Waking Frequently (Continued)

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
MMcG
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Waking Frequently (Continued)

Post by MMcG » Thu Oct 21, 2021 9:05 am

I've been using a Devilbiss Blue (Intellipap 2 in US I think) for about six weeks now. It's been a real struggle. I'm averaging 5 hours of mask usage during the night with about four hours sleep, usually waking twice, i.e. three sleep segments. Then after that I usually remove the mask, but struggle to get back to sleep, and when I do, it's only shallow sleep. I'm probably only getting about five hours sleep per night (it was worse a few weeks ago) and am exhausted most of the time. My pressures min/max pressures were set at 5-14 initially, but are now at 6-9. I've included some OSCAR screen shots of recent nights. Any idea if something needs to be adjusted? Or perhaps I have an exhale puff issue (I use a nasal pillow). All help appreciated.
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Last edited by MMcG on Thu Jan 13, 2022 12:34 pm, edited 1 time in total.

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Julie
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Re: Waking Frequently

Post by Julie » Thu Oct 21, 2021 9:38 am

Curious why your max pressure is only at 9, rather than quite a bit higher, e.g. 20, which is more usual and now potentially could keep the min. pressure (the one that can intercept apneas) from rising as it might need to.

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Pugsy
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Re: Waking Frequently

Post by Pugsy » Thu Oct 21, 2021 9:54 am

MMcG wrote:
Thu Oct 21, 2021 9:05 am
My pressures min/max pressures were set at 5-14 initially, but are now at 6-9.
Who decided on these changes? You? Your doctor? Your machine supplier?

Any special reason the max was lowered? Aerophagia maybe?

Where are you located??

Do you take any medications of any kind? If so what?
Mask: Bleep no headgear mask.. https://bleepsleep.com/
Machine: AirCurve 10 VAuto

I may have to RISE but I refuse to SHINE.

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Miss Emerita
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Re: Waking Frequently

Post by Miss Emerita » Thu Oct 21, 2021 10:35 am

Your AHI is excellent, so my inclination is to focus on comfort so you can sleep deeply for a full night.

I recommend using SmartFlex set at 3. I believe this will drop your pressure by 3 cm each time you exhale. Full disclosure: I'm not familiar with your machine and got my information about SmartFlex here:

https://www.devilbisshealthcare.com/pro ... /smartflex

Using SmartFlex should make breathing more comfortable for you, and it may help with flow limitations and possibly hypopneas.

Normally you'd want to raise your minimum to offset the exhalation drop, but you're doing so well on the obstructive-apnea front that this may not be necessary. But I do recommend that you raise you minimum to 7 so that you'll get the benefits of SmartFlex consistently. (The lowest the machine can go is 4, so at a pressure of 6, you could get only a drop of 2.)

I see that you are spending a fairly high percentage of time with large leaks. These may be disruptive to your sleep, and they also mean your machine can't really do its job during large-leak periods. What mask are you using? And how do you think the leaks are occurring?
ResMed Aircurve VAuto
Bleep mask

Oscar software is available at https://www.sleepfiles.com/OSCAR/

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Pugsy
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Re: Waking Frequently

Post by Pugsy » Thu Oct 21, 2021 10:54 am

A quick word about Devilbiss machine reports from what I remember seeing in the past.
There have always been a higher than usual hyponea count shown. I don't know if this is from definition criteria for flagging or not. Also in the past the usual increase in minimum pressure advice didn't seem to fix or reduce hyponea numbers.
It is entirely possible that the hyponea flags are SWJ stuff and more pressure can't fix arousal/awake breathing issues.
In the past we didn't have flow rate breath by breath graphs to even look for arousal or asleep breathing.
Looks like now we do.

Oh....disregard the red line statistic thing as for time over red line for leaks.
That statistic is based on the ResMed red line of 24 L/min and DeVilbiss uses a much higher large leak threshold. I forget exactly what it is but it is more in line with Respironics threshold.
If there isn't a LL flag up on the events graph....there were no large leaks. The events graph...that's what the machine reports and not something that OSCAR calculates.
Mask: Bleep no headgear mask.. https://bleepsleep.com/
Machine: AirCurve 10 VAuto

I may have to RISE but I refuse to SHINE.

