New APAP user, lots of events despite high pressure

mannsch wrote: ↑

Mon Aug 19, 2019 10:37 pm

Many of the CAs do show a big change in the breathing pattern before they happen. Is that a sign of them being arousal related?

Yes.

In the zoomed in images...to me the only one that was maybe real asleep was the first one on the first image and it was a maybe.

Nasal congestion can make the FL graph ugly.

Here's my report from last night: https://prnt.sc/ox7bq0

I am still struggling with getting my AHI down. The CA AHI is still around 5 each night, the Hypopnea AHI around 3 and then the OA has ranged from 0.5-1.8.

I've been using Otrivin nasal spray, one spray in each nostril, before going to bed. This rules out the nasal blockage as my nose stays wide open throughout the night.

I have also been experimenting with keeping EPR on (at 3) or completely off. Last night it was completely off. I don't see that it has any effect on the AHI, but keeping it on is way more comfortable.

The last two nights I've been waking up with really dry mouth. Last night I got up to drink water twice because of it.

My humidity level is already at 5 and the water reservoir is empty by the time I wake up. Any tips for dealing with dry mouth?

I am considering buying an ASV machine. Any thoughts on this?

Put the ASV thoughts on the back burner for now unless you stumble across one that is stupid cheap.
I am not 100% sure that it is actually going to be needed for several reasons but if you find one that is really cheap...wouldn't hurt to grab it up. It can be used even if it isn't really needed. Heck, I used one for a couple of years just because I liked it and I have never had a problem with centrals.

Lets try increasing the minimum pressure from 10 to 12 tonight and see what happens. Leave EPR off if at all possible.

The dry mouth is most likely from the mouth breathing and you may have to experiment with the various products out there that are available to help with dry mouth. Many people find that even with the humidifier at maximum it simply can't add enough water to the air to hydrate the oral cavity well enough. It was never designed for the oral cavity but instead designed the hydrate the nasal cavity which is much smaller.
Water consumption is determined by a few things
1...pressures used
2...leaks
3...ambient humidity in the bedroom
Hopefully if we can get the pressures to not go so wild and the leaks better managed it may not use up all the water....and you could maybe add a little more humidity setting to the mix and not run out of water.

Thanks. I will try the 12-20 pressure tonight, EPR off.

May I ask why you recommend keeping the EPR off?

Regarding the ASV, I am pretty well off financially and I don't mind spending on a new ASV machine if it can help with my sleep.

If money were not an issue, do you think it would be worth getting an ASV machine? If yes, which is the absolute best machine that money can buy?

mannsch wrote: ↑

Sun Aug 25, 2019 1:42 pm

May I ask why you recommend keeping the EPR off?

I don't like making 2 changes at one time....especially when I am wanting to increase the baseline pressure and using EPR effectively reduces the baseline pressure.
Makes the evaluation of results much more problematic...don't know which did what ...if anything happens.

While I don't think that EPR is the cause of your centrals...I want to keep that potential cause out of the mix for right now. Makes the pressure experiment cleaner. We can add it in later if needed but for now I am trying to figure out if more baseline pressure will reduce your obstructive events first and then see if the centrals change in number one way or the other.

The ResMed ASV machines....that would be what I would want...and I have tried both the ResMed and Respironics ASV models.
So either the AirCurve 10 ASV (latest model) or its older brother the S9 Adapt model 36037. There are 2 models in the Adapt line and the older 36007 doesn't have the auto mode that the 36037 has. While the auto mode might not be critical to use...better have it and not need it than need it and not have it especially when the cost difference isn't really going to be all that different on those machines.
They aren't easy to find on the secondary market and most doctors won't write a script for one unless there is a proven need....unless you have a doctor friend who will do what you simply ask of him but insurance won't pay without a proven need and some hurdles to jump.

I bought both my ResMed and Respironics ASV machines from a private individual. No way would my doctor do anything like that and no chance of my ever getting insurance to pay because I didn't technically need it to treat my OSA.
ASV can be used to treat plain OSA easily....it's not offered routinely because of the cost mainly and more recently has come under scrutiny for potential causing a higher morbidity rate among people with congestive heart failure that is bad. Long story there that I don't have time to explain but if you have a history of heart problems....tell me and I will explain so that you are informed.

