Help With OSCAR Chart

I was diagnosed with apnea back in 2012. Initially I was prescribed straight Cpap but then my doctor determined that I have complex apnea and changed me to Bipap.

I know I have been only hurting myself but after many unsuccessful tries of getting used to it I gave up and stopped using the machine. Fast forwarding to today as I have gotten older I think that my apnea might have gotten worse because I started falling asleep on the couch at night which I rarely did before. I am also diabetic and my blood pressure has been running high. So combination of advancing age, some medical conditions, and my falling asleep on the couch at night I have finally decided better late than never that I have to make friends with Cpap therapy. I think that part of my problem before may have been a bad mask. I was using a GoLife mask and I never liked it. I just got a Dreamwear under nose nasal mask and I seem to be tolerating therapy better.

I don't have my initial sleep study report but I do remember being told that I had something like over 50 events during the night. Because I stopped using my machine I have not had follow up appointments or pressure level adjustments. My AHI is high and I am having a lot of CA, OA, and H events. I am trying to understand my OSCAR results to determine what is the cause of the high AHI and why I am having so many events.

I have posted my latest OSCAR charts and my current machine settings. I was told that Tidal Volume is something to look when you are on Bipap so I have posted both standard and advanced charts. I have 10 days of therapy in my Cpap reboot and here are my last 3 days of AHI readings prior to the chart that I have posted: 11.32, 10.09, 11.37. If previous days charts are needed I will post them.


Mask - Dreamwear Nasal

Machine Settings:
Mode ASV
Min EPAP 8.00 cmH2O
Max EPAP 9.00 cmH2O
Min IPAP 13.00 cmH2O
Max IPAP 25.00 cmH2O
PS Min 5.00 cmH2O
PS Max 14.00 cmH2O
Auto On On
Breath Rate Auto
Flex Level 2
Flex Mode Bi-Flex
Hose Diam. 22mm
Humid. Lvl 4
Humid. Mode Fixed (Classic)
Humidifier Connected
Mask Res. Lock Off
Mask Resist. 1
Ramp Pressure 4.00 cmH2O
Ramp Time 30.00 Minutes
Show AHI On
Tube Lock On

Is your machine the model 950 or 960? model number should be on the bottom of the blower unit.

Are there any other modes available besides ASV?

Are you sleeping soundly with the machine or are you having a lot of time spent awake with mask and machine on?

Pugsy wrote: ↑

Fri Sep 25, 2020 12:48 pm

Is your machine the model 950 or 960? model number should be on the bottom of the blower unit.

Are there any other modes available besides ASV?

Are you sleeping soundly with the machine or are you having a lot of time spent awake with mask and machine on?

Model is DS950HS

I went into the provider set up and I do not see a mode option. Getting a new machine where there are mode options will be unlikely. My provider said that unless my current machine breaks and is deemed unrepairable insurance will not approve a new machine.

A little off topic but when I had the GoLife mask way back when I was mostly awake with the mask on which is why I eventually gave up which I should not have done I should have kept trying with different masks. But more relevant the answer now is that with the Dreamwear nasal I am sound asleep but only for about 4 to 5 hours. After 4 or 5 hours I wake up. So in my therapy reboot I have not been able to get any more than 4 to 5 hours of sound sleep.

If it helps in interpreting the charts I am a back sleeper. I try to stay on my side when I am going to sleep but I always wake up on my back.

The model 950 only has the one mode.
I just didn't remember it offering a minimum and maximum EPAP though but it's been some years and I don't remember all those little details with every machine and every model like I used to.

So...for the 5 hours or so of usage you are pretty much asleep.
The hyponeas and OAs we assume to be obstructive in nature but sometimes hyponeas can fool us. For now though we can assume obstructive.
EPAP plus PS equals IPAP but your EPAP max is restricted to 9 cm and EPAP is the first thing we look at when we want to fight obstructive stuff that might be happening.

When your PS jumps up that is when it is breathing for you and most like a central apnea has happened.

I suspect a diagnosis of complex sleep apnea...where you had both obstructive sleep apnea and central sleep apnea.

Can you set max EPAP to a higher number and see if the machine will give you a higher EPAP for the obstructive stuff?
Like minimum EPAP 8 cm and max EPAP 12 or something like that? I don't remember if the 950 model will do that or not.
If not....try increasing minimum EPAP to around 10 cm and see what happens.

The 960 model had both the ASV mode and the Auto SV mode...the ASV mode in the 950 may have some limitations in the settings and won't be able to auto adjust for the obstructive stuff...maybe. Like I say...I can't remember exactly what it would or wouldn't do.

You need more EPAP....either in allowing the machine to auto adjust upwards if it will do it or just start with higher EPAP. If it lets you do a range for EPAP...it will auto adjust but right now with 8 min and 9 max...it has no where to go past the 9 EPAP and you need more than 9 EPAP. Make sense???

If there is a separate setting for minimum IPAP...and you want to raise EPAP then IPAP may also need to be changed.
EPAP plus PS equals IPAP. Leave the PS settings alone. You need the range for the central apnea treatment and it only gives you the burst when you need it.

All this is of course assuming that the hyponeas and OAs seen flagged are obstructive in nature. Playing the odds. While not impossible that they are central in nature the chances are they are obstructive. EPAP is what we look at first for obstructive stuff...EPAP is the baseline pressure holding the airway open in the first place and preventing the obstructive collapses. So....more EPAP some how or other either as a baseline or if it will auto adjust a range that will go higher.

Pugsy wrote: ↑

Fri Sep 25, 2020 2:12 pm

The model 950 only has the one mode.
I just didn't remember it offering a minimum and maximum EPAP though but it's been some years and I don't remember all those little details with every machine and every model like I used to.

So...for the 5 hours or so of usage you are pretty much asleep.
The hyponeas and OAs we assume to be obstructive in nature but sometimes hyponeas can fool us. For now though we can assume obstructive.
EPAP plus PS equals IPAP but your EPAP max is restricted to 9 cm and EPAP is the first thing we look at when we want to fight obstructive stuff that might be happening.

When your PS jumps up that is when it is breathing for you and most like a central apnea has happened.

I suspect a diagnosis of complex sleep apnea...where you had both obstructive sleep apnea and central sleep apnea.

Can you set max EPAP to a higher number and see if the machine will give you a higher EPAP for the obstructive stuff?
Like minimum EPAP 8 cm and max EPAP 12 or something like that? I don't remember if the 950 model will do that or not.
If not....try increasing minimum EPAP to around 10 cm and see what happens.

The 960 model had both the ASV mode and the Auto SV mode...the ASV mode in the 950 may have some limitations in the settings and won't be able to auto adjust for the obstructive stuff...maybe. Like I say...I can't remember exactly what it would or wouldn't do.

You need more EPAP....either in allowing the machine to auto adjust upwards if it will do it or just start with higher EPAP. If it lets you do a range for EPAP...it will auto adjust but right now with 8 min and 9 max...it has no where to go past the 9 EPAP and you need more than 9 EPAP. Make sense???

If there is a separate setting for minimum IPAP...and you want to raise EPAP then IPAP may also need to be changed.
EPAP plus PS equals IPAP. Leave the PS settings alone. You need the range for the central apnea treatment and it only gives you the burst when you need it.

All this is of course assuming that the hyponeas and OAs seen flagged are obstructive in nature. Playing the odds. While not impossible that they are central in nature the chances are they are obstructive. EPAP is what we look at first for obstructive stuff...EPAP is the baseline pressure holding the airway open in the first place and preventing the obstructive collapses. So....more EPAP some how or other either as a baseline or if it will auto adjust a range that will go higher.

Thank you for your analysis. I think that it makes sense. Yes I was told back in 2012 that I had complex apnea so when you say you suspect that you are correct.

I will look into the adjustments that you have suggested and see what the machine allows me to do. I may eventually need to consult with a doctor and if the doctor thinks a new machine is needed then maybe his diagnosis might help with the insurance part of this. So I will post back in a couple of days after I see what I can do with adjustments and then if I can adjust the settings see if it changes my results.

It should allow at least a higher minimum EPAP but you may have to adjust minimum IPAP first. Sometimes these machines won't let you increase a minimum until something else is increased first.

Down the road if you talk with your doctor and can get a new machine....get the ResMed AirCurve 10 ASV....trust me...it will do a better job and it is more quiet doing it.

The 950 model wasn't out very long before the 960 was released which has a specific auto adjusting mode.
I never did understand it except I think they did it to compete with the ResMed S9 Adapt (which was their ASV at the time) and the S9 Adapt model 36037 had a fixed EPAP mode AND and auto adjusting mode available so Respironics came out with the 960 to be competitive I guess. I don't think the 950 will auto adjust as much but I might be wrong.

I think that if you can at least set the minimum EPAP to 10 that your OAs and hyponeas will reduce quite a bit. Might need a little bit more but I like to be conservative when using ASV machines because a little goes a long way with them.

Pugsy wrote: ↑

Fri Sep 25, 2020 3:46 pm

It should allow at least a higher minimum EPAP but you may have to adjust minimum IPAP first. Sometimes these machines won't let you increase a minimum until something else is increased first.

Down the road if you talk with your doctor and can get a new machine....get the ResMed AirCurve 10 ASV....trust me...it will do a better job and it is more quiet doing it.

The 950 model wasn't out very long before the 960 was released which has a specific auto adjusting mode.
I never did understand it except I think they did it to compete with the ResMed S9 Adapt (which was their ASV at the time) and the S9 Adapt model 36037 had a fixed EPAP mode AND and auto adjusting mode available so Respironics came out with the 960 to be competitive I guess. I don't think the 950 will auto adjust as much but I might be wrong.

I think that if you can at least set the minimum EPAP to 10 that your OAs and hyponeas will reduce quite a bit. Might need a little bit more but I like to be conservative when using ASV machines because a little goes a long way with them.

OK thank you so much. I know this is not medical advice but your knowledge is enough for me to try to make my own adjustments and see if I can accumulate some data to then talk to a doctor about seeing if the results are convincing enough to see if insurance will cover a new machine.

@Pugsy

I am able to separately change my min and max Epap so I will increase the max Epap to 12.0 as you suggested.
I do not see an option to change the IPAP setting.

So my settings that I have set for tonight:

Max Pressure 25.0
Epap Min 8.0
Epap Max 12.0
PS Min 5.0
PS Max 14.0
BPM Auto

Can you confirm that this is what you are suggesting? You first replied to set a min Epap of 8.0 and a max of 12.0. Then in your second reply you said that a min Epap of 10.0 might help to reduce the OA and hypopneas. So do you suggest min/max Epap of 8.0/12.0 or 10.0/12.0?

Min EPAP 8
Max EPAP 12
Auto BPM is fine
That will work. Let's see first if EPAP will even go up when given it a chance. If it doesn't or this doesn't work then we can try increasing minimum EPAP to 10 and give it a better head start on things.

It should auto adjust as needed for the obstructive stuff up to 12 EPAP.
With the old settings it probably wanted and needed to go higher than the 9 max that was allowed.

IPAP settings end up being a byproduct of EPAP plus PS (pressure support) and I didn't know if you had settings for it or not. Some of the older models did. We want the machine to be able to not only auto adjust as needed with the PS range for central treatment but also auto adjust EPAP (and by default IPAP once PS is added) for the obstructive stuff.

If nothing else the EPAP range will tell us where the machine wants to go in terms of EPAP for the bulk of the night and give us a good idea where the minimum might need to be. Example if we see it hitting 12 for the bulk of the night then we know you probably need more minimum and more maximum available.

We don't know how much EPAP you need to hold the airway open and prevent the collapses. Gotta start somewhere and this is a good starting point. See what the report shows tomorrow morning.

@Pugsy

Here are my standard and advanced charts from last night.

My AHI came down a little bit from 10.94 on Thu night to 8.81 Fri night.
Clear Airway 10 events Thu, 3 events Fri
Obstructive 10 events Thu, 4 events Fri
Hypopnea is still a problem. 34 events Thu, increase to 45 on Fri

I see that there are a group of hypopneas at the start of the sleep session and then there is another grouping around 6:20 when I first woke up. I then fell back to sleep around 6:30 when another group of hypopneas happened. So is that indicative of anything where groups of hypopneas are happening when I am just starting to fall asleep and waking up?

If something jumps out to you then let me know as I'd like to try to solve the hypopnea problem. Also I have been unable to put together a solid 7 to 8 hours of sleep. I am waking up every day after 4 to 4 1/2 hours. Do the charts suggest a reason why?

I suspect some of they hyponeas flagged at around known awake times aren't real asleep events and if that is the case they don't matter.
Watch the videos here
http://freecpapadvice.com/sleepyhead-free-software
Bear in mind that while it talks mainly about CA/central apneas....we can have false positives in any category.

Take a look at the videos and then zoom in on the hyponea clusters and tell me if you think that you were asleep or not when the clusters of hyponeas were flagged. If you weren't asleep then they are what we call SWJ or sleep/wake/junk.

It does look like crappy sleep but at this point are the flagged events the cause of the crappy sleep or a symptom of the crappy sleep.

And one of the reasons I don't like the Respironics ASV as much as the ResMed...the response to the real asleep stuff. Seems like Respironics always has a lot more hyponeas flagged but from my end here I can't tell if it is because they aren't real and don't need to be responded to or it's just the Respironics slower less responsive algorithm at work.
Sometimes it's a combination of problems... real asleep events causing poor sleep which causes more SWJ flagging and makes it look even worse.

Ideally you need an in lab titration on the ASV to be done by someone who knows what they are doing and aggressive enough to titrate to the point where you have that baseline high enough to deal with the obstructive stuff. But in this day and time and now with covid....hard to get even in the best of circumstances. Read this and see if it makes much sense to you.
http://www.isetonline.org/yahoo_site_ad ... 190318.pdf

We can do it at home but obviously takes longer and involves more trial and error to get there. Not impossible, as I don't think anything is impossible, but definitely more work. I am more than willing to try to help you do the work as long as you are.

Normally for hyponeas we think more IPAP and usually with adding more PS but in your situation I am hesitant to add more PS all by itself. You are already at 5 cm PS. More PS can also trigger centrals. So the other way of adding more IPAP is to increase the EPAP baseline which by default when PS is added to EPAP you get more IPAP.

So do the zoom in thing and report back....do the hyponeas look like you were asleep or not?
If the bulk of them appear asleep...like the cluster at the known awake time or the first cluster at the end of the ramp time....then lets increase the minimum EPAP to 10 and you can raise maximum EPAP to 14 but it won't ever go there. The machine isn't roaming around much with the pressures except for brief periods of time during the night when you have some centrals and those times aren't all that often. I tend to think that your obstructive apnea stuff is most likely the primary diagnosis and central was secondary and a small secondary at that.

As far as 7 to 8 hours of solid sleep .....it's normal to wake up after each REM cycle anyway. Most of the time we roll over and go back to sleep and don't remember it but it is normal to wake after REM and unfortunately for some of us we are awake long enough to remember it. Sometimes we even have trouble going back to sleep which compounds the problem. To actually have lights out and close eyes and go to sleep and not remember anything or wake up until lights on...actually rare. It's nice when it happens but it's actually rare.
We always have arousals or wake ups after REM but just don't remember it. When you tell me you are waking up a lot...I know that you are having post REM wake ups and probably even more wake ups not related to REM...which is of course not a good thing.
You can google "sleep stages" and look at the normal hypnograms for when we normally cycle through REM and see what I mean.
It's normal to have those wake ups but we just don't want to be remembering them.

