Newbie (((struggling))) - mixed central/obstructive apnea questions

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
Omega Proxy
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Newbie (((struggling))) - mixed central/obstructive apnea questions

Post by Omega Proxy » Mon Oct 31, 2022 10:10 pm

Howdy stranger,

I'm a skinny guy with both central and obstructive (mostly the tongue I suspect as an ENT told me it was a "Grade 3" size tongue, & I also, fairly successfully used a tongue suction device for years) sleep apnea.
I've been deteriorating in terms of mood and brain function. Scary, as I just turned 46.

Just switched to the ResMed BiPAP and I'm hopeful I can get some help to optimize my settings.
I switched from a CPAP with pressure setting around 6, because I did another a sleep study and they told me I needed to be at a pressure setting of 10....!!??
I was like, WTF? What happened. I'm literally the same weight now. My weight doesn't fluctuate and I'm not overweight. It was scary to me. I had a head MRI done. Nothing.


I'm running around 0.5 to 0.8 AHI. Most recent was 0.6 with 0.4 listed as central.
I just turned my Max IPAP up to 10 from around 8 and my Min EPAP up to 6.8 from around 6.
My biggest complaint that got me switched from a CPAP to BiPAP was swallowing air, which was causing cramping and waking me up, so I'm trying to avoid cranking up the pressure too much, but I don't know what else to do.

When I wake up from a 0.8 AHI night, I don't feel good. Mild headache and poor mood and poor brain function.
When I wake up from a 0.5 AHI night, I feel okay.
I can't remember feeling good for a long time.

Sorry to not have more detail here, but it's late and I work the next two days.

Thank you so much for being here and trying to help.

Best regards,
Slim Sleepy

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ChicagoGranny
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Re: Newbie (((struggling))) - mixed central/obstructive apnea questions

Post by ChicagoGranny » Tue Nov 01, 2022 11:23 am

Omega Proxy wrote:
Mon Oct 31, 2022 10:10 pm
I'm running around 0.5 to 0.8 AHI. Most recent was 0.6 with 0.4 listed as central.
These are wonderful AHI scores. They would not account for how poorly you feel. What is your leak level?

Why do you think you have central or mixed sleep apnea? What was your official diagnosis? Do you have a copy of the summary page of your study?

Please complete your equipment profile.

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robysue1
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Re: Newbie (((struggling))) - mixed central/obstructive apnea questions

Post by robysue1 » Tue Nov 01, 2022 12:20 pm

Omega Proxy wrote:
Mon Oct 31, 2022 10:10 pm
I switched from a CPAP with pressure setting around 6, because I did another a sleep study and they told me I needed to be at a pressure setting of 10....!!??
I was like, WTF? What happened. I'm literally the same weight now. My weight doesn't fluctuate and I'm not overweight. It was scary to me. I had a head MRI done. Nothing.
The pressure needed to prop the airway open is not necessarily correlated with either the severity of the OSA nor the weight of the person.

My best guess is that your first titration study, which suggested a CPAP pressure of 6, may have just not included much REM sleep or much supine sleep or much REM while supine sleep. And that during your most recent titration study that said you need pressures up around 10 did contain more REM sleep, more supine sleep, and more REM while supine sleep.

I'm running around 0.5 to 0.8 AHI. Most recent was 0.6 with 0.4 listed as central.
I just turned my Max IPAP up to 10 from around 8 and my Min EPAP up to 6.8 from around 6.
Why?

Did you do this on your own, or did the doctor order it? Around here, you're not going to get scolded for just changing it on your own---lots of us do that. But the question is what your justification was for increasing the pressure. Have you looked at any data other than that provided by your machine's LCD? In other words, have you downloaded your data into OSCAR or SleepHQ and looked at it? And if so, what was there in the data that made you decide to increase the pressure settings.