There are some advantages to using ASV to treat just OSA if a person wants to do it. It's why I used one for over 2 years.
If you want to try one and can find one...I will help you with it but for now I will target what you have now to work with.
It is not yet proven that you actually really need ASV for your centrals....now once it is proven that those are real asleep centrals and they don't reduce and adequate time has passed to allow your body to adjust and they are still a bit too numerous...then we would have the ASV discussion.
You are too new to therapy right now to know for sure and your OSA therapy is still not yet optimized.

Last night: https://prnt.sc/oxm7tb (pressure 12-20, EPR off)

Total AHI: 8.64
CA: 4.26
OA: 1.83
H: 2.56
Leak rate: 0.00%

I did have dry mouth again last night, but it wasn't as bad as the previous night.

Most of the obstructive apneas happened at high pressure, often at 20. Do you know what is the max pressure of the Aircurve 10 ASV?

Some notable breathing troubles:
https://prnt.sc/oxmbjm
https://prnt.sc/oxmc1r
https://prnt.sc/oxmci7

I am not sure how the machine is determining the difference between CAs and OAs. Both seem to happen either with or without flow limitations and they look mostly the same on the flow rate chart.

The ResMed AirCurve 10 ASV machine will go to 25.

ResMed uses something called FOT Forced Oscillation Technique to distinguish centrals from obstructives
page 8 of the manual here explains it a bit
https://www.respshop.com/manuals/ResMed ... %20her.pdf

Most of the centrals you show above IMHO look like they are post arousal from a real OA. Meaning the OA happened and caused you to wake up (you may or may not remember it) and the centrals aren't real asleep centrals. Arousal related more.
Did you watch the videos here
http://freecpapadvice.com/sleepyhead-free-software

You have a lot of awake breathing pattern going on when the bulk of those central flags are showing up...not asleep breathing.
Some of the OAs also appear to be awake/arousal breathing related.
It's hard to tell for sure because we can't see enough of the breathing that went on just prior to the flagged events to see if you were asleep or not.

Were you on your back very much last night?

Yes, the machine maxed out a lot. It tried its best to prevent those OAs but couldn't because it couldn't go higher.

Want to try raising the minimum to 15 tonight? Keep EPR off if you can handle it.

I suspect that you at least need a machine that will go above 20 cm at some times during the night....and you might get by with a regular bilevel (will go to 25) if the bulk of those centrals are indeed arousal related. The AirCurve 10 VAuto might be enough....the AirCurve 10 ASV machine would also work and would take care of both the OAs that need higher pressure and if those centrals are real centrals and even if they aren't.

Here is an example of a couple of OAs that happened while asleep....note the extremely regular breathing pattern


This is all asleep breathing


This is asleep breathing circled...followed by arousal breathing and the stuff flagged during the arousal isn't real. If you aren't asleep they aren't real. The machine has no way to tell if we are asleep or not. It measures air flow only and our awake/arousal breathing is very irregular and it can make the machine flag stuff that isn't real asleep stuff.


A more zoomed out view of the circled asleep breathing. All the breathing after the circled part is arousal related or awake...the flagged stuff...not real and they don't count.


So you have to evaluate not only the flagged stuff but the breathing that happened before the flagged stuff which is what I can't see well on your examples above.

Finally flow rate from a different machine and different software but in a format where you can easily see asleep breathing from arousal breathing.


And this one where the bulk of everything is arousal related. This guy didn't have OSA (per an in lab sleep study) but his AHI was always around 8 ish on the machine but none of the flagged events were real. He had crappy sleep from a large number of arousals and a lot of false positive flagging going on.


If you want to let me go through the bulk of your flow rate results up close and get my opinion as to asleep vs awake I can do it but I would rather wait until we get the pressure up to where it is at least dealing with the OAs a little better if we can.
There is a way for you to get me the contents of your SD card so I can plug it into my software and I can review the flow rate for the entire night.

I haven't mentioned it before because it's not time for me to do this....your obstructive therapy isn't optimal yet ...you are new to therapy and I can tell you aren't sleeping soundly and until you are sleeping as best you can...and I already know what I am going to see and have to say which is more pressure until we decide the obstructive stuff is handled as best it can be handled with this machine.
We are getting close...the maxing out of the pressure line is telling us that but I still see so much obvious arousal stuff muddying up the evaluation that I wanted to wait a bit longer before I did that extra work and I also wanted you to learn to identify awake vs asleep.
It's not an easy job sometimes. Even for me...I can't always tell for sure.