GrumpyHere
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Re: Waking Frequently

Post by GrumpyHere » Thu Oct 21, 2021 10:55 am

Would you mind formatting your future screenshots to the preferred order?

I have some instructions here:
https://www.cpaptalk.com/viewtopic.php? ... &#p1394856

This is my first attempt to help interpret a chart. So it's the blind leading the blind. :mrgreen:

1. Based on clusters of purple EP flags in the 1st and 3rd screenshot, I think you are having chipmunk cheeks/mouth breathing. Maybe they're bothering you enough to cause awakening??
Emilia wrote:
Wed Nov 30, 2011 11:17 am
Expiratory Puffs
EPI, unique to DeVilbiss AutoAdjust devices, is provided as a number and as a graph. Exhale puffs are a breathing pattern described as ‘in through the nose and out through the lips’. EPI is the number of exhale puff events detected per hour. If exhale puffs are present in significant numbers, the AutoAdjust algorithm will prevent the pressure from increasing because an increase in the pressure will create more exhale puffs in a patient with obstructive sleep apnea.
You can deal with mouth breathing by:
  • Taping your lips
  • Train your tongue to push up against the roof of your mouth by default
  • Scuncis
  • firm foam cervical collar
2. The Flow Limitation flags occur when FL chart hits 3. So it looks you're having a fair amount.
palerider wrote:
Tue Nov 01, 2016 10:22 am
Flow limitations are bad for two reasons, one, as pugsy says, they're a sign of a narrowed airway, and are seen as precursors of apnea/hypopneas.

But, just as important, they also increase the effort of breathing, and that increased effort can tire you out, try breathing through a straw for a while, you can do it, but it takes more effort to get the air into your lungs, you're still getting a lungful of air (so no hypopnea, but it takes more work) now imagine doing it all night long. raised pressure opens up the straw and makes it easier to breath.

also, watch this: https://www.youtube.com/watch?v=-gie2dhqP2c
Please follow Miss E's suggestions regarding FLs by:
  • raising the minimum pressure to 7 to deal with the FLs
  • using the SmartFlex feature if you find it hard to exhale against pressure of 7 cm
ResMed S9 VPAP Adapt, p10 mask

MMcG
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Re: Waking Frequently

Post by MMcG » Thu Oct 21, 2021 11:34 am

Pugsy wrote:
Thu Oct 21, 2021 9:54 am
MMcG wrote:
Thu Oct 21, 2021 9:05 am
My pressures min/max pressures were set at 5-14 initially, but are now at 6-9.
Who decided on these changes? You? Your doctor? Your machine supplier?

Any special reason the max was lowered? Aerophagia maybe?

Where are you located??

Do you take any medications of any kind? If so what?
I rent my machine which includes a technician who adjusts my settings. I can't adjust the settings. He lowered the max, because I suspected that when it hit high levels, albeit infrequently, it was waking me. I still see that I rarely hits my new max, so probably not a problem as my AHI's are low? I'm in Ireland. No medications of any consequence, just statins, which I've been taking for more than twenty years.

MMcG
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Joined: Sun Sep 26, 2021 8:08 am

Re: Waking Frequently

Post by MMcG » Thu Oct 21, 2021 11:39 am

Miss Emerita wrote:
Thu Oct 21, 2021 10:35 am
Your AHI is excellent, so my inclination is to focus on comfort so you can sleep deeply for a full night.

I recommend using SmartFlex set at 3. I believe this will drop your pressure by 3 cm each time you exhale. Full disclosure: I'm not familiar with your machine and got my information about SmartFlex here:

https://www.devilbisshealthcare.com/pro ... /smartflex

Using SmartFlex should make breathing more comfortable for you, and it may help with flow limitations and possibly hypopneas.