My biggest complaint that got me switched from a CPAP to BiPAP was swallowing air, which was causing cramping and waking me up, so I'm trying to avoid cranking up the pressure too much, but I don't know what else to do.
The air swallowing and the problems it causes are collectively called "aerophagia" around here, by the way. While a lot of people have mild problems with aerophagia, an unlucky few (including me) wind up having pretty significant aerophagia problems at the start of PAP therapy. Switching to bi-level is one way of trying to minimize the aerophagia problem.

I can tell you that in my case the switch to BiPAP did help me adjust to xPAP therapy. It still took a while, but the stomach found some relief almost from the start of using a BiPAP instead of a CPAP/APAP. And after a couple of pressure adjustments, I was able to find pressure settings that give me a good, working compromise between keeping the pressure low enough to keep the aerophagia under control and high enough to keep my OSA under control. My typical AHI is between 1.5 and 2.0 and I wake up most mornings with no stomach pain and feeling rested and reasonably refreshed. And I have the energy I need to get through my days without any problems. If I look at my detailed data, it's clear that some (not all) of those events in my AHI are most likely so-called "sleep-wake-junk" (SWJ) where it's not clear if I'm really asleep or just transitioning between sleep and wake. In other words, I get events that are often scored during the first 10-15 minutes when I'm not really sound asleep or in the last 10-15 minutes before I actually get out of bed, but I'm lying in bed dozing and knowing that I'm not really asleep, but I just don't want to get out of bed yet.

Since you yourself state that you are "trying to avoid cranking up the pressure too much", the question still needs to be asked: Why did you increase both your Max IPAP and your Min EPAP? In other words, what problem are you trying to fix by increasing the pressure?

Also it would help us help you if we know what is your PS set at, and what your median and 95% IPAP/EPAP pressures look like. There's more to optimizing xPAP therapy (particularly when aerophagia is involved) than just achieving a super low AHI night after night. In order to make this therapy work, you actually have to have good sleep with the mask on your nose, not just apnea-free sleep. And good sleep involves minimizing the number of aerophagia-related arousals and wakes as well as preventing the apneas & hypopneas from occuring.

When I wake up from a 0.8 AHI night, I don't feel good. Mild headache and poor mood and poor brain function.
When I wake up from a 0.5 AHI night, I feel okay.
I can't remember feeling good for a long time.
Are you still dealing with the swallowing air problems? Even with a BiPAP, some people can continue to have enough aerophagia to make everything more difficult in terms of xPAP therapy.

Is is possible that you simply had more aerophagia on the night when you woke up with an 0.8 AHI and didn't feel good the next day? The reason I ask is somewhat complicated, so you may need to read this more than once.

Statistically speaking there's not much difference between an AHI = 0.8 and an AHI = 0.5. In both cases, the AHI typically indicates very few events for the entire night, and most of the time, there are no real clusters of events, except possibly minor clusters of probable post arousal CAs that would not have been scored on an in-lab NPSG test. But arousals---for any reason---can be disruptive of your sleep and if there are enough arousals, that can lead to you feeling bad the next day.

And here's the thing: aerophagia and arousals can go hand-in-hand in a nasty positive feedback loop: Arousals can lead to air swallowing, but air swallowing leads to discomfort, which leads to more arousals, which leads to more air swallowing, which leads to more discomfort, and so on and so forth. And it's possible that none of the arousals involved are connected to a real obstructive sleep apnea event. But pile up enough arousals & aerophagia in one night, and that can leave you feeling pretty miserable the next day.

It's also worth noting that as the number of arousals goes up, the amount of SWJ in the data goes up, and since wake breathing is more ragged than sleep breathing is, it's possible for the AHI to go up on a "bad aerophagia" night simply because a lot more post-arousal "events" get scored, even though those events are not real sleep disordered breathing events that would be scored on an in-lab sleep test.

So one suggestion that I would make in trying to troubleshoot what's going on is to track your problems with the cramping and waking up from the aerophagia rather than just worrying about the treated AHI number on your machine each morning.

In other words, you need to be focusing on whether your recent pressure increase is making you swallow more air rather than decreasing your already low treated AHI towards 0.

