Need a new plan for BiPAP / CSA

Hi everyone,

At the beginning of the yea I switched over from a DreamStation 1 to a Resmed AirCurve 10 due to needing a replacement at the time (FoamGate). I got a BiPAP on the advice of another well known apnea forum due to showing some flow limitations that had not been adequately treated by the DS1. This was after I had mentioned complaints of still feeling fatigued after a couple of years with the DS1.

Since starting BIPAP I've had very good results getting my Hypopneas / OAS under control but I've been struggling with Central Apneas since day one after switching. Central Apneas were not really ever an issue when I used my DreamStation 1, so I'm assuming these are treatment emergent due to Pressure Support. My AHI overall is much better now compared to DS1 days, but mostly everything has been replaced with CAs.

I've been trying to get a handle on these the last few months but I'm starting to get discouraged and I'm just mentally drained at this point. I was hoping that these CAs would resolve or at least get better over the months but it doesn't seem like much has changed. I have some nights with minimal CA (1 - 4), and others with more (usually 8 - 15). I initially started at PS of 4 and EPAP at 8 in January, but have adjusted up/down in pressure settings and tried different Trigger/Cycle settings as well. A higher PS (like 5) seems to lower my FLs and smooth out my flow curve but cause more centrals.

Current settings are: EPAP: 9.0 PS: 3.0 Trigger: High Cycle: Medium

I often see a waxing and waning pattern that seems to eventually collapse into a CA. It doesn't always result in a CA but this pattern is quite frequent throughout the night regardless, so I'm not sure if there is any signifance to this. At this point I'm not sure if I should keep sticking with my current settings and hope that CA goes away, or to lower PS further and try a higher EPAP to combat FL and call it a day? Or not even worry about FL?

Anyway, I apologize for the rant and the info dump. I've posted charts of things I mentioned below. Please let me know if you'd like to see any other details and I'll get them uploaded as soon as possible.

Appreciate you!


---------------------------------
Last night's chart - a good night




Waxing and waning





Another typical day




Close up of CA




Flow Rate - pattern at PS 3, not smooth




Flow Rate - pattern at PS 5, smoother but more CA

What you shouldn't worry about are the insignificant amounts of CAs you're having.

palerider wrote: ↑

Tue May 16, 2023 9:47 pm

What you shouldn't worry about are the insignificant amounts of CAs you're having.

Thanks that is good to hear! I'm not an expert by any means but aren't CAs considered just as bad for your sleep and health as regular old apneas/hypopneas? I figured a few a night, like the 3 or 4 in my first chart, are OK but anything more would be disruptive to the quality of my sleep.

I don't feel I've been getting particularly good sleep which I've been attributing to the CAs. Would you recommend I stick with the settings I'm at now or bump up my PS?

I'll also add that using a trigger of Very High cuts down on centrals quite a bit. I used it quite a bit in the first few weeks of getting my machine, but I ultimately found it uncomfortable to use. It is very sensitive and would trigger my inhales from my heart beat alone. I'm not sure if Cycle can be used to help with centrals in the same way.

Respirator99 wrote: ↑

Tue May 16, 2023 10:52 pm

I have some nights with minimal CA (1 - 4), and others with more (usually 8 - 15).

Do you mean 1 - 4 central apneas per night? Or a central apnea index of 1 - 4? The chart you posted (May 15) shows three apneas in six hours of sleep - this is negligible and should be ignored. Likewise, 15 apneas in a night's sleep is not worth worrying about. On the other hand, if your central apnea index was 8 - 15 then you have a problem and should post a chart showing that.

By the way, please turn the calendar off - it covers up important data.

Sorry, I meant central apneas per night. Some nights there are fewer, but when I do see more the CA index is usually around 2 - 2.5 . The highest I've seen was a few weeks back with index of 4.18 but that is an outlier. I will get rid of the calendar in the future as well

SwirlySauce wrote: ↑

Wed May 17, 2023 6:02 pm

palerider wrote: ↑

Tue May 16, 2023 9:47 pm

What you shouldn't worry about are the insignificant amounts of CAs you're having.

Thanks that is good to hear! I'm not an expert by any means but aren't CAs considered just as bad for your sleep and health as regular old apneas/hypopneas? I figured a few a night, like the 3 or 4 in my first chart, are OK but anything more would be disruptive to the quality of my sleep.

Well, here's what I have to say, and there's a little exercise to make up your mind.

Hold your breath for 15 seconds. You probably do this unconsciously multiple times during the day while doing things. Now start breathing again, notice anything at all? Most people don't.

Now, pinch your nose and lips closed, and try your hardest to breathe for that same 15 seconds (yes, 10 is all that is needed for an apnea to be counted).

Now, how do you feel? That's the difference on your body, and your sleep when comparing a central apnea to an obstructive apnea. One is zero stress, the other is stress off the charts.