Normally you'd want to raise your minimum to offset the exhalation drop, but you're doing so well on the obstructive-apnea front that this may not be necessary. But I do recommend that you raise you minimum to 7 so that you'll get the benefits of SmartFlex consistently. (The lowest the machine can go is 4, so at a pressure of 6, you could get only a drop of 2.)

I see that you are spending a fairly high percentage of time with large leaks. These may be disruptive to your sleep, and they also mean your machine can't really do its job during large-leak periods. What mask are you using? And how do you think the leaks are occurring?
I experimented with Smartflex for a few days, because I had trouble falling asleep. But my technician advised against relying on it longterm. Anyway, since I got used to the machine I fall asleep fairly easily. I'm fairly sure the acceptable leak rate for Devilbiss is quite high (90?), so I'm way below that. The "quick view" menu on my machine shows that leaks are not a problem. The occasional large leaks are when I remove the mask on waking, to drink some water or go to the bathroom.

MMcG
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Re: Waking Frequently

Post by MMcG » Thu Oct 21, 2021 11:41 am

Julie wrote:
Thu Oct 21, 2021 9:38 am
Curious why your max pressure is only at 9, rather than quite a bit higher, e.g. 20, which is more usual and now potentially could keep the min. pressure (the one that can intercept apneas) from rising as it might need to.
Started at 14. Then reduced to 12 by the technician (my machine is rented and comes with technical back-up as required). Further reduced to 9 recently as it appeared I rarely went over 8.

MMcG
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Re: Waking Frequently

Post by MMcG » Thu Oct 21, 2021 11:46 am

Pugsy wrote:
Thu Oct 21, 2021 10:54 am
A quick word about Devilbiss machine reports from what I remember seeing in the past.
There have always been a higher than usual hyponea count shown. I don't know if this is from definition criteria for flagging or not. Also in the past the usual increase in minimum pressure advice didn't seem to fix or reduce hyponea numbers.
It is entirely possible that the hyponea flags are SWJ stuff and more pressure can't fix arousal/awake breathing issues.
In the past we didn't have flow rate breath by breath graphs to even look for arousal or asleep breathing.
Looks like now we do.

Oh....disregard the red line statistic thing as for time over red line for leaks.
That statistic is based on the ResMed red line of 24 L/min and DeVilbiss uses a much higher large leak threshold. I forget exactly whaimet it is but it is more in line with Respironics threshold.
If there isn't a LL flag up on the events graph....there were no large leaks. The events graph...that's what the machine reports and not something that OSCAR calculates.
Thanks. Yes, I think the Devilbiss leak threshold is as high as 90! That may be why it wake me, even at a max pressure setting of 9! It doesn't show up as a problem on the machine "quick view" but on the phone app, it sometimes shows a very high "puff exhale percentage" but it fluctuates wildly from night to night for no apparent reason (3-44%), so I'm inclined to disbelieve it.

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Pugsy
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Re: Waking Frequently

Post by Pugsy » Thu Oct 21, 2021 11:58 am

MMcG wrote:
Thu Oct 21, 2021 11:39 am
I'm fairly sure the acceptable leak rate for Devilbiss is quite high (90?),
Yes. Acceptable leak rate is actually quite high. The Statistical "time over red line" thing is an OSCAR generated data point based on another brand's red line and in your situation it it way off.
Ignore it or just turn it off and rely on the LL line in the events graph for large leak monitoring.
To turn it off....Preferences/CPAP tab and remove the check mark for show red line statistic.
You could also give it a new threshold number but I don't remember where it is for your machine but upwards of 80 L/min I am sure.

Statins can cause sleep issues. While not probably the entire cause...could be a contributing factor.
https://www.goodrx.com/blog/could-your- ... -insomnia/

As for higher pressure causing the wake ups....maybe it was the apnea event itself that the machine was trying to kill with more pressure that caused the wake up and not the higher pressure. Something to think about.

