Another newbie getting to grips and with CSR concerns

lynninnj wrote: ↑

Sun Dec 11, 2022 4:55 pm

I’m looking at the ramp on auto and thinking that makes it tougher. I like my 5 minute ramp. Minimum setting may need upward tweak, if I’m reading it right.

maybe a veteran will concur.

If I were to change anything it would first be the max setting (increase it as a "just in case" thing) before worrying about the minimum and see how it goes.

There was a recent night with AHI less than 2.0...quite respectable for someone so new to this therapy and I wouldn't be worrying about it.
I would wait for more nights to evaluate in terms of that minimum (assuming someone is comfortable with starting with 5 or 4 if using ramp).
I have never used the ramp...even back when my starting minimum pressure was 10 cm.

I'd also bump the minimum pressure to 8, along with raising max to 20.

palerider wrote: ↑

Sun Dec 11, 2022 4:50 pm

Miss Emerita wrote: ↑

Sun Dec 11, 2022 1:54 pm

About the pressure maxing out at 9: the pressure increases seem to be largely driven by your flow limitations. Increased pressure doesn't actually do much to address flow limitations,

Um, yes, yes it can, and usually does. that's WHY the machines increase pressure for flow limitations.

As always, I'm very glad to learn from you. I had thought ResMed machines responded so (relatively) vigorously to FLs on the theory that FLs could signal the onset of a collapsing airway, with hypopneas or OAs to follow. I guess my question would be whether it's OK to cap pressure *if* Hs and OAs are under good control and the PAP user isn't bothered by FLs.

I'm also curious what you think about the best way to address FLs for people who are bothered by them. For me, pressure increases made no difference, but pressure support did. But that's just me. (And of course for the OP, PS would not be such a good idea, given the CAs.)

Miss Emerita wrote: ↑

Sun Dec 11, 2022 6:15 pm

And of course for the OP, PS would not be such a good idea, given the CAs.)

PS would be a bad idea only if the PS was a factor in increasing the centrals and since the OP had quite a few centrals not even on cpap....we don't have any proof that PS has anything to do with the central numbers.

Remember the first usual go to machine to treat centrals is a bilevel machine with PS. Not everyone will have the centrals be triggered by PS.

Miss Emerita wrote: ↑

Sun Dec 11, 2022 6:15 pm

palerider wrote: ↑

Sun Dec 11, 2022 4:50 pm

Miss Emerita wrote: ↑

Sun Dec 11, 2022 1:54 pm

About the pressure maxing out at 9: the pressure increases seem to be largely driven by your flow limitations. Increased pressure doesn't actually do much to address flow limitations,

Um, yes, yes it can, and usually does. that's WHY the machines increase pressure for flow limitations.

As always, I'm very glad to learn from you. I had thought ResMed machines responded so (relatively) vigorously to FLs on the theory that FLs could signal the onset of a collapsing airway, with hypopneas or OAs to follow. I guess my question would be whether it's OK to cap pressure *if* Hs and OAs are under good control and the PAP user isn't bothered by FLs.

How do you determine if the pap user isn't bothered by FLs? FL's also disturb sleep, in addition to signalling airway restriction, the extra effort involved in breathing with FLs can lead to arousals, (sleep disturbances) that the user normally won't be aware of.

Miss Emerita wrote: ↑

Sun Dec 11, 2022 6:15 pm

I'm also curious what you think about the best way to address FLs for people who are bothered by them. For me, pressure increases made no difference, but pressure support did. But that's just me. (And of course for the OP, PS would not be such a good idea, given the CAs.)

Seeing what the person's data looks like is the only way to tell.

I'm all for letting the machine do it's thing without restrictions unless something else, like aerophagia, crops up. Then raising the min pressure to smooth out the pressure line so it's not all over the map like the OPs is.