Centrals are a problem when you're having so many of them than your SpO₂ is dropping, which usually means you're having to have a lot of them.

SwirlySauce wrote: ↑

Wed May 17, 2023 6:02 pm

I don't feel I've been getting particularly good sleep which I've been attributing to the CAs.

Probably the reverse, if your sleep isn't particularly good, you'll be more likely to get transition apneas (which the machine will usually report as centrals) as you drift in and out of sleep.

SwirlySauce wrote: ↑

Wed May 17, 2023 6:02 pm

Would you recommend I stick with the settings I'm at now or bump up my PS?

Well, at this point, you're not really getting much benefit from the bilevel (never bipap, that's the other manufacturer), that someone else told you that you should get, so... based on what little we've seen, i dunno.

SwirlySauce wrote: ↑

Wed May 17, 2023 6:02 pm

I'll also add that using a trigger of Very High cuts down on centrals quite a bit. I used it quite a bit in the first few weeks of getting my machine, but I ultimately found it uncomfortable to use. It is very sensitive and would trigger my inhales from my heart beat alone. I'm not sure if Cycle can be used to help with centrals in the same way.

Interesting, I cranked up trigger on my machine to cut down on the number of obstructives I was having, because I'd see times where as my (my supposition) my throat was starting to close, I'd see some very small inhalations before an apnea, bumping up trigger helped me by giving me the PS when I was attempting to inhale. (and I'm not saying that others should blindly do the same, just that it worked for me, after I saw that pattern in the data).

Re: your latest image, you've set the machine to be a fixed pressure machine, it can't respond to anything, I wouldn't worry about the amount of centrals, but it doesn't look like your sleep is very good that night.

Why were you 'advised' to get a bilevel machine? Oh, right, because you were replacing a nightmarestation.

Just going to an Autoset would probably have been all you needed, but you've got the vauto now.

MinEPAP 9, MaxIPAP 25 (and just ignore it and leave it alone) PS3, and let's see what she'll do.

SwirlySauce wrote: ↑

Tue May 16, 2023 7:02 pm

Please let me know if you'd like to see any other details and I'll get them uploaded as soon as possible.

Can you retrieve and post all the images from TOF?

Waxing and waning is usually the result of too much (or not enough) something or other.

Need some SleepHQ files and a lot more history, but initial thought is instead of cpaptalk.com you need my sleepisFU.com.

Rubicon wrote: ↑

Thu May 18, 2023 2:27 am

Waxing and waning is usually the result of too much (or not enough) something or other.

Upon further review that might be the most worthless post ever.

Rubicon wrote: ↑

Thu May 18, 2023 2:29 am

Rubicon wrote: ↑

Thu May 18, 2023 2:27 am

Waxing and waning is usually the result of too much (or not enough) something or other.

Upon further review that might be the most worthless post ever.

Hey now, Lazarus might get upset if you start elbowing in on his territory.

Thanks Palerider, appreciate your thoughts on this


Centrals are a problem when you're having so many of them than your SpO₂ is dropping, which usually means you're having to have a lot of them.

Makes sense. I think I was just alarmed when I went from having 0 centrals with DS1 to all of these practically overnight.

Interesting, I cranked up trigger on my machine to cut down on the number of obstructives I was having, because I'd see times where as my (my supposition) my throat was starting to close, I'd see some very small inhalations before an apnea, bumping up trigger helped me by giving me the PS when I was attempting to inhale. (and I'm not saying that others should blindly do the same, just that it worked for me, after I saw that pattern in the data).

Yes I can imagine that a higher trigger setting would be beneficial for obstructive as well. The rapid rise/burst of air pressure probably helps prop open airways better than a lower setting - like a mini version of PS.

I think with regards to Central Apneas, it snaps you out of a central apnea simply because the trigger is so sensitive even the tiniest alteration in flow will trigger the machine to switch to IPAP and force an inhale. At least on Very High. But I don't think it changes the underlying issue; removing too much CO2 due to PS. So does it really matter in the end?

Re: your latest image, you've set the machine to be a fixed pressure machine, it can't respond to anything, I wouldn't worry about the amount of centrals, but it doesn't look like your sleep is very good that night.

The one from April 17? That one I posted for Respirator as an example. That night was the highest I've seen my CA index go so its definitely an outlier.

But yes, I've started capping my machine's pressure range as of late. I wanted to see if pressure increases during the night were destabilizing my breathing further, leading to more centrals. Some people are sensitive to these changes according to a certain YouTuber.

Why were you 'advised' to get a bilevel machine? Oh, right, because you were replacing a nightmarestation.

Back when I was using the nightmarestation (Hah!) the machine was reporting a lot of flow limitations. It was suggested I either keep increasing pressure to clean up my flow curves, or I could get a bipap. Pressure Support is the best option for treating UARS / Flow Limitations so I figured that was the way to go since I needed a new machine anyways. I did some reading on Barry Krakow's theories on treating UARS as well.

I guess the big question is, how much do flow limitations actually matter to sleep quality? When are they too much? All I know is my flow curves aren't as nice looking as other peoples and that could potentially cause unrestful sleep

Heres an example of flow limitations when I used the DS1 back in the old days. The flow limitation index (or whatever it is for Philips) was always around 0.2 - 0.5 for most nights -



Just going to an Autoset would probably have been all you needed, but you've got the vauto now.

MinEPAP 9, MaxIPAP 25 (and just ignore it and leave it alone) PS3, and let's see what she'll do.


Sounds like a plan to me! I'll keep you posted.

Rubicon wrote: ↑

Thu May 18, 2023 2:27 am

SwirlySauce wrote: ↑

Tue May 16, 2023 7:02 pm

Please let me know if you'd like to see any other details and I'll get them uploaded as soon as possible.

Can you retrieve and post all the images from TOF?

Waxing and waning is usually the result of too much (or not enough) something or other.

Need some SleepHQ files and a lot more history, but initial thought is instead of cpaptalk.com you need my sleepisFU.com.

Wait, what is TOF? What is sleepisFU.com?

SwirlySauce wrote: ↑

Thu May 18, 2023 6:16 pm

Centrals are a problem when you're having so many of them than your SpO₂ is dropping, which usually means you're having to have a lot of them.

Makes sense. I think I was just alarmed when I went from having 0 centrals with DS1 to all of these practically overnight.

"all of these" being pretty much nothing, except for the last post, and even that isn't in the "we should worry about it" stage.

SwirlySauce wrote: ↑

Thu May 18, 2023 6:16 pm

But I don't think it changes the underlying issue; removing too much CO2 due to PS. So does it really matter in the end?

More PS will drive down your CO₂, and depress respiration, and you seem (at first glance) to be sensitive to that, which makes me wonder why you were advised to get a machine that just (mainly) offers MORE PS.

SwirlySauce wrote: ↑

Thu May 18, 2023 6:16 pm

. Some people are sensitive to these changes according to a certain YouTuber.

what people absolutely are sensitive to are the breathing issues that *cause* the pressure changes. (something certain youtubers don't seem to 'get'. fix the breathing issues, and the pressure changes won't happen as much, and sleep will be better.

SwirlySauce wrote: ↑

Thu May 18, 2023 6:16 pm

I guess the big question is, how much do flow limitations actually matter to sleep quality? When are they too much? All I know is my flow curves aren't as nice looking as other peoples and that could potentially cause unrestful sleep

Here's my exercise for seeing what FLs are like while awake, get a drinking straw, put that in your mouth and breathe through it for a while... after a relatively short period of time, I start getting fatigued, because I'm having to work harder to pull air through the small tube... and that's essentially what a flow limitation is, it's your airway being narrowed and you being limited on the flow rate of the air you can inhale, so you work harder to get air in, and that will disturb your sleep, which is why the auto machines raise pressure to reduce/eliminate the flow limitations.

SwirlySauce wrote: ↑

Thu May 18, 2023 6:16 pm

Heres an example of flow limitations when I used the DS1 back in the old days. The flow limitation index (or whatever it is for Philips) was always around 0.2 - 0.5 for most nights -

The FLs weren't even enough there for the machine to flag one... of course, you don't get as much good data from a philips machine as you do with Resmeds.

SwirlySauce wrote: ↑

Thu May 18, 2023 6:18 pm

Wait, what is TOF? What is sleepisFU.com?

The Other Forum. The images that were used to justify BiPAP (BiPAP BiPAP BiPAP)(sorry, inside joke). Although you did post one image from the DS. IDK. Not particularly remarkable.

An imaginary forum. IMO the working theory is your underlying sleep has issues where you might get more bang for the buck.

Speaking of which, of all the machine and settings changes, are there any where you feel truly rested (not sleepy)? You mention fatigue, but fatigue is not sleepy so what you're trying to fix may not be CPAPable. While you claim "good results" from the current therapy you also state you are "discouraged and I'm just mentally drained at this point" so need to clarify exactly what that means.

SwirlySauce wrote: ↑

Thu May 18, 2023 6:18 pm

What is sleepisFU.com?

Sorry, I apologize. I inadvertently put in a space that shouldn't be there. The non-existent forum is

MySleepIsFU.com.

Or maybe just PM me (and perhaps PR who may also be interested) the link to the other forum to view the data. All information is good information.

In one of your images there is some funny stuff going on during expiration:



And those "FLs" are so flawlessly unwavering as to invite debate in re: where/why.