I wish you the best of luck in battling through the aerophagia problems and getting BiPAP to work for you so that you can wake up in the morning with no stomach pain and no cramping, and feeling rested and refreshed.
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Re: Newbie (((struggling))) - mixed central/obstructive apnea questions

Post by Omega Proxy » Thu Nov 03, 2022 10:50 am

Hi ChicagoGranny!

Thanks for asking.

Leak score 5L/min. Is that high?
Believe it or not, though my scores are not "high", subjectively I am not doing well. If it's not the apnea, I don't know what it is. I've noticed a difference in how I feel between the days I wake with a 0.8 AHI and 0.6 AHI. I seem to feel worse the days I have the higher AHI score (mood, headache).

I think I have mixed central and obstructive sleep apnea, because I've been diagnosed with this. I used to use a tongue suction device and felt I slept well. That stopped working. I started a CPAP. I did fairly well with a pressure ranging around 6-8 for a few years. However, my most recent sleep study they recommended my pressure go up to around 10! I have no clue why the change.... it scared me, as I was already swallowing too much air some nights and waking up with abdominal cramps from swallowing air....

My equipment profile? I'm sorry I searched around a little. Didn't find a section to fill out my equipment profile. I just made some adjustments to my machine settings (two three days ago) as I was not doing well. Here are my settings:

Mode: Vauto
Max IPAP now 11 (was around 8.5ish?)
Min EPAP now 6.6 (it was around 5ish?)

PS 2.0
Ti Max 2.0s
Ti Min 0.9 (was 0.5)

Trigger - Very High (was average)
Cycle Very High (was average)

Mask Full Face (I'm very interested in finding an engineer interested in designing a mask with a tongue suction device built in, if safe to do so. If I could just eliminate my tongue obstruction issue, I believe the obstructive part of my apnea would be almost completely resolved and I would be able to tolerate much lower pressures and sleep much better. Any idea who I might speak to about this? I tried a tongue reduction surgery with no success in the past. Considering inquiring about surgery to remove any unnecessary tissue in the back of my throat to make room for breathing....

Ramp time: 20 min
Start EPAP 4.0
Leak alert is off
Humidity level 4

Now for my sleep report from last night:

My events per hour were amazing 0.1 (super excited here about the adjustments I made), although I woke up after just 5.31 hours of use. Not sure why I woke up so early, but I was unable to get back to sleep. This makes me suspect apnea, as the stress response for my body has made it impossible to get back to sleep so many times in the past from apnea event awakening.

Pressure 8.1
Exp. Pressure 6.1
Leak 5L/min
Vt 440mL
RR: 14
MV: 6.5L/min
Ti 1.4s
I:E 1:1.9
Spont Cyc 97.5%

AHI 0.6
Total AI 0.5
Central AI 0.4

Please let me know if I missed any information.

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Re: Newbie (((struggling))) - mixed central/obstructive apnea questions

Post by ChicagoGranny » Thu Nov 03, 2022 11:08 am

That's good information. I have no experience with central apnea, so others should chime in. Most likely, they will want to see OSCAR charts - see near the top of the index page.

As far as aerophagia, you might get some good tips from the wiki - wiki/index.php/Aerophagia

Here is a link to the equipment profile - ucp.php?i=ucp_profile&mode=equipment_info

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Re: Newbie (((struggling))) - mixed central/obstructive apnea questions

Post by robysue1 » Thu Nov 03, 2022 12:40 pm

Omega Proxy wrote:
Thu Nov 03, 2022 10:50 am
Believe it or not, though my scores are not "high", subjectively I am not doing well. If it's not the apnea, I don't know what it is. I've noticed a difference in how I feel between the days I wake with a 0.8 AHI and 0.6 AHI. I seem to feel worse the days I have the higher AHI score (mood, headache).
Good sleep requires more than just being apnea-free sleep. The real question, I think, that you need to consider is whether there are other potential causes for your sleep still not being restorative.

One that immediately comes to mind is just plain old spontaneous arousals or wakes. In other words, are you arousing or waking for reasons that are not directly related to the sleep apnea, which is quite well treated based on the treated AHI?