I had another great night last night with no changes to the recipe. I recorded an AHI of 1.58 made up of 0 CA, 0.7 OA and 0.88 H. I woke up feeling refreshed and went out for a walk before anybody else in the house has risen (another first), thinking "Ah, so this is what waking from sleep is supposed to feel like, is it?". I really had no idea how bad I was feeling previously because back then I just didn't know what good looks like. What's surprising to me right now is how great I'm feeling on just six hours of sleep, but I guess six high quality hours are better than any amount of broken light sleep constantly interrupted by the brain going into panic mode.

Thanks again to everyone here for all your amazing help.

Responses to various posts below:

Pugsy wrote: ↑

Sun Dec 11, 2022 10:30 am

We need to see your flagged CSR breathing to have any idea if it is a real problem for you especially since you did have enough centrals during the diagnostic sleep study to earn the complex sleep apnea.

I got that wrong actually. My diagnosis was for severe obstructive sleep apnea.

Pugsy wrote: ↑

Sun Dec 11, 2022 3:06 pm

GolfGardener wrote: ↑

Sun Dec 11, 2022 2:47 pm

Out of interest, how do you know when you are in REM sleep to determine that it is 5 times worse?

Documented when I had an in lab diagnostic sleep study.
Overall diagnostic AHI when not in REM was around 12 but in REM (what little REM I got) it was documented at 53 per hour.
Supine sleeping has never been that big of a deal for me but REM sure is. It's fairly common and some people have OSA only during REM.

I just checked my sleep study. REM AHI was 60. NREM 64.8, so no real difference, although I only got 46 minutes of REM (and 0 deep sleep) the entire night. I'll take a look at how I can spot REM sleep from my breathing patterns so I can look into this further.

Pugsy wrote: ↑

Sun Dec 11, 2022 5:04 pm

lynninnj wrote: ↑

Sun Dec 11, 2022 4:55 pm

I’m looking at the ramp on auto and thinking that makes it tougher. I like my 5 minute ramp. Minimum setting may need upward tweak, if I’m reading it right.

maybe a veteran will concur.

If I were to change anything it would first be the max setting (increase it as a "just in case" thing) before worrying about the minimum and see how it goes.

There was a recent night with AHI less than 2.0...quite respectable for someone so new to this therapy and I wouldn't be worrying about it.
I would wait for more nights to evaluate in terms of that minimum (assuming someone is comfortable with starting with 5 or 4 if using ramp).
I have never used the ramp...even back when my starting minimum pressure was 10 cm.

Tweaks to each of those settings are now on my to-do list, but for now I'm going to run with the settings I've got, see if I can stabilise the AHIs where they have been the last couple of days, and try to get the big picture of what's happening.

palerider wrote: ↑

Sun Dec 11, 2022 7:41 pm

I'm all for letting the machine do it's thing without restrictions unless something else, like aerophagia, crops up. Then raising the min pressure to smooth out the pressure line so it's not all over the map like the OPs is.

That's interesting. I had thought until now that the pressure line being "all over the map" was a good thing so long as it wasn't hitting the stops at either end, as that was a sign that the machine is doing its job of adjusting to the current circumstances properly.

Have I got that wrong? Should I be looking for a flatter pressure line once I've made all the necessary adjustments?

GolfGardener wrote: ↑

Mon Dec 12, 2022 12:38 am

I got that wrong actually. My diagnosis was for severe obstructive sleep apnea.

Did you have a large number of central apneas during the diagnostic sleep study? Enough to have a central apnea AHI greater than 5?
If you did...there's a good chance you have a problem with centrals despite severe OA diagnosis.
Wouldn't be the first time that someone got a wrong or incomplete diagnosis but I did find it odd that the titration study "9 cm fixed all the apneas" when someone is supposed to have complex sleep apnea. Not a big deal as long as your AHI on cpap stays nice and low like you got again last night. Sometimes cpap/apap will deal with central apneas....not common but it can happen which is why people with central sleep apnea have to try cpap first before moving on to the high dollar machine that can deal with centrals. Sometimes cpap will work.