Thanks again for the very helpful answers. I am watching the videos now.

Looks like the majority of these events could just be false positives. Many of the hypopneas look just like normal breathing and many of the OAs and CAs look like there is arousal before they happened.

If that is the case, wouldn't it make more sense for me to try to optimize for comfort and compliance instead of for maximum pressure? I will try 15-20 though.

Not sure why the machine keeps ramping up the pressure this much, it looks like it is measuring flow limitations and starts ramping up the pressure even before I fall asleep.

Any idea why that would happen?

One of the things the machine will try to do is prevent Flow Limitations and snores. So when you see the pressure go up and the flow limitations are showing up, even without a flagged event of some sort, the machine is responding to the Flow Limitations.
Flow Limitations are the early warning signs of the airway trying to close off. The machine is increasing the pressure to try to prevent the closure.

While we can get false positive FL flagging....false positive flow limitations aren't common unless someone is experiencing a lot of nasal congestion.
So if you are experiencing a lot of nasal congestion the air flow is reduced but its from nasal issues but the machine has no way to know if the reduction in flow is nasal or not. So it responds per the algorithm for flow reductions.

Your flow limitation graph is pretty ugly. If you aren't experiencing much nasal congestion then we know the airway is still very compromised or trying to collapse and more pressure is needed.

To give you a reference point...here's my FL graph from a couple of weeks ago. And yes...if someone is having a lot of arousals it makes sense to try to address the cause of the arousals first but sometimes it's the sleep disordered breathing stuff going on that is a primary factor in causing the arousals.
Sometimes we don't know which comes first but in your situation with the FL graph looking the way it does I can't help but wonder if the FLs are disturbing your sleep first and the arousal stuff is because of the FLs.

Here's a good video that explains a bit why FLs are important.
https://www.youtube.com/watch?v=-gie2dh ... e=youtu.be
People often think just about the AHI numbers but FLs and snores are just as important if not more important in terms of overall sleep quality. You can have an AHI of 0.0 and have a truck load of FLs and still feel like crap because you sleep like crap.
The usual course of action for FLs...(assuming not nasal related) is more minimum pressure.
Which is why I keep suggesting bumping up the pressure.

Now it is also possible that the arousals are simply related to the newness of all this stuff. The brain hasn't accepted the new normal of having the alien plastered on your face kind of thing BUT since you have the ugly FL graph and the machine is responding like it is...I can't help but want to try to reduce the FLs and see what happens with your sleep quality. It needs to be done anyway.

All this assuming you aren't experiencing some nasty nasal issues and if you are then those have to be addressed with the usual ways to clear up nasal congestion first. More pressure won't fix nasal congestion FLs.
We then have to back up and try to fix the nose stuff first.

Make sense?

Yes, that does make sense. And that video was very helpful, thanks.

I took a nap and initially tried the 15-20 setting (no EPR), but I just couldn't do it as it was too uncomfortable to breathe while trying to fall asleep.

If I really need a pressure of 20 or higher then I think I should get a Bipap or ASV so that it is more comfortable to exhale.

I changed to 11-16 with EPR of 1 and this is the result: https://prnt.sc/oxssfa

Now that I have learned to better recognize what is going on with the chart, I think I can see what is real and what isn't.

Looks like perhaps two obstructive events that led to arousal:
1 - https://prnt.sc/oxsu68
2 - https://prnt.sc/oxsugi

The only OA seems to be a false positive, but it happened after a true hypopnea which led to arousal.

I am not sure what to make of this cluster of CAs. It looks like I could still be awake: https://prnt.sc/oxt1cv

Other than that it looks like I am waking up randomly with no correlation with the flow limitations.

I'm wondering if it's possible that this flow limitation measurement is partly false because it starts showing up just minutes after I put the mask on and I usually take much longer to fall asleep than that. So it is measuring flow limitation while I am awake and alert.

mannsch wrote: ↑

Mon Aug 26, 2019 1:18 pm

These are the 'iffy" ones. Hard to say for sure. There is obviously some arousal breathing happening and then things are a bit irregular but starting to smooth out but not fully smooth. These centrals might be what we call sleep onset centrals. They get flagged during sleep stage transition...it's normal and not usually a big deal unless they happen so often they keep bouncing us out of sleep and they happen all night long..or cause desats.
If it normally takes you a little while to fall asleep...makes more of a case for sleep stage transition from awake to sleep.
Looks like they started up roughly about 30 minutes after you started the machine.