And you write
I think I have mixed central and obstructive sleep apnea, because I've been diagnosed with this. I used to use a tongue suction device and felt I slept well. That stopped working. I started a CPAP. I did fairly well with a pressure ranging around 6-8 for a few years. However, my most recent sleep study they recommended my pressure go up to around 10! I have no clue why the change.... it scared me, as I was already swallowing too much air some nights and waking up with abdominal cramps from swallowing air....
Swallowing air and the abdominal cramps that result from it are called aerophagia.

And aerophagia can lead to a lot arousals and those arousals and the resulting cramping can really destroy a good night's sleep even though the AHI is still nice and low. Just as important problems with swallowing air lead to a very nasty feedback loop:

Spontaneous arousals can cause you to swallow air AND swallowing air can lead to cramps which lead to more arousals

My best guess is that your on-going problems with aerophagia are why you are not feeling very well these days. In other words, if we can help you figure out a way to reduce the aerophagia, then your sleep should improve---in terms of how you actually feel during the daytime.

You also write
I just made some adjustments to my machine settings (two three days ago) as I was not doing well. Here are my settings:

Mode: Vauto
Max IPAP now 11 (was around 8.5ish?)
Min EPAP now 6.6 (it was around 5ish?)

PS 2.0
Ti Max 2.0s
Ti Min 0.9 (was 0.5)

Trigger - Very High (was average)
Cycle Very High (was average)
Why did you make these particular changes?

Are you just randomly changing a bunch of things in hopes that one of the changes will magically make your sleep better? That kind of dial-winging usually doesn't work too well. And some of your dial-winging choices may be making your aerophagia worse. And the aerophagia may be one of the reasons you're not yet feeling better.

Let's go through what each of those settings actually means and how the change might be affecting what's going on in terms of the air swallowing problem.
Mode: Vauto
Max IPAP now 11 (was around 8.5ish?)
Min EPAP now 6.6 (it was around 5ish?)
You are running in auto bi-level mode. Your minimum EPAP pressure is now 6.6, which represents a 1.6cm increase in pressure from your old min EPAP. Your max IPAP pressure is now 11, which represents a 2.5cm increase in pressure from your old IPAP.

We don't have any data about just where your machine is going each night. We know that you aren't having very many events scored. But if there is a lot of flow limitation or snoring being detected, that could easily mean that you are breathing against quite a bit more air pressure than you were before you changed the settings.

And breathing against more air pressure can trigger the problems with swallowing air that seems to be your biggest complaint.

So unless you had actually bad AHIs at the old settings, there probably was not a real good reason to just bump these settings up.

PS 2.0
Ti Max 2.0s
Ti Min 0.9 (was 0.5)
PS = 2.0 means that your EPAP is always exactly 2cm lower than the current IPAP. With your current Min EPAP = 6.6, Max IPAP = 11, that means that when your ramp period is over, the machine is using EPAP = 6.6 and IPAP = 8.6. As flow limitations, snoring, and the occasional event happen, the machine might raise the pressure all the way up to EPAP = 9 and IPAP = 11.

Ti Max and Ti Min settings are bounds on how long the machine is allowed to remain at the IPAP pressure. (PaleRider and Pugsy, let me know if I get this backwards since I'm working from memory.)

Ti Min = 0.9 means that the machine will alway keep the pressure at the current IPAP level for at least 0.9 seconds. This only affects things if you have an exceptionally short inhalation. Your previous setting would allow the machine to go to EPAP in 0.5 seconds for an exceptionally short inhalation.

Ti Max = 2.0 means the machine should decrease the pressure from IPAP to EPAP at the end of 2 seconds if it has not already done so because it detected the beginning of your exhalation.

In other words, the machine will decrease the pressure to EPAP when you start to exhale as long as the start of the exhalation is between 0.9 seconds and 2.0 seconds after the beginning of the inhalation occurred.

Now if Ti Min is set too long or Ti Max is set too short, that might give you the impression that the machine is not in-sync with your breathing patterns, and when it feels like the machine is not in-sync with your breathing, that can create a situation that encourages air swallowing.