GolfGardener wrote: ↑

Mon Dec 12, 2022 12:38 am

I just checked my sleep study. REM AHI was 60. NREM 64.8, so no real difference, although I only got 46 minutes of REM (and 0 deep sleep) the entire night. I'll take a look at how I can spot REM sleep from my breathing patterns so I can look into this further.

Doesn't surprise me that the REM was really limited during the diagnostic study and you didn't get any deep sleep. With the AHI being 60 ish in both REM and non REM you were most likely waking often from the OA events (that's about 1 apnea event a minute). When I had my sleep study done in the sleep lab they told me that every time I would go into REM the OAs came fast and furious and kept kicking me out of REM and they actually had to do a bit of extrapolating to come up with an hourly figure. I certainly didn't stay in REM for an hour.
More like 10 minutes and they had to multiply the number of events by 6 to come up with an hourly figure.
When you wake often then you have to start all over with the sleep stage progression and when that happens you don't get enough or all the sleep stages. One event per minute will sure cause the wake ups enough to have to reset the sleep stage progression.

I have never been able to spot probable REM by just eyeballing the breathing pattern. Now some people say they can and maybe they can but I haven't ever been able to spot enough of a difference in the patterns to conclusively know it was REM. It's not easy to see very subtle difference in the breathing patterns that we can see on the data the machine gathers. Remember these machines only measure air flow...they can't even tell if we are for sure asleep or not. Now I have spotted the pattern to the pressure increases sometimes but not always and since I know the overall general pattern of REM stage in terms of when we would have REM I make educated guesses as to when REM was happening.
Like when I first started on cpap I would always have a rather dramatic increase in the pressure about 90 minutes after sleep onset. I used to just call it my witching hour because I would see it consistently at the 90 minute mark and during the wee hours of the morning I would see more pressure variation. The wee hour REM...I didn't/don't see that so often as the 90 minute change. I think that is probably because in those wee hours I may not get as much REM because I start waking often during those wee hours from pain issues. Most likely bounces me out of REM and I have to also reset the sleep stage progression but that's because of pain issues waking me up and not a problem with my machine settings.

For this reason I have always had a rather volatile pressure line at times...but not always.
And while some people want a more stable pressure line I haven't been one of those people because the pressures roaming around everywhere haven't really bothered me. One of the reasons I don't advised dramatic increases in the minimum pressure right off the bat unless I see a potential problem or someone tells me they think the pressure changes are causing a problem with sleep. I am much more conservative with my ideas than some people are. That's just me....you get advice based on my own personal experience as well as reviewing thousands of these machine reports. Palerider is more aggressive with ideas than I am. That's based on his own personal experience and the thousands of reports he has reviewed. There is no hard fast rule about how much pressure variation is too much and so the pressure variations maybe needs to be smoothed out with a lot more minimum.

If you continue with AHI less than 2 and tell us

GolfGardener wrote: ↑

Mon Dec 12, 2022 12:38 am

I woke up feeling refreshed and went out for a walk before anybody else in the house has risen (another first), thinking "Ah, so this is what waking from sleep is supposed to feel like, is it?".

there certainly isn't any urgent need to go changing things either subtly or dramatically.
The goal is sleep good and feel good.

Now you can always make the changes at some time in the future just to see if it changes anything (which I did do myself a long time ago) and there's nothing wrong with experimenting and in your situation I don't see an urgent need to change the minimum at this time.
Now the maximum change...if you continually see your max setting being hit for any prolonged duration then for sure the max probably should be increased. The machine won't go higher just because it can go higher without having a good reason. It is entirely possible that when you hit the 9cm that if the machine could go higher it might only want to go to 10 cm even if it could go to 20 cm.
As long as the "going higher" doesn't cause a problem...no harm in letting the machine go higher.