If you want to take a break from the pressure increases and concentrate on being as comfortable as possible so you have a greater chance of sleeping better (more soundly)...that's fine. I don't think that your centrals are related to using EPR...so use it if you need it.
Just remember that when we use EPR we are effectively lowering the therapy pressure during exhale. Might allow a few OAs or hyponeas to happen until you are using a higher minimum that compensates well enough for that drop during exhale.

You gotta be comfortable breathing with the machine first and foremost to be able to sleep....and without sleep none of this matters.

When you do put the mask on...take time to make a special note as to the status of your nasal airway...the least little congestion can be misconstrued by the machine and it will show up on the FL graph. If you are getting some flagging while awake...might be some false positives there.
It would be nice if these machines could distinguish all this stuff for us but the details we are given were really never meant to be put under the microscope like we are doing....and they simply have no way to know if we are asleep or not.
They just measure the air flow and call it like it sees it...but sometimes it doesn't get a good picture to look at.

I gotta close for now...thunderstorm and I am without power and on battery and it won't last long on my computer.

Just remember you are still very new to this therapy and believe it or not you are already miles ahead of where I was at this stage of my therapy. It took me 3 full months for the brain to quit waking me up just to tell me there was an alien on my face.
I was just beginning to tweak my settings to optimize my therapy at 2 weeks in.

Gotta take a big dose of patience...and trust me...I know that is a big pill to swallow.

You are itching and thinking you might need ASV....and you might need it but I haven't seen enough for sure proof that you do at this stage of things. I got no problem with you trying one if you can get your hands on it and you don't have any history of heart problems and I would be happy to help you experiment with it (lord knows I did it to myself) but I hate to have you spend that much money unless you really need to because I am the queen of cheap.

Thanks again for your help. I am going to try to optimize for comfort and compliance for a while but still try to keep the pressure relatively high.

Maybe the arousals will reduce when I get more used to having the mask on my face.

Looks like the high AHI isn't that much of a real issue since so many of them seem to be false positives, so I won't worry about that for now.

I will also put off the ASV for now. I agree that I probably don't really need it.

I will share this little story with you.
A few years back I had the chance to help a guy whose AHI was in the mid 20s to 30s...about half obstructive and half central.
I thought for sure that he was a good candidate for ASV until he happened to mention his insomnia issues.
He was spending LOTS of time with the machine and mask on but not asleep. Poor little machine was going crazy.
I told him to quit doing that...if he couldn't sleep get up and do something else and then go back to bed.
Plus he got a little help from his doctor to help him battle his sleep problems.
Once he quit having so much time awake with mask and machine on...his AHI dropped to 2.2 with no change in settings and certainly no need for the high dollar machine.

It's not always easy to stop the arousals though...not only do we have the ones which can come from the airway closing off but we can have the spontaneous arousals that can come from anything and they are not related to any airway problems at all.
I get a lot of spontaneous arousals due to pain issues...My AHI usually runs between 1 and 2 sometimes a little more and 90% of it is arousal related no matter what the number ends up being..low or high...the bulk of anything flagged is arousal related or what I call SWJ or sleep/wake/junk.
Sometimes we don't know what is causing the arousals and its kinda hard to fix a problem if you don't know what is causing the problem.
Heck, I know the problem and still can't fix it all that great.

Thanks again for the help.

Something very interesting happened last night. I put on the 12-20 pressure again, this time with EPR of 3.

But I forgot to add water to the tank, so there was no humidity. Then I went to bed again in the day since I had to wake up too early and I just turned the humidity setting to Off.

I also tried a slightly different side sleeping position which may have helped.

AHI went way down.

Last night + this morning: https://prnt.sc/oyo5j9
This morning after noon: https://prnt.sc/oyo98l

So I think I will be keeping the humidity off from now on, or maybe experiment with a very low setting, and using this new side sleeping position. This seems to have helped a lot, although just a single night could be a fluke.