Trigger - Very High (was average)
Cycle Very High (was average)
Trigger controls the amount of inhalation flow the machine needs to detect before it increase the pressure from EPAP to IPAP.

Cycle controls when the machine decides you're done inhaling and hence it controls when the machine decreases the pressure from IPAP to EPAP.

Now, palerider is the person who can give you the best idea of what changing those settings from Medium (i.e. average) to Very High are.

If I recall correctly, Trigger determines when the machine "triggers" the pressure to change to IPAP. Setting Trigger to Very High means there has to be a lot of inhalation flow to "trigger" the pressure to change to IPAP. Effectively this can delay the change to IPAP for a fraction of a second as compared to having Trigger set at Medium.

And if I recall correctly, Cycle determines when the machine "cycle" the pressure to change to EPAP. Setting Cycle to Very High will cause the machine to "cycle" to EPAP when there is still some inhalation flow wave being detected. In other words, setting Cycle to Very High can cause the machine to change to EPAP earlier than it will if Cycle is set to Medium.

The net result of having both Trigger and Cycle set to Very High, is that the change between EPAP and IPAP just might be far enough out of sync with your perception of your breathing pattern to trigger a feeling that the machine is encouraging you to inhale or exhale (or both) before you are ready to do that. And if it subjectively feels like the changes between EPAP and IPAP are out of sync with your breathing, that too can lead to additional air swallowing.

In other words, I think you need to work on finding settings that encourage you to swallow less air rather than focusing on your machine scored AHI numbers. I'd suggest keeping track of how bad the aerophagia is each night and see if there is a strong correlation between how bad the aerophagia is and how you feel the day.

I'll write more in a bit about the other stuff you mention in your post.
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Re: Newbie (((struggling))) - mixed central/obstructive apnea questions

Post by robysue1 » Thu Nov 03, 2022 1:33 pm

Omega Proxy wrote:
Thu Nov 03, 2022 10:50 am
Leak score 5L/min. Is that high?
No, a leak rate of 5 L/min is not high.

It's worth noting, however, that you are getting this number off the machine's LCD. So, it means that your unintentional leak rate was less than or equal to 5 L/min for 95% of the time the machine was running. That's actually a really good leak rate. But if the leaks are bothering you by waking you up, then that's important. Do you remember waking up feeling like the mask was leaking? If so, do you remember waking up a lot fighting pesky leaks?

Now for my sleep report from last night:

My events per hour were amazing 0.1 (super excited here about the adjustments I made), although I woke up after just 5.31 hours of use. Not sure why I woke up so early, but I was unable to get back to sleep. This makes me suspect apnea, as the stress response for my body has made it impossible to get back to sleep so many times in the past from apnea event awakening.
Let's put this in context of the rest of the data you posted later on:
AHI 0.6
Total AI 0.5
Central AI 0.4
So when you say your "events per hour" were 0.1, you must mean that the obstructive apnea index (OAI) is 0.1. I'll work on that assumption since OAI = Total AI - CAI = 0.5 - 0.4 = 0.1

Looking at the data in OSCAR would settle your question about whether an OA woke you up for good: Since your OAI = 0.1 in 5.31 hours of use, that means you had exactly one OA scored all night long: 1/5.31 = 0.19, and the machine's LCD truncates the number to 0.1 rather than rounding it to 0.2. If that one event is not within a minute or two of when you woke up, the wake was not caused by an obstructive apnea.

Notably, since the AHI = 0.6 and the Total AI = 0.5, it looks like you also had a HI = 0.1. So you also had exactly one hypopnea scored during the whole night. And if that one hypopnea is not within a minute or two of when you woke up, the wake was not caused a hypopnea.

Now, it could be that you may have had some flow limitations or snoring scored right around the time of your wake, and those might have been responsible for the wake. Looking at the data in OSCAR will resolve this question of whether an obstructive event caused the wake pretty completely.

Finally, I'll also add that the CAI = 0.4 means that you probably had 2 or 3 CAs scored during the entire night. (It depends a bit on how your machine's LCD is doing the rounding in the computations. But I suspect that you actually had 2 CAs, 1 H, and 1 OA for a total of 4 events.) If a CA (or two) was scored right before your wake, that event could very well be a normal transition event that would not be scored on a sleep test.
Pressure 8.1
Exp. Pressure 6.1
These are 95% pressure levels. Meaning your your (IPAP?) pressure was at or below 8.1cm for 95% of the night and your EPAP pressure was at or below 6.1cm for 95% of the night.

Given that your starting ramp pressure is 4cm and your min EPAP = 6.6 and max IPAP = 11, you might expect that the 95% pressure numbers would be as high as your min EPAP = 6.6 and min EPAP + PS = 8.6. But you have a 20 minute ramp that starts at 4cm, and 20 minutes is about 6% of a night that is 5.31 hours long. In other words, the ramp pressures are bringing these numbers down just below your therapeutic pressure settings.

More importantly, however: Your machine is not increasing the pressure above its minimum setting for any length of time. That indicates the machine is not finding anything in your sleep breathing patterns to respond to. In other words, your sleep disordered breathing is excellently controlled by your current settings and, given the aerophagia problem, it's worth asking whether decreasing the Min EPAP setting might give you a sweet spot of controlling the aerophagia (and thus improve the sleep) while still not allowing too many obstructive events to occur (i.e. providing good quality therapy for the sleep disordered breathing.)

All of which points to my original question: Did you really need to increase the min EPAP in the first place? Or is increasing the min EPAP leading to more aerophagia and more spontaneous wakes which are ruining your sleep even though you are not having any sleep disordered breathing events while using xPAP?

Vt 440mL
RR: 14
MV: 6.5L/min
Ti 1.4s
I:E 1:1.9
These are also 95% numbers concerning the data the machine gathered about the
  • the number of breaths you took per minute (RR)
  • the size of your inhalations (MV)
  • the length of your inhalations (Ti)
  • the ratio of the length of the inhalations to exhalations (I:E)
The fact that Ti = 1.4 is important only because it points to Ti Min = 0.9 probably not being too long and Ti Max = 2 probably not being to short. If you looked at the data in OSCAR, the median Ti number (i.e. median inspiration time) would be a better indicator of whether Ti Min = 0.9 is too long.

Spont Cyc 97.5%
I believe this means that 97.5% of the time, your own exhalation caused the machine to "cycle" to EPAP. That also means that 2.5% of the time, the machine was deciding to "cycle" to EPAP on its own. My guess is that occasionally the machine was cycling to EPAP at the end of 2 seconds, but you were still actively in the inhalation stage of breathing.

Please let me know if I missed any information.
It would be useful to look at this night's data in SleepHQ or OSCAR. I think you will find that your wake after 5.31 hours of usage was not triggered by an OA or an H.

Finally, how was the aerophagia when you woke up? Better than usual (i.e. less cramping and less pressure), about the same, or worse? I ask because I continue to think that the reason you are not feeling better has less to do with whether your AHI is 0.8 or 0.5 and more to do with how much air swallowing went on during the night.
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Re: Newbie (((struggling))) - mixed central/obstructive apnea questions

Post by Omega Proxy » Fri Nov 04, 2022 6:59 pm

Hi Robysue1,

Excellent questions. Thank you for asking.

Your thought about REM and supine is a good one. Likely both significant factors.
I have not downloaded m my data as I was not familiar with OSCAR or SleepHQ, until you just mentioned them.
I made the setting adjustments somewhat on my own. The only hard data I had that made me increase the pressure was my last sleep study, how I've been feeling and wanting to feel/sleep better. "the problem I'm trying to solve by adjusting settings": I wanted to see if I could bring down my AHI and or notice an improved subjective quality of sleep. I hadn't increased the pressure setting initially with the new BiPAP because I didn't want the Aerophagia. With my initial pressure settings on the BiPAP I don't recall waking up from Aerophagia cramps. However, I am having some cramping now with the new settings, but it hasn't seriously disturbed my sleep that I can tell. Ultimately, what I'd like is to be able to use my tongue suction device and the BiPAP together. I'm confident I could use a much lower pressure level with that combination. I'm unaware of any device engineered to accommodate that. Not sure if there is a market to get engineers interested.

"Statistically speaking there's not much difference between an AHI = 0.8 and an AHI = 0.5. In both cases, the AHI typically indicates very few events for the entire night, and most of the time, there are no real clusters of events, except possibly minor clusters of probable post arousal CAs that would not have been scored on an in-lab NPSG test. But arousals---for any reason---can be disruptive of your sleep and if there are enough arousals, that can lead to you feeling bad the next day."

I have to tell you. Though I don't feel that my healthcare providers were listening or taking it seriously. Regardless of what my numbers suggest and diagnosis of "mild" sleep apnea. My subjective experience was that the physiological stress response from my apnea events (too often) were severe enough that I would wake up and not be able to get back to sleep for 1-2 hours. Totally disruptive to my quality of sleep.

I appreciate your positive feedback aerophagia explanation. Good to know. I may have gone overboard adjusting so many settings at once. I will try lowering my pressures and watch the AHI index and how I feel.

I've started intermittent fasting for general health reasons and mainly for my newest reason: reduce gastric discomfort from aerophagia. I find the earlier I eat my last meal of the day (currently around 2-4pm), the less aerophagia bothers my digestive system. Plus I understand eating too close to bed time can cause sleep disruptions and is less healthy in general. So, might as well keep it as clean as possible :)

Thanks again for taking the time to share and ask questions!

I posted most all my numbers in another post here if you'd care to take a look.

Best,
Slim Sleepy

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Re: Newbie (((struggling))) - mixed central/obstructive apnea questions

Post by Omega Proxy » Mon Nov 07, 2022 3:29 pm

Robysue1, you've been a huge help.

Yes, I was making a lot of changes without totally understanding what I was doing.
Yes, I believe it's the aerophagia that is my main issue at this point.

Seems like I could benefit from adjusting my PS up so that my expiratory pressure will be lower. That could help with my aerophagia, correct?

I just made adjustments as follows:
IPAP down to 9.4 (I was only hitting mid 8's on my nightly review anyway)
EPAP down to 4.0
PS up to 3.4

Will test that for a few nights to see how the aerophagia is impacted.
I'm considering lowering my EPAP to 3, but not sure if 6.4 is enough pressure.
If I do lower my EPAP to 3, I'd bring my PS up to 4.4. These would probably be my next adjustments if I'm still getting bad aerophagia.

Does it seem like I'm headed in a good direction now?
Why would I want my EPAP to be higher? My thinking is I want EPAP to be as low as possible to allow for me to belch air out if I do end up swallowing air.

I appreciate your guidance and tutelage.

Best regards,
Slim Sleepy

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robysue1
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Re: Newbie (((struggling))) - mixed central/obstructive apnea questions

Post by robysue1 » Mon Nov 07, 2022 5:47 pm

Omega Proxy wrote:
Mon Nov 07, 2022 3:29 pm
Robysue1, you've been a huge help.

Yes, I was making a lot of changes without totally understanding what I was doing.
Yes, I believe it's the aerophagia that is my main issue at this point.

Seems like I could benefit from adjusting my PS up so that my expiratory pressure will be lower. That could help with my aerophagia, correct?

I just made adjustments as follows:
IPAP down to 9.4 (I was only hitting mid 8's on my nightly review anyway)
EPAP down to 4.0
PS up to 3.4