Right now the "all over the map" is ranging from 5 to 9....that's not a huge "all over the map" IMHO...that's a 4 cm variation. I have seen 8 cm difference (because of my REM events being stubborn and needing a lot more pressure) and it doesn't cause me any problems at all.
Now if your max was 20 and we were seeing pressures go to the teens often and changing all night...that I would classify as "all over the map". Your choice but I don't see an urgent need to go changing things at this time. If I thought you urgently needed to go changing things right now....I would tell you so.

You haven't been on cpap all that long...I like to give things time to settle in and then evaluate things unless I see an urgent need for a change that is critical. I don't see it yet in your reports. I would for sure want to see what happened with an increase in maximum first before I would advise a minimum change unless someone feels air starved at 5 cm. There are people who just feel better in terms of breathing with a higher minimum and that's okay too. There aren't many hard fast rules with this therapy.

Now if your AHI was consistently a lot higher and composed of a lot of OAs and hyponeas we would be having a different discussion.

Fantastic news, GG!

Pugsy wrote: ↑

Mon Dec 12, 2022 5:59 am

GolfGardener wrote: ↑

Mon Dec 12, 2022 12:38 am

I got that wrong actually. My diagnosis was for severe obstructive sleep apnea.

Did you have a large number of central apneas during the diagnostic sleep study? Enough to have a central apnea AHI greater than 5?

If you did...there's a good chance you have a problem with centrals despite severe OA diagnosis.

My CA index was 20 in the original sleep study.

Thanks for all the other sage advice in that message. I am traveling at the moment so can’t give a more detailed response but yes, I’m going to leave things as they are for now unless any problems arise then start to do some fine-tuning when I’ve got more data to work with.

GolfGardener wrote: ↑

Mon Dec 12, 2022 12:38 am

That's interesting. I had thought until now that the pressure line being "all over the map" was a good thing so long as it wasn't hitting the stops at either end, as that was a sign that the machine is doing its job of adjusting to the current circumstances properly.

Have I got that wrong? Should I be looking for a flatter pressure line once I've made all the necessary adjustments?

yes you have. Because the machine trusts whoever set the min pressure to know what they were doing, and that means setting the min pressure high enough to prevent the majority of events outright.

Otherwise, you'll be experiencing breathing problems all night long that you don't need to experience, that drives the pressure up to where you're breathing OK, at which point, that foolishly trusting machine says "well, I was TOLD that the min pressure was x, so I'll start lowering the pressure back down to x" at which point you have more breathing issues that cause pressure to increase again.

Better to just prevent most of the breathing issues.

When the min pressure is too low, like yours is, you get that roller coaster pressure curve, like you have.

GolfGardener wrote: ↑

Mon Dec 12, 2022 11:25 am

My CA index was 20 in the original sleep study.

That qualifies for central sleep diagnosis in my book.
Add it to your obstructive AHI and I would get complex sleep apnea diagnosis.
Obstructive is primary but with a minor in central...

With the history of diagnostic centrals and the sparse flagging of centrals and some CSR flagging that sort of looks real on some reports...I would advise caution with pressure increases anywhere.

Just go slow with any changes and watch your data carefully.

GolfGardener wrote: ↑

Mon Dec 12, 2022 12:38 am

I had another great night last night with no changes to the recipe. I recorded an AHI of 1.58 made up of 0 CA, 0.7 OA and 0.88 H. I woke up feeling refreshed and went out for a walk before anybody else in the house has risen (another first), thinking "Ah, so this is what waking from sleep is supposed to feel like, is it?".

wow! another newbie responding to therapy. so good to see it.

Hi everybody,

Just thought I'd check in after being away travelling for the last week.

Current situation:
My data is starting to look more consistent and the results now appear (to my untrained eye) to be great. Over the last 7 days my average AHI has been 1.49 (OA: 0.19, H: 0.92, CA: 0.38) which is a lot better than where I started off. I haven't made any changes to settings so I assume this is just down to getting used to this new way of sleeping, sorting out mask fit/comfort, avoiding leaks etc.

