one central.
I didn't go higher because higher really wasn't comfortable for me.

Boshwash wrote: ↑

Fri Dec 14, 2018 10:13 am

I increased my PS because I hoped it would help stop me from breathing so shallow (the increase in pressure would 'push' more air in thus increasing the size of the breathe). I can see how there is such a thing as too much given your reasoning above. Last night I didn't feel like the increase from 7 to 10 bothered me. Perhaps I should at least drop the PS from 5 to 4, as long as it isn't uncomfortable and inhibit my ability to sleep, I don't guess it can hurt right?

You are thinking that the machine can make you breathe more deeply...it can't do that. How deeply you breathe is entirely up to you and if you aren't breathing deeply no amount of PS will force you to breathe deeper using this type of machine.
It's not a ventilator...it won't force you to do anything your body doesn't want to do on its own.
Now using PS will aid a person who has compromised lung functions or maybe neuromuscular issues where their body wants to breathe more deeply but can't...but it can't force the air into the lungs. To do that you need a fast and high PS response and that's where ASV or back up rate machines come in to the picture.

Boshwash wrote: ↑

Fri Dec 14, 2018 10:13 am

I assume you get less false positives on obstructive apneas than clear airway apneas. Would it be safe to say that if you were going to 'chase' something, chase the obstructive apneas first? I was surprised to see so many obstructive apneas after raising the pressure last night. I have also noticed that sometimes, before falling asleep, that I can have an obstructive apnea while exhaling... which seems weird, I figured most people would experience obstruction on the inhale... so maybe that further supports the idea of having a higher EPAP...

One would think that but it's not necessarily the case. The machine is easily fooled.
Not long ago I had a night with an AHI of 3 something and not all centrals and in fact centrals were the smallest number.
I had a nice mix of all 3 categories. AHI of 3 something (I think it was pushing 4) is unusually high for me so I took the time to zoom in on the flow rate around each flagged event. Not a single one was a real asleep flagged event. They were all SWJ. Sure surprised me that so many OAs and hyponeas were false positives...but they weren't even maybes...they were definitely SWJ.
It happened to be a bad night of sleep quality in general due to back pain issues. I woke a lot and remembered tossing and turning a lot.
Lots of arousals and some of those arousals had flagged events right after the obvious awake breathing happened or during it.

Night before last...8 total events over 6 hours of sleep...all either OA or hyponeas..no centrals at all.
2 real asleep OAs....all the rest was SWJ.

I watched the video that gives tips on being able to differentiate between arousal false positive CAs (central apneas) and what could be an actual CA.

Here is a collage of the clear airway events detected last night: