Switching from CPAP to APAP advice

And here is one of the hypopneas during my “I can’t get back to sleep” time with the mask on. So if this is me awake, I really don’t breathe well.

It's not so much that you aren't breathing well while awake as that what you see is normal irregular awake breathing that you don't realize is going on.

Before the Resperdonix recall came up my Dreamstation Auto was maxing out with a 95% presure
of 18 to 20 and an AHI of 8.9 . So my Dr. sent the order in for a ResMed Air curve Vauto set for
24 inhale and 20 exhale. My first 2 nights were horrible with an AHI of 9.45 and 11.15 . Then I talked
the Dr. into lowering the presure . He lowered it to 17 inhale and 13 exhale and after that my AHI has
been 4 or less heck last night it was a .8 I am not all that shure this is because I switched to a bilevel
because right before I got it I started using a ResMed Elite set to 15 and was getting a AHI of about 4.8
so I just think I do a whole lot better with an ResMed than that cursed Dreamstation.

I went back to straight CPAP last night. I was just too worn from the past few days and wanted the reassurance of what I was used to - even if only briefly.

I did put my CMS50D+ pulse oximeter on, to see what desaturation I might have with straight CPAP (10cm). Not bad, just a brief excursion to 92% (NOT 40%, that was an artifact as I took it off), most of the time 94% and above. But it did disturb my sleep, because it took me over an hour to download the first session into OSCAR in its totality in the middle of the night (multiple tries until more than 25 minutes would load). I’ll do a separate thread on that so it doesn’t derail/mess up this CPAP>APAP focused thread.

Before bed I had also checked the air pressure with a column of water. Both my old PRS1 CPAP machine and this well-used-but-new-to-me ResMed in CPAP mode displaced the column of water the same 10cm. I checked the ResMed at both 8cm and 10cm, both were correct displacement of water column. So I know we’re not dealing with incorrect pressures. Side note: PRS1 comes on like a fire hose, jumping the water column beyond 10cm at first, then bouncing back. ResMed eases up to the line like a smooth elevator.

What I have learned from the night on CPAP:
1. I’m ditching the CMS50D+ for a while. I don’t like fretting about it, and it is a pain in the finger.
2. I wasn’t feeling well last night, so I’m guessing my body isn’t at its best, no matter which treatment method.
3. Pugsy’s idea to try a higher APAP minimum and narrower range makes greater sense to me, but I’m guessing 10cm minimum.
4. At 10cm I’m treated, but my breathing shows flow limitations.

What I’m guessing from the last few nights:
I think my leak pattern is remarkably consistent in its shape and appearance. I’m guessing my lips open at particular sleep stages. The 3M tape held better last night (I double taped, overlapping), but leaks still appeared and showed the pattern.

Some screen shots: I’ll add some steady-breathing examples in the next post.

Here are two examples of steady breathing in the night, when I believe I was asleep, not leaking, and not having events. I do not like the shape of either of them.
Is this an issue to be “solved”?
Does it suggest higher pressure needed?
Does it suggest EPR needed?
(And/or does it suggest I just need an attitude adjustment and stop being picky?)

I don't know how important it is to smooth out the flow limitations. I guess a lot will depend on the old "clinical correlation is needed" thing.

Is EPR actually "needed"....unknown and no way to know for sure. Easy experiment to try though.

I don't know if it is so much that you are "picky" and need to adjust your expectations as you seem to want concrete answers to questions that we simply can't give concrete answers to based on the limited data the machine gives. They aren't perfect and they were never really designed to do diagnostic detailed stuff that you are looking at. They were designed to just show overall trends and patterns.
The level of detail you are wanting answers to really can only be accurately obtained in a sleep lab setting. Just too many variables possible with what we are seeing when just going by what the machine gives us.
Biggest thing is we don't really know for sure if we were really asleep or not an if not asleep nothing counts. We can make good educated guesses but in the end we really can't be 100% sure so there is always room for error in our evaluations. I am pretty good at evaluating flow rate for sleep vs awake breathing and even I have times where I can't say for sure what it is. Until these machines can reliably give us sleep status it is just a limitation we have to live with.

I think you are wanting picture perfect stuff...numbers and graphs and forgetting about subjective stuff.
What are your goals...good math scores and pretty graphs or sleep good and feel good? You seem to be targeting good math scores and pretty graphs because I don't really see much where you talk about how you are feeling and sleeping other than you had a crappy night last night for several reasons....
which begs a question...why in the hell would you want to mess up sleep trying to download anything in the middle of the night. That's a recipe for disaster in terms of sleep quality. On the list of what to do if you wake up in the middle of the night doing a download doesn't even make the list if you want to go right back to sleep which is what anyone should want when they wake up in the middle of the night to stand any chance in hell of feeling decent.

Good numbers and pretty graphs don't guarantee much of anything. They don't guarantee optimal therapy or sleep or feeling good. There's a lot more to optimally treating sleep apnea problems than just what we see available on these machines. Not to mention that one huge thing....that big old YMMV sticker.

Your breaths appear to be sometimes flow limited if going by the chart below. Not hugely so but occasionally. Is this something that is critical...dunno and no way to really know but the 2 most common ways of dealing with it...either more minimum pressure and/or adding EPR into the mix and then you evaluation both the breaths AND how you are sleeping and feeling. Even with the data we have available there is still a lot of trial and error involved because of the limitations of the data and that old YMMV sticker thing.

One other thing...about desats.
It is normal to desat when asleep...about 3 to 4 % below baseline is normal to see. So some desat is expected and no big deal.
Unless someone is spending much time below 90%...it doesn't even warrant a blink of an eye anyway.
In the US we have to be below 88% for anyone to even raise an eyebrow..
and loss of contact desats don't count.

While doing your experiments I would agree that removing the pulse oximeter stress and discomfort is a wise choice ...and I don't see you having desats that would warrant a concern at this time.
Maybe later once the other experiments are completed you might add it back in just for reassurance but I don't see it being an urgent need at this time.

One more thing....I think that your zoomed in flow rate graph is probably showing some cardiac echoes between breaths.
Sure looks like it might and your max respiration rate reflects that possibility. Makes it look like you are breathing faster than you really are at times. No big deal and a normal artifact but it does make for a weird looking flow rate graph.
Search the forum for ballistocardiographic discussions.

A couple of footnotes to Pugsy's posts.

There's a nice idealized flow rate trace inside the "O" on the welcome page of Oscar. That's probably more typical than the top trace in the chart that shows types of distorted traces.

I'm attaching a snippet from one of my own graphs that shows the cardioballistic artifact Pugsy mentioned. It is truly nothing to worry about. The beating of your heart causes just enough change in your trachea to register between breaths.

I think it'd be well worth trying some EPR. You could start with one and see how you like it. Some people find their sleep disturbed by flow limitations, and others don't. EPR can definitely help with FLs. In addition, some people find that EPR makes breathing feel more natural. It's a good experiment to try.

SleepyCPAP wrote: ↑

Sat Jul 31, 2021 8:11 am

4. At 10cm I’m treated, but my breathing shows flow limitations.

Then you're not "treated".

SleepyCPAP wrote: ↑

Sat Jul 31, 2021 8:21 am

Here are two examples

they're tiny and scrunched, too small to see anything.

right click on the title 'flow rate', select 'x-axis' and change it to -60 to 60.

SleepyCPAP wrote: ↑

Thu Jul 29, 2021 7:16 pm

Pugsy, I won’t try EPR just yet. I didn’t use c-flex (my PRS1 felt like it was trying to make me breath on it’s own pattern, too annoying). I’m used to exhaling against full pressure. Later, after I’m used to this new machine, I’d like to try it, as the ResMed relief system is different and might work for me.

FWIW, I felt this way with my old Phillips machine at times and it was annoying, like the breaths were shorter than what it was comfortable for me to breathe. I haven't felt that way using EPR with the Resmed machine. I don't know, maybe it matches my normal breathing pattern better? Just wanted to mention that, if you decide to give the EPR a try, you may find it works better, or differently, than the Phillips did.

palerider wrote: ↑

Sat Jul 31, 2021 1:36 pm

they're tiny and scrunched, too small to see anything.

right click on the title 'flow rate', select 'x-axis' and change it to -60 to 60.

Hi palerider,
Here are the same moments, with the Y-axis adjusted -60 to 60.

ILoveFlowers wrote: ↑

Sat Jul 31, 2021 2:00 pm

…I haven't felt that way using EPR with the Resmed machine. I don't know, maybe it matches my normal breathing pattern better? Just wanted to mention that, if you decide to give the EPR a try, you may find it works better, or differently, than the Phillips did.

Miss Emerita wrote: ↑

Sat Jul 31, 2021 11:01 am

I think it'd be well worth trying some EPR. You could start with one and see how you like it. Some people find their sleep disturbed by flow limitations, and others don't. EPR can definitely help with FLs. In addition, some people find that EPR makes breathing feel more natural. It's a good experiment to try.

Pugsy wrote: ↑

Sat Jul 31, 2021 9:33 am

Is EPR actually "needed"....unknown and no way to know for sure. Easy experiment to try though.

Thanks ILoveFlowers, Miss Emerita and Pugsy about EPR. I am willing to give ResMed EPR a try.

Pugsy wrote: ↑

Sat Jul 31, 2021 9:43 am

One more thing....I think that your zoomed in flow rate graph is probably showing some cardiac echoes between breaths.
Sure looks like it might and your max respiration rate reflects that possibility. Makes it look like you are breathing faster than you really are at times. No big deal and a normal artifact but it does make for a weird looking flow rate graph.

Pugs and Miss Emerita, this is new for me. Thank you for pointing me in this direction about the cardioballistic artifact. I looked at various previous posts on CPAPtalk and also research papers. Very interesting. And Pugsy, in regards to “pretty” breathing, I remember from old posts about a doctor who wanted all his patients on ASV to make the breath waves look pretty, thinking that it had health benefits. There was another study that said snores were causing arterial plaque, so I was focused on smooth waves as indication that wasn’t happening. I don’t mind if my heartbeat is causing squiggles, I didn’t realize that was part of my waveform not looking like the “poster child” chart.

Pugsy wrote: ↑

Sat Jul 31, 2021 9:33 am

Your breaths appear to be sometimes flow limited if going by the chart below. Not hugely so but occasionally. Is this something that is critical...dunno and no way to really know but the 2 most common ways of dealing with it...either more minimum pressure and/or adding EPR into the mix and then you evaluation both the breaths AND how you are sleeping and feeling. Even with the data we have available there is still a lot of trial and error involved because of the limitations of the data and that old YMMV sticker thing.

I don’t know if it is critical either, Pugsy, but I want to deal with it while I’m paying attention now, finally putting my CPAP monitoring back on the front burner after other distractions in life (there was a long stretch of time when I wasn’t paying close attention, just getting on the machine each night and not looking, and my raised AHI and leaks show I should have been). My PRS1 “Pro” CPAP had a “CPAP-Check” mode, where it would give a single pressure but adjust that pressure every few days based on breathing events. I should have left it in that mode during my distractions. The problem with that mode was it wanted to round down, not up, (I assume for “comfort”). When I pay attention I can adjust pressure to better results than that auto mode. Part of my motivation to try APAP is so I don’t have to be in control all the time, and trust the machine to keep giving me appropriate therapy (if given enough head room on max, and supportive enough min).

I am comparatively lucky with my OSA, I realize that about my CPAP journey (and did back in 2010). I got pretty good results in the lab which convinced me I could get a good night’s sleep and feel good again (at first that and this forum kept me going when I wasn’t replicating that success at home). My mixed apnea with centrals began resolving on their own without having to go to BiPAP, and from this forum (especially reading your posts, Pugsy) I found good masks. I stuck with it and CPAP worked. It just doesn’t work if something changes (weight gain and lack of exercise during COVID for example) and I’m not paying attention to the data. The foam recall made me remember I hadn’t downloaded my cards for a while, yikes.

Have fun with your various experiments but always remember you need to also document how you slept and how you felt as well. It's hard sometimes but in the long run an important part of any experiments results.
I did a LOT of experimenting my first few years on cpap.
All the way from various settings to even ASV and ST bilevel machines.
Be patient...keep a log so you can refer back and see if something gave you good results or bad results ...don't trust your memory. Especially true when logging sleep quality and how you feel during the day along with any unusual factors that might have messed with anything.

Always give any changes you make a period of time for the body to adjust unless the change causes something really bad.

And of course cardinal rule of any experiment....keep changes to a minimum so that you can know if the change was the cause of some different result. So only one change at a time. If you do more than 1 change at a time and you get remarkable results (good or bad) you won't know which change might have been the cause of the result.

You may or may not like EPR but don't knock it until you try it because it isn't anything like CFlex.
EPR is more like what you would get if you were using a real bilevel machine.
CFlex exhale relief functions entirely differently and is based on how forcefully you actually breathe. It's a timing thing more than a drop during exhale thing. I tried it and depending on the setting it either made me feel like it was rushing me to breathe or it was lagging behind.

So give EPR a try while awake...all the settings and see how it feels. Pick whatever simply feels the best to you. You may or may not like any of them and that's fine but it is different from Flex so you can't really compare Flex and EPR...apples and oranges comparison. Both are forms of exhale relief and that's where it ends in terms of comparisons.