I am fairly confident that the 6:20 and 6:40 stuff are most likely awake breathing SWJ....and I have my suspicions about the first cluster at the end of ramp. If we remove those from the AHI....not a bad night in terms of numbers....but you aren't sleeping good which is of course the ultimate goal. I never go by numbers alone....subjective sleep quality is also very important.

@Pugsy

Since you took the time to write such a thorough reply I just wanted to get back to you. I will do the research that you have suggested, but I have a busy weekend so it might be a few days before I can post back. Thanks.

That's okay. Take your time. Rome wasn't built in a day. I need to get some stuff done myself that I have been putting off because I just haven't felt like it and today it looks like I might feel like it.

Haven't been sleeping so great myself lately (totally unrelated to cpap or apnea though) and last night I got better sleep or at least more sleep for a change and I really needed it.

Technically we made an adjustment in the settings and really need a few days at the new settings anyway to see if any trends or patterns emerge. Part of the DIY at home thing....need to give it a bit of time.

@Pugsy

I have reviewed my hypopnea clusters compared with the flow rate and this is my best guess

9/26
cluster 2:35 - awake
cluster 2:50 - asleep
cluster 3:00 - looks like some arousal
cluster 4:30 - looks like some arousal
cluster 5:45 - looks like some arousal
cluster 6:30 - looks like some arousal

9/27
cluster 1:05-1:10 - awake
cluster 1:45-2:10 - asleep
cluster 3:30 - looks like some arousal
cluster around 3:45 - asleep
cluster between 4:00-4:30 - looks like some arousal

9/26 AHI - 8.51
9/27 AHI - 13.30 However I woke up around 5:00am and turned off machine for a few minutes. Then I wanted to try some more so I put machine on but only for 10 minutes before shutting it off for good. The first sleep session of 4 plus hours the AHI was 11.48 and then that extra last 10 min minutes it was 55.13. So that last 10 minutes increased the total AHI to 13.30 but if we discount that then the AHI for the bulk of the session was 11.48. I have posted the 11.48 session because I don't think that the short second 10 minutes is that useful but if you want to see that I can post it.

If you have more advice for me I'd be grateful to hear it. Thank you.

If it were me I would be trying to figure out why I wasn't sleeping as soundly as I would like. The bulk of your hyponeas appear to be awake or arousal related. It's not always easy to fix a sleep quality problem even once we figure out the cause.

and no....I don't need to see that very short session of 10 minutes. I already know what it looks like because you probably never really went back to sleep.

I see a lot of numbers being reported but I don't see any reports of how you are sleeping or feeling in general.
From the looks of the reports I would assume not sleeping so great and thus not feeling as good as we would want to feel but confirmation would be helpful.

I don't know why you aren't sleeping so great....assuming you confirm that fact. It could be medication side effects, it could simply be newness to therapy and the new settings...it could be other health issues or pain or whatever. The machine can't tell us what is causing poor sleep unfortunately.

Now you could try another minimum EPAP increase to say 9 or 10 cm and see if it changes anything or not. Might be worth trying if you can't blame the poor sleep on any other outside factors like the ones I mentioned above.

It might be just the fact that your body/brain needs to learn to adjust to the ASV way of doing things. For some people it simply can take a few months for the brain to learn to accept this new thing its human is doing.

If the bulk of your AHI is blamed on awake or arousal breathing false positive flagging....we have to try to figure out why the arousals or awake times are happening and fix it from that end. Fix the poor sleep and if the poor sleep isn't from airway issues then all the tweaking of the machine in the world isn't going to help. To fix a problem we first have to identify the problem and start from there.
These machines can't fix bad sleep that is caused by anything other than airway issues...no matter how much we want to put all our sleep problems in the apnea basket. It just doesn't work that way.