Help needed please.

I'll try to keep this as short as I can but I've been told that I can get a little long winded when I try to explain just about anything.

After two lab sleep studies back in 2012 I was diagnosed with moderate to severe sleep apnea. I forget the numbers but if needed I could find them. I began using a Philips Respironics System One RemStar BiPAP Auto with Bi-Flex (750P) in 8/2012. I've had good results with this machine and with the current settings my year long average AHI is around 4.28.

After 7 years of use I was due for a new machine (my insurance will pay for a new machine after 5 years). I had just switched doctors (insurance purposes) at that time and I had my first appointment with my new doctor for a physical (I'm in great health) and to talk about my sleep apnea.

The doc gave me the option of an at home sleep test or a lab test. I chose the at home test. After taking the test and sending the machine back for analysis I received a call from my doc's assistant with the results. She told me that I did not have sleep apnea and that I could discontinue the use of my machine! Wait! What?

My understanding is that sleep apnea never goes away, unless a person has lost a lot of weight or had surgery. I weigh about the same (not overweight) and have not had any surgery. I asked her how I could have been diagnosed with moderate to severe sleep apnea, used a machine for 7 years, and now I'm told that I don't have sleep apnea? She said that I would have to come in and speak with the doc. I did and the doc decided that I needed another lab study. I had one and the results were the same, no sleep apnea.

Either I was misdiagnosed back in 2012 or there's something wrong now. My doc said that perhaps I needed to see a specialist. I was told when I first selected him as my new doc that he was very knowledgeable in this field, apparently not. He referred me to the local specialist, Dr M.

I saw Dr M and after he reviewed everything, including my original sleep studies, he came to the conclusion that I did indeed have sleep apnea but it pretty much only occurred when I slept on my back (I thought that I was a side sleeper). Anyway, I got my new machine. A Philips Respironics DreamStation Auto BiPAP currently with these settings, PAP Mode: Auto Bi-Level (Variable PS) Min EPAP 8.0 Max IPAP 15.0 PS 4.0-7.0.

Here's where I need help. I can't get my apneas consistently below about 7 or 8. I've had a few nights with very low numbers but they don't stay low.

Here are my screen shots from my old machine (using SleepyHead) and below that from my new machine (Oscar). (I hope that I have done this right)

Conrad wrote: ↑

Tue Jan 14, 2020 1:48 pm

I'll try to keep this as short as I can but I've been told that I can get a little long winded when I try to explain just about anything.

welcome back. i can't comment on the charts because i barely understand apap let alone bilevel machines. (i think the answer is more minimum pressure, but i'm uncertain.)

i'm here to help with chart organization. what you want is-
Flow Rate
Pressure
Leak rate

more info-

wiki/index.php/Oscar:organize#How_to_order_the_charts

and then whatever the bilevel experts want.

good luck!

Welcome to the forum.

The 750 reports PS differently...and what you see is actually the PS max to 11...what you don't see is a hidden PS minimum of 2. It's the default minimum in auto bilevel mode that people don't ever see. It wasn't until the 760 model was released that we got a minimum and maximum setting that we could see both and do anything about.

The bulk (75% or so) of your AHI is Clear Airway apnea (centrals) events and more pressure probably won't help them.
You do have a few OAs and hyponeas and snores going on and those might be disturbing sleep somewhat and causing false positive central apnea flagging.

How is your sleep quality now....waking up fairly often and spending some time with mask and machine on and you are awake???
Or are you sleeping soundly now for the most part?

If it were me I think I would try to mimic the old settings better by setting PS minimum to 2 instead of 4...see what happens.
No other changes at this time.
Reduce PS to minimum 2 cm....leave the max PS where it's at.

*points to previous post*
What she said. reduce minPS to 2 for a starting point.

Pugsy wrote: ↑

Tue Jan 14, 2020 3:54 pm

Welcome to the forum.

The 750 reports PS differently...and what you see is actually the PS max to 11...what you don't see is a hidden PS minimum of 2. It's the default minimum in auto bilevel mode that people don't ever see. It wasn't until the 760 model was released that we got a minimum and maximum setting that we could see both and do anything about.

The bulk (75% or so) of your AHI is Clear Airway apnea (centrals) events and more pressure probably won't help them.
You do have a few OAs and hyponeas and snores going on and those might be disturbing sleep somewhat and causing false positive central apnea flagging.

How is your sleep quality now....waking up fairly often and spending some time with mask and machine on and you are awake???
Or are you sleeping soundly now for the most part?

If it were me I think I would try to mimic the old settings better by setting PS minimum to 2 instead of 4...see what happens.
No other changes at this time.
Reduce PS to minimum 2 cm....leave the max PS where it's at.

First of all, thanks to all of you for the replies! I very much appreciate it. And thanks for the welcome!