Will test that for a few nights to see how the aerophagia is impacted.
These are reasonable settings for Max IPAP, Min EPAP, and PS. But you need to commit to sleeping with them for at least 3 or 4 nights and not panicking if the first night results in an AHI that is larger than you are used to seeing, but is still under 5.
I'm considering lowering my EPAP to 3, but not sure if 6.4 is enough pressure.
The minimum EPAP allowed by your Resmed VAuto is 4cm.
If I do lower my EPAP to 3, I'd bring my PS up to 4.4. These would probably be my next adjustments if I'm still getting bad aerophagia.
You can't lower min EPAP to 3; the machine only allows min EPAP to go down to 4cm. If using Max IPAP = 9.4, Min EPAP = 4, PS = 3.4 results in bad enough aerophagia for you to feel like you need to change the settings, you could lower Max IPAP = 8, but since your 95% IPAP is only 8.1, that might not really do anything.
Does it seem like I'm headed in a good direction now?
Focusing on how the aerophagia feels instead of whether the AHI is below 0.5 is a good direction. Only worry about the AHI if there is a huge jump---like up into the 3.5+ range.
Why would I want my EPAP to be higher? My thinking is I want EPAP to be as low as possible to allow for me to belch air out if I do end up swallowing air.
EPAP is the pressure that is needed to prevent the OAs from happening; EPAP also is the pressure that minimizes or eliminates snoring. IPAP helps prevent hypopneas, RERAs, and flow limitations. If lowering EPAP to 4.0 allows too many OAs to happen or too much snoring to occur, you can have arousals that trigger the air swallowing with those events.

In other words, aerophagia's connection to pressure is a bit more complex than "more EPAP means more aerophagia".

For some people, the EPAP is the important factor. For some people, the PS is---too large or too small of a PS can trigger the air swallowing. Finding the sweet spot for PS can take experimentation. And for some people, making sure the max pressure never gets too high is important in managing aerophagia; for these people, there's a careful need to build a working compromise between enough pressure to fix the OSA but not so much pressure to trigger an unacceptable amount of aerophagia. (Too low of a Max IPAP also prevents the EPAP from increasing to the level it might need to reach to prevent the OAs from occuring.)

In my case keeping EPAP less than a certain level has traditionally been important in keeping my aerophagia under control. But I've been using a PR BiPAP Auto which has a different algorithm than your Resmed VAuto. I'm currently at the beginning of trying out a loaner Resmed AirCurve 10 VAuto and it is going to take me some experimenting to figure out how to let the Resmed provide the IPAP I need to keep the hypopneas, flow limitations, and RERAs under control while not triggering problems from having my EPAP get too high or my PS be too large.

But it helps when you are experimenting to change only one setting at a time. So if you run into problems with Max IPAP = 9.4, Min EPAP = 4.0, and PS = 3.4, the next step would be to choose one of the three settings to change. Which setting would be based on exactly what problems you run into with these settings.

And for that you need at least 3 or 4 nights of data---unless something goes spectacularly wrong.
Joined as robysue on 9/18/10. Forgot my password & the email I used was on a machine that has long since died & gone to computer heaven.

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Omega Proxy
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Re: Newbie (((struggling))) - mixed central/obstructive apnea questions

Post by Omega Proxy » Tue Nov 29, 2022 3:00 pm

It's been Hectic holidays.

I want to express sincere appreciation for the questions asked, information and guidance received.
Your help made a significant difference for me. my sleep has much improved.

I think I'm fairly well dialed in now. ^_^

I'm still interested to learn of anything that can reduce central sleep apnea.

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Pugsy
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Re: Newbie (((struggling))) - mixed central/obstructive apnea questions

Post by Pugsy » Tue Nov 29, 2022 3:08 pm

Omega Proxy wrote:
Tue Nov 29, 2022 3:00 pm
I'm still interested to learn of anything that can reduce central sleep apnea.
Well to fix any problem we have to first identify the problem before we can try to fix it.

A few central apneas are normal and to be expected and we don't give them a second thought.

Now if someone is having a high number of centrals....then if someone wants to reduce the number then they need to figure out the cause of the centrals because how to reduce the numbers is different depending on the cause of the centrals in the first place.

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Re: Newbie (((struggling))) - mixed central/obstructive apnea questions

Post by Julie » Tue Nov 29, 2022 3:20 pm

And if your AHI is reasonable and you feel good, don't worry about number of hrs slept - you will sleep less when things go well because you're not trying to make up for events, etc. that keep you from good sleep.