I'm still consciously waking two or three times most nights. Not sure what the reason is but I can live with this and am trying to pinpoint the causes.

Planned changes:

• The pressure is still bumping up against the max setting of 9 pretty much every night, so I'm going to put it up to 12 and see what happens over the next few days.
• Once I've found a more sensible max I'll then begin to increase the minimum (currently at 4).

Some other observations:

• The stuff that looked like CSR which was causing me some concerns hasn't appeared again since I last mentioned it. I've no idea why, but I'm certainly happy with that.
• I'm training myself to become a nose breather. I thought this was going to be really difficult, if not impossible, after a lifetime of mouth breathing but it seems to be going well. I did two weeks of sleeping with a single vertical strip of tape over my mouth, which served as both a basic seal and (I think more importantly) as a reminder of what my lips should be doing. I've also been making a conscious effort to keep mouth shut and tongue resting up against my palate during the daytime. Last night I didn't bother with the tape for the first time and it went well apart from a couple of mouth leaking incidents which were quickly sorted out.
• I had a few nights with irritating levels of "chipmunk mouth" but I think the training mentioned above is going to fix that as well. I read in one post here about the "valve" that controls the airway between nose and mouth and although I can't pinpoint exactly what's going on, it feels like I'm starting to get some sort of control over that, which should help keep the air where I want it.
• The complete absence of any hangovers after a few drinks is a benefit I never expected from this treatment. I must remember to use this superpower wisely.

Finally, a couple of questions:

1. After around 6 hours or so mask-on, I often wake up feeling like I'm unable to get back to sleep again with the mask, but if I remove the mask I can probably roll onto my side and catch another hour or so of light sleep. Is this a bad idea? Am I likely to be putting my body under stress by going back to an untreated sleep apnea mode? If so I guess I just need to keep adjusting for comfort and training my brain to get accustomed to the mask, and/or just get out of bed even though I feel like I haven't slept quite enough.
2. The central apneas, which were around 20 in my initial sleep study have now dropped to under 1. What exactly is going on there? I understand at a basic level how the CPAP device can prevent obstructive apneas, but how is it also removing the centrals?

One last thing: thanks for the simple words of encouragement from some of posters here in addition to all the great advice I've had. I get the impression that I'm having an easier transition to CPAP than many others here have experienced, for which I'm really grateful. I'm still finding the mental adjustment quite difficult though and your support and encouragement means a great deal.

Once other parameters/settings are working well, what seemed to be CSRs so often turn out to be 'just' SWJ, or 'sleep wake junk', usually just as you fall asleep and/or just before waking, and are not necessarily true CSRs... so that may be a good thing for you.

OK, here are the results of last night's trial with a higher max pressure (12):



Overall it felt like a pretty good night's sleep. I could certainly feel the extra pressure, but while I was definitely conscious of that along with some leaks a few times during the night, I was never roused to the kind of "wide awake" state where I'd normally be checking the time, thinking about a bathroom visit etc.

The other good news appears to be that my pressure chart isn't getting clipped at the high end anything like as often as previously, so 12 looks like a better max pressure than 9 where it was before.

The bad news is that the AHI is back up to 16 with mostly all of the events registered being CAs during extended period of CSR. Here's a zoom into one of those:



Now like I mentioned earlier, I was definitely conscious of some leaks during the night, even though I'd tightened the straps a little before sleeping. I also notice that there is a clear correlation in this chart between the amplitude of the Flow Rate during the stuff marked as CSR and the Leak Rate shown below. The same pattern is repeated in the other sections marked as CSR. So I'm wondering if this is the algorithm failing to correctly disaggregate the leak data from the flow rate data, and incorrectly identifying CSR and CAs. i.e. is this exactly the kind of SWJ that Julie referred to in the previous post in this thread?

As is stands my plan for the next few nights is to leave the pressure settings where they are, try to address the mask leaks and see if the numbers improve as a result. Any other advice/suggestions gratefully accepted.