Pugsy, I am waking up occasionally during the night and I lay there for a while awake with the mask and machine. Lots of times when I'm like this I'll look at the clock and note the time (normally it's around 2:30a) and it feels like I'm awake for a long time but when I look at the clock again two hours has gone by. So at some point I went back to sleep. I do wake feeling rested though. Very seldom do I sleep the entire night through without waking.

I'll drop the PS min to 2 as you suggested and see what happens. I'll report back.


Thanks again!

These new machines sure seem to be super sensitive to awake breathing irregularities which really messes up our evaluation process.
Sometimes just using a new machine at slightly different settings is enough to cause people to have more awake time than they had with the old machine....adjustment period of sorts just to something new even if it is only slightly different from old.

The machines only measure air flow (or lack of) and have no way to know if we are asleep or not.
Awake/semi awake breathing is much more irregular when compared to asleep breathing and quite often the machine will mistake awake/arousal irregular breathing as some sort of apnea event and flag it. Think of those as false positives for lack of a better term.
Obviously with sleep apnea events one must actually be asleep for them to matter. Awake pauses in breathing happen all the time and mean absolutely nothing other than we were awake when maybe we should have been asleep.

Now do I think all your flagged events are false positive...no I do not but I have no way of telling which is what from what is shown here.
There are some things you can do if you wish to help figure out how many of those events are awake/arousal related and can be ignored safely. When you wake up and it seems like you are having trouble going back to sleep....reach over and turn the machine off and then right back on again. This will let the known awake time be clearly seen on the therapy line because there will be a broken line where we can assume that anything immediately preceding or following the break in therapy can most likely be attributed to false positives.
For the ones you can't blame on known awake time you can actually look at the air flow and get an idea if you were asleep or not.
Go here and watch all the videos.
http://freecpapadvice.com/sleepyhead-free-software

Finally why I suggested reducing the PS....some people are super sensitive to PS or the difference between inhale and exhale and for a very small subset of people PS can cause central apneas to pop up when a person wouldn't have any centrals usually.
So with the new machine you started out with 4 cm PS which is an increase of 2 cm over the old machine and sometimes just a little bit of extra PS can cause centrals in numbers we worry about. I have a friend who get about 15 centrals per hour with PS of 4 but if we drop the PS to 3 she gets essentially no centrals...maybe one or two over the entire night which is normal and no big deal.

I don't know if you are one of those people or not but it's worth at least trying the 2 cm PS just in case you are because it's an easy fix.

Success!

I dropped the min PS to 2 as suggested, I had an AHI reading of 1.4 last night and I slept great! I did wake up once at 2:00 but went right back to sleep.

I know that one night doesn't mean that much but it's a good start. I did have some low numbers with the previous settings (a record low AHI of 0.77) but those low numbers weren't consistent.

"Finally why I suggested reducing the PS....some people are super sensitive to PS or the difference between inhale and exhale and for a very small subset of people PS can cause central apneas to pop up when a person wouldn't have any centrals usually."

"So with the new machine you started out with 4 cm PS which is an increase of 2 cm over the old machine and sometimes just a little bit of extra PS can cause centrals in numbers we worry about. I have a friend who get about 15 centrals per hour with PS of 4 but if we drop the PS to 3 she gets essentially no centrals...maybe one or two over the entire night which is normal and no big deal."

I think that this is the case for me. With the reduced min PS I found my breathing with the mask/machine on to be much more natural. Before I found myself trying to match my breathing to the machine instead of the other way around.

Again, I appreciate you taking the time to look at my data and make recommendations.

I think that a little more fine tuning and I'll get back to the consistently low numbers that I had with my old machine.

Thank you!

Conrad wrote: ↑

Thu Jan 16, 2020 8:09 am

. Before I found myself trying to match my breathing to the machine instead of the other way around.

The amusing thing is that your machine is 100% driven by *your* breathing...

palerider wrote: ↑

Thu Jan 16, 2020 11:20 am

Conrad wrote: ↑

Thu Jan 16, 2020 8:09 am

. Before I found myself trying to match my breathing to the machine instead of the other way around.

The amusing thing is that your machine is 100% driven by *your* breathing...

I understand this but it doesn't always feel like it's 'my breathing'. So often the machine will switch to exhalation before I'm done inhaling and it throws off the rhythm of my breathing. Sometimes it's the other way around. At least it was before the change suggested here.

AHI last night of 0.8.

I am so happy that it was something so simple as a little change in PS that helped you get to where you need to be.

Pugsy wrote: ↑

Sat Jan 18, 2020 9:03 am

I am so happy that it was something so simple as a little change in PS that helped you get to where you need to be.

Thanks Pugsy! I'm glad too.

Last night's AHI was up a bit at 5.3. At least it's lower than it has been before I changed the min PS. I'll keep the settings 'as is' for a little while and see how it goes. If it doesn't improve I may try dropping the min EPAP to 7 or 7.5 down from 8 to more closely match what my previous settings were in my old machine.

What do you think?