First think you need to do is try to figure out if the flagged events you see are arousal/awake related irregularities getting flagged or real asleep airway related issues.
Watch all the videos here with special attention to the bottom video.
Bear in mind that while it talks mainly about central/clear airway apneas.....false positive flagging isn't limited to just centrals. We can have it happen in any event category.
http://freecpapadvice.com/sleepyhead-free-software

Remember these machines can only fix bad sleep that is airway related. They can't fix bad sleep from any other reason and the list for potential causes of bad sleep is miles long.

If the bulk of your flagged events are arousal/awake related then tweaks of settings may not help.
Gotta fix the cause of the arousals and that is often easier said than done.
Mask: Bleep no headgear mask.. https://bleepsleep.com/
Machine: AirCurve 10 VAuto

I may have to RISE but I refuse to SHINE.

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palerider
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Re: Waking Frequently

Post by palerider » Thu Oct 21, 2021 12:13 pm

MMcG wrote:
Thu Oct 21, 2021 11:34 am
I rent my machine which includes a technician who adjusts my settings. I can't adjust the settings.
You could if you wanted to.
MMcG wrote:
Thu Oct 21, 2021 11:34 am
He lowered the max, because I suspected that when it hit high levels, albeit infrequently, it was waking me.
Your suspicion was probably wrong.
Get OSCAR and come chat on IRC: #cpaptalk on irc.libera.chat

Accounts to put on the foe list: dataq1, mper!?, DreamDiver, Geer1, almostadoctor, sleepgeek, ajack, stom, mogy, D.H., They're often post misleading, timewasting stuff.

MMcG
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Re: Waking Frequently

Post by MMcG » Thu Oct 21, 2021 12:26 pm

palerider wrote:
Thu Oct 21, 2021 12:13 pm
MMcG wrote:
Thu Oct 21, 2021 11:34 am
I rent my machine which includes a technician who adjusts my settings. I can't adjust the settings.
You could if you wanted to.
MMcG wrote:
Thu Oct 21, 2021 11:34 am
He lowered the max, because I suspected that when it hit high levels, albeit infrequently, it was waking me.
Your suspicion was probably wrong.
How can I adjust the settings? These options are locked on the machine interface. And even if there is a technical work around, I would probably be in breach of contract if using external software to get around this. Just wondering?

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Pugsy
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Re: Waking Frequently

Post by Pugsy » Thu Oct 21, 2021 12:32 pm

MMcG wrote:
Thu Oct 21, 2021 12:26 pm
How can I adjust the settings? These options are locked on the machine interface.
You go here and request the clinical/provider manual for your model machine and the manual explains the secret button pushing combination handshake needed to get into the clinical setup menu.

https://www.apneaboard.com/adjust-cpap- ... tup-manual

The menu can be unlocked easily.

Up to you if you want to do it but it can be done....and quite easily.
Mask: Bleep no headgear mask.. https://bleepsleep.com/
Machine: AirCurve 10 VAuto

I may have to RISE but I refuse to SHINE.

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palerider
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Re: Waking Frequently

Post by palerider » Thu Oct 21, 2021 12:58 pm

MMcG wrote:
Thu Oct 21, 2021 12:26 pm
palerider wrote:
Thu Oct 21, 2021 12:13 pm
MMcG wrote:
Thu Oct 21, 2021 11:34 am
I rent my machine which includes a technician who adjusts my settings. I can't adjust the settings.
You could if you wanted to.
MMcG wrote:
Thu Oct 21, 2021 11:34 am
He lowered the max, because I suspected that when it hit high levels, albeit infrequently, it was waking me.
Your suspicion was probably wrong.
How can I adjust the settings? These options are locked on the machine interface. And even if there is a technical work around, I would probably be in breach of contract if using external software to get around this. Just wondering?
Settings are in a hidden menu, they're not really "locked". By restricting the machine's ability to respond to breathing needs, you (or your tech) are potentially preventing it from keeping your airway open.
Get OSCAR and come chat on IRC: #cpaptalk on irc.libera.chat

Accounts to put on the foe list: dataq1, mper!?, DreamDiver, Geer1, almostadoctor, sleepgeek, ajack, stom, mogy, D.H., They're often post misleading, timewasting stuff.