What is my problem? Noobie needs settings advices

Hello everyone,

I'm a French 25 years old guy, 1m85 and 75kg. I'm a back and a bit side sleeper. I have morning headaches and morning fatigue for around 5 years now. I have tried to find the cause of these problems with several specialists: neurologist, nutritionist, osteopath, physiotherapist... Nothing. Then finally, the nutritionist decided that it would be interesting to have me undergo a polygraphy even though I didn't have the typical profile of someone who has sleep apnea (I don't snore either).

The test revealed an AHI of 21.4 (on 56 mins of apnea, I had 8 mins of HYP, 22 mins of OSA, 7 mins of CSA and 18 mins of MSA). I first had a mandibular advancement device for a few months, which had no effect. So we decided to try CPAP.

Initial settings: APAP 5-10, EPR 1 ramp only. I used it for 42 days, and here is the evolution of my AHI with the modifications I have made:
Sleeping with CPAP was very difficult at first, but now I can sleep easily with it. However, I don't feel any improvement in my morning fatigue. The headaches seem to have diminished though. That's why I have made quite a few changes to the settings by reading the forum in relation to the problems I encountered and what I could analyse on OSCAR.

What is striking to me when I look at the charts is that I seem to have mostly central apneas.
I had read (before I went to read the FAQ and found out it was over-rated) that pressure could induce CSA. So I wanted to experiment last night by reducing my pressure to the 6-7 range to see if it would have a significant impact on my events.

Here is an example of a night I spent with the 6.8-10 EPR 3 setting and no improvement upon waking up:
Here's the result from last night with the 6-7 EPR 1 setting and soft response (no improvement in symptoms either, but a better looking flow rate outside flags upon closer inspection):
Honestly, I'm a little confused about what I should do to improve my therapy. I feel like my settings are not right (or the machine?), but at the same time it doesn't seem like a good idea to change settings every day.

Do you have any advice for me?

Thanks in advance!

What was the breakdown in the AHI on your diagnostic sleep study? How much in each category? You gave use the time in each category but it's hard for us to do backwards math to figure out the exact breakdown.

Obviously the current main issue is going to be the centrals but you had some centrals even without cpap being added to the mix. We need to compare your pre cpap central hourly average to the current on cpap central hourly numbers.

I do have an idea to try and whether it will help or not is anyone's guess but it is something to try.

Turn off EPR totally...or if you need it to fall asleep comfortably set it to ramp only and make use of the ramp feature for a short period of time.
Set your minimum pressure to 6 and maximum to 6. Essentially remove the pressure changes during the night. Sometimes centrals can be caused just by the variations in pressure.
Be prepared to not change the setting for 1 week unless something bad happens with these settings.

You had centrals prior to starting cpap...the machine you have can't do anything to reduce centrals unless there is something in the settings (that we can change) actually causing the centrals...but you had some centrals before cpap so obviously some of your centrals are NOT related to the use of cpap or settings.

Hello Pugsy and thank you very much for your answer.

Here is the breakdown for a 7:00:02 sleep:

• Total: 21 HYP, 54 OSA, 26 CSA and 42 MSA (total 143).

• Per hour: 3.2 HYP, 8.1 OSA, 3.9 CSA and 6.3 MSA (total 21.4)

Do you think home sleep study without EEG is accurate in detecting CSA?

I will try the settings you are advising and will keep you updated, either during the week if I encounter problems, or after the week of test.

Thanks again !

Xantat wrote: ↑

Mon May 23, 2022 3:55 pm

Do you think home sleep study without EEG is accurate in detecting CSA?

EEG is more for measuring sleep status itself than than distinguishing between obstructive and centrals.
You probably had some sort of belt around your chest or abdomen and that is what is used to help identify a central vs obstructive.
With obstructive events you make and effort to move air and the belt measures that effort and with central apneas there simply isn't any effort. You simply stop breathing. Hold your breath for 15 seconds...that's essentially what happens with a 15 second central apnea.

You had obstructive apneas, hyponeas...which were probably obstructive in nature, central apneas and mixed apneas which is sort of a combination of central and obstructive that is hard to describe. Sometimes one kind morphs into the other kind.
I never really understood mixed apneas all that much.

I don't know if my idea will help or not. It is about the only thing you can do with this machine though and if it doesn't help enough or at all then I strongly urge that you have a chat with your doctor (probably should be done anyway) to see if he is concerned about the centrals. I have no idea how they look at things in France when it comes to "how many centrals is a problem" but here in the US the doctors won't worry much about them until someone is seeing 4 or 5 average per hour every night.

There is a possibility (long shot) that cpap can fix centrals that were present before starting cpap. Long shot but at least worth trying the cpap.
Your diagnosis should have been Complex sleep apnea and if you combine the mixed apneas with the central apneas...it's about half and half obstructive vs central.

Your doctor may just want to give things a little more time but I am going to be brutally honest...it would be almost a miracle for this machine to do the trick.
BUT....I have seen this miracle work. I can count the numbers on one hand but at least I can count them.

EPR can trigger centrals in some people...so that's why I suggested turning EPR off.
Auto adjusting pressures can trigger centrals in some people...so that's why I suggested fixed pressure that would most likely also deal with your obstructives effectively once we remove the drop for exhale.

It's really all I can think of to offer. There is a different machine available that can better deal with both centrals and obstructives when the central numbers are troubling. You may not be reaching that number depending on what the French health care system goes by which is why I say get in touch with your doctor. You are borderline right now even if you were in the USA.

I will say a little prayer and cross my fingers and toes and hope for a miracle for you.

I do strongly suggest that you make an appt with your doctor for some time in the sort of near future for follow discussion with your doctor about this issue. If the miracle happens you can always cancel.

Good luck.

Keep me posted. If your OAs and hyponeas increase very much with the setting of 6 we can increase it a little bit.

The first image you uploaded indicates you've been changing settings on an almost daily basis recently -- that's far too frequent.

Do you know your type of home sleep study is reliable in distinguishing post arousal central sleep apnea, from those that "come out of nowhere"?

Inspiration is triggered by CO2 accumulated in the blood. Not enough CO2 - and you don't try to breathe. Not breathing when your airway is not obstructed = "central" apnea. Pressure that is too high for what you need can cause this CO2 accumulation, and then you don't breathe for longer periods.

Pressure changes can also trigger arousals in some people, and in your case, it seems to me you may also have arousal caused by leaks. Arousals mean you're not sleeping well -

Xantat wrote: ↑

Mon May 23, 2022 11:38 am

However, I don't feel any improvement in my morning fatigue. The headaches seem to have diminished though.

That's exactly the point: No headaches because your oxygenation has improved, but fatigue as a result of sleep disruptions.

Question for Pugsy: Any special reason for APAP at min 6 and max 6, and not CPAP mode?

My suggestion:

• As recommended by Pugsy: keep your pressure lower, and stable.
• Fix those leaks: try another mask, try another pillow, try different kinds of hose management - if I had leaks like that, I wouldn't have slept much at all

Once the pressure is stable, use OSCAR to focus on the CA's you still have: how many of them appear suddenly, in an otherwise regular breathing pattern, and how many of them appear after you first see disrupted breathing - e.g. a deep breath being take?

ozij wrote: ↑

Mon May 23, 2022 8:55 pm

Question for Pugsy: Any special reason for APAP at min 6 and max 6, and not CPAP mode?

No special reason other than habit from years of telling people using Respironics auto adjusting machines and needing to try fixed pressures to just keep in auto mode but minimum to equal max because if we went to cpap mode we would lose FL flagging in cpap mode on Respironics machines.

Just an old woman with years long habits that are hard to break. CPAP on a ResMed machine wouldn't cause us to lose anything like it does on Respironics machines but my brain and fingers still type the same thing.
I have typed that same response so many times that I can type it without even thinking.....and obviously I still do it without thinking much.

I always thought that Respironics choice to turn off FL flagging in cpap mode was the stupidest thing I have ever seen (until the foam fiasco) because if FLs are so damn important to cause pressure increases so much in auto mode then maybe it might be at least nice to know if they are happening in cpap mode even if the machine can't do anything about them in cpap mode.

I usually type that response without even referring to see which brand of a machine someone is using...laziness on my part I guess. Laziness and old habits.

Thanks for the detailed reply, Pugsy.

Pugsy wrote: ↑

Mon May 23, 2022 9:17 pm

I always thought that Respironics choice to turn off FL flagging in cpap mode was the stupidest thing I have ever seen (until the foam fiasco) because if FLs are so damn important to cause pressure increases so much in auto mode then maybe it might be at least nice to know if they are happening in cpap mode even if the machine can't do anything about them in cpap mode.

Absolutely!

Edited to remove a question I think I've found the reply to....

ozij wrote: ↑

Mon May 23, 2022 9:48 pm

Another question:
How come for Xantat's machine, OSCAR shows "Cheyne Stokes Respration" 0.00, and on my - presumably identical machine (on CPAP mode) - "Cheyne Stokes Respiration" is not there at all?

You haven't ever had any episodes of CSR flagged is why you don't see it on your events graph.
The OP in this thread had a small amount shown in the last 30 days and a little bit (less than 1% which is nothing at all to worry about) but none in last night or this past week.
Look on the statistics page under the last 30 days column to see it. For all we know it might have been for one or two or three nights early on in his therapy. Certainly didn't have any last night on the report he shared with us.

If you never have it then it won't show up in the events graph at all. My ResMed would flag it as well if I ever had it but coming on 3 years on this machine and I have never had it flagged so on my events graph there isn't a line for CSR either on any of my resports. It is absent from my statistics page as well as I am sure your doesn't list it either.
And I get some Centrals flagged but they are all awake breathing centrals so I wouldn't expect any of mine to qualify for Cheyne Stoke Respiration breathing.

So that's why you don't see that line in the events graph...you never had an episode of breathing that the machine even thought might be CSR (sometimes the machine does get it wrong but not very often). If you happen to have it flagged one night only then if it never shows up again the machine will report CSR but 0.0.

Whew, I'm glad you caught my question before my edit!!!

I was wrong in what I thought was the reason -- and thanks a lot, once again, for the detailed explanation!

Thank you for these elements Pugsy!

I have an appointment with my doctor in about a month. We'll see what he thinks.

So, I had a really bad night with the new settings, numbers not looking very good: My girlfriend told me I woke up several times talking about stuff that were in my dreams.

I don't know which one comes first, but if you look at the graphs, you can see that many of the events come right after a leak raise and drop. Maybe leaks wake up, the I reajust my mask, and then I have sleep onset centrals?

ozij wrote: ↑

Mon May 23, 2022 8:55 pm

Once the pressure is stable, use OSCAR to focus on the CA's you still have: how many of them appear suddenly, in an otherwise regular breathing pattern, and how many of them appear after you first see disrupted breathing - e.g. a deep breath being take?

Hello and thanks for these elements. Out of the 47 CSA events, I counted around 1 or 2 that appeared suddenly, while the rest appeared after wierd breathing patterns.

Time for a new learning/educational experience for you to see if we can mentally ignore some of the centrals.
Go here and watch the videos and learn how to zoom in on the centrals to see if you were awake (you may or may not remember the arousal so don't assume all are asleep flagged events) when a central flag was made.
http://freecpapadvice.com/sleepyhead-free-software

These machines don't have any way to know if we are asleep or not because they only measure air flow and they can and will sometimes flag an air flow reduction while awake or with an arousal that isn't a real asleep change in air flow.
Our awake breathing is extremely irregular when compared to asleep breathing but the machine only knows what it wants to see as asleep breathing and if the flow rate (breathing) doesn't look like it wants it to look we get a flag of some sort.
While this link talks mainly about central apneas that are what I call "false positive flagging" it can actually happen with any flagged event. I have seen the proof myself on my own flow rate graphs.

It wouldn't be impossible for the leak to create the arousal/awakening and the central flagged be a false positive from the irregular arousal/awake related breathing.

Now do understand that while sometimes people can have the bulk of any centrals flagged be false positives (I am one of those people) I don't expect that with you because you had centrals during your sleep study. I am only thinking that maybe we can eliminate a few of your flagged central events as false positive. I tend to think that the bulk of your centrals are the real deal since you had about half your diagnostic AHI composed of centrals on your sleep study.

Also understand that to have a small handful of real asleep centrals isn't that big of a deal. It's normal to have an occasional central at times like when we transition from awake status to asleep status and those centrals are called sleep onset centrals. They normally aren't a problem unless present in large numbers and bouncing us out of sleep.
So an occasional real asleep central is actually normal...but the number you are seeing isn't normal and we can't blame all of them on "sleep onset".

One question I forgot to ask (or really two questions)
Do you take any medications that might suppress respiration? Usually we are looking at pain meds of some sort...stout meds like opiates or in that general category????
Where do you live in France? At what altitude? France has mountains doesn't it?
and third question...any history of head injury?

I will share some examples in a bit to maybe help with the flow rate event education. I need more coffee...early morning where I live. I need to wake up a bit.

Okay, so here are a few examples to help you learn how to spot awake/arousal breathing and asleep breathing.
Anything flagged as a result of arousal/awake breathing really doesn't count in terms of therapy effectiveness per se.
Now if we see a LOT of flagging that is arousal related that of course points to poor sleep quality which is of course something that is unwanted and not good because good sleep is one of our prior goals with this therapy. If that happens we have to do some detective work to figure out what it might be that is keeping us from sleeping well.

Here's an example of asleep breathing and awake/arousal breathing. I circled the asleep breathing in red. Anything outside the circled area doesn't count because I wasn't sound asleep and there's a lot of it.


Now here is that same time frame as above but more zoomed out so you see a bit large expanse of time. All that stuff after the end of the red circle on the right side is arousal related. I wasn't sound asleep. This sort of stuff was kinda common for me back when I saw this because I have some old age arthritis pain issues really messing with my sleep. Totally unrelated to OSA poor sleep quality and very related to pain issues I have/had.


Here's a truck load of centrals I had one night when I had insomnia really bad and it took literally hours to fall asleep.
I actually never fell asleep until after that second cluster of centrals. Bad night...problems with my aging mom so stress related insomnia.


You have to look at the flow rate immediately preceding the flagged event. Asleep breathing is nice and smooth and rhythmic.

So like this one which is a real asleep flagged event.


And this one (not mine but someone else's) that is more zoomed out. Everything flagged is not a real asleep event...all those flags are false positives.

Thank you for these very informative elements!

I'll first answer your questions:
I don't take meds and I dont live in altitude. However, I've had 2 head injuries: one minor, falling from a horse, and another one when I got beaten up by a group of guys 5-6 years ago. I was drunk and received at least some hard hits to the head (I don't remember clearly). I didn't go to the hospital, but it didn't seem to be that bad.

Now for the flow rate analysis: it seems that the vast majority of my clear airways events are false positives... Most of them are preceded by chaotic breathing patterns. Here are a few examples: Another one: This one is a bit more ambiguous to me: Would it be possible that I kept waking up during my sleep study? And it led to an overestimation? I remember I had a hard time sleeping with the equipment. If CPAP does not clear centrals, then I don't understand why I dont have as much centrals as during my sleep study on my OSCAR data.

Thanks again for your help!

I honestly don't know if or what the chance of false positives on the home sleep study might be.
Very possibly higher than we thought since the home study didn't measure sleep status.
Would it be possible that you did a pause in your breathing and you were awake and the chest/abdominal belt said "whoa...no effort to breathe so a central was flagged"....I would think entirely within the realm of possibilities....but I will be the first to admit that I am not 100 % certain.

If indeed the bulk of your flagged centrals are false positives and the examples you showed I would agree not sound asleep.
If that is the case then the next question is what is happening that is messing with your sleep so badly to cause those arousals.

You have seen some slight improvement in headaches though since going on cpap.
Are your headaches maybe partly related to poor sleep quality as well?? I know when I have a night where I don't sleep well I tend to have a nagging headache the next day just feeling like crap in general.

Usually headaches that are sleep apnea related are more from low oxygen levels...desats associated with the apnea events.
Did you home study tell you how low your oxygen levels went to and for how long? I know I had really bad headaches upon awakening pre cpap and my O2 levels went down to 73%. They would last about 2 hours every day. Those headaches totally went away once I was on the cpap machine.

What other unwanted symptoms did you have? Have those reduced at all?

Xantat wrote: ↑

Tue May 24, 2022 4:45 pm

....
Would it be possible that I kept waking up during my sleep study? And it led to an overestimation? I remember I had a hard time sleeping with the equipment. If CPAP does not clear centrals, then I don't understand why I dont have as much centrals as during my sleep study on my OSCAR data.

Yes it would be possible you woke up a lot. Furthermore you had quite a number of obstructive events during the study. Keep in mind that a mixed sleep apnea is also one that is obstructive - you stop breathing for an x amount of time for some unknown reason, but when you try to resume, your airway is obstructed see Mixed Sleep Apneas and those can be successfully treated with CPAP.

Here's what you told us of your sleep study:

Here is the breakdown for a 7:00:02 sleep:
Total: 21 HYP, 54 OSA, 26 CSA and 42 MSA (total 143).
Per hour: 3.2 HYP, 8.1 OSA, 3.9 CSA and 6.3 MSA (total 21.4)

Xantat wrote: ↑

Tue May 24, 2022 1:37 am

My girlfriend told me I woke up several times talking about stuff that were in my dreams.

What stands out to me in your OSCAR data is the amount of leaks at such relatively low pressure.
While waiting for the doctor's appointment, I would spend at least as much time on getting a handle on those leaks which may be disrupting your sleep as I would on changing the pressure.
Check the fitting instructions / videos for your mask.
Make sure it's the right size
Consider a hose management system - when I had a mask with the hose coming from above I absolutely needed a hose management system. When I changed masks, I no longer needed that.
Maybe a different pillow would help.