New user trying to understand why apnea events are not <5

Thank you so much for your additional insight. I will adjust both levels tonight and see how it goes.

Gagne wrote: ↑

Wed Aug 07, 2024 1:57 pm

https://sleephq.com/public/14a2f1ce-308 ... 6eb937a382

Zoom in to the breathing graph at 0108-0109... see that flat-topping? Big FL spike... the machine wanted to take you to the moon... it maxed out at 16cm... *and that didn't help*. It was the big leak that caused the arousal that ended that mess. The machine did not flag an event... but we can see the graphs. Probably went on your back at that time. Never went back to 8 and hardly touched 10cm... looks like 12cm would be a good min, at least for that night. At 2am looks like it wanted 17cm... just for a little while.

If you can get put on a bi-level machine I think that would help. I'm on 21/17 and it's smooth sailing. At 16cm the EPR is not helping punch up the waveform tops... that's something the Aircurve excels at.

Anyway good luck... you're in excellent hands.

Vandownbytheriver: Thank you for your thoughts. I don’t think the insurance will change my machine yet as I have only had it for about 5 weeks. I can’t even see the actual sleep neurologist until January 2025. The medical equipment supplier refuse to change the settings without a new prescription (I changed it myself) so there is no way they will give me a different machine so early in the journey.

Last night, I changed the low pressure to 12 and the high pressure to 18. I woke about 3am and the AHI was 2.9. I went back to sleep then started to have issues between 4:30-5:30am. The mask was leaking a lot (sleeping on my side) and my ears felt like they were filled with pressure/hurt a little. The AHI was 4.4 when I shut the machine off for good. So, an improvement but maybe the high pressure needs to go down to 17? I had zero leaks at 16 and my ears did not hurt. Thoughts?

https://sleephq.com/public/52413236-36b ... 0b65c379c4

Thanks in advance for the help. You are all a wonderful resource!

Gagne wrote: ↑

Thu Aug 08, 2024 8:03 am

Vandownbytheriver: Thank you for your thoughts. I don’t think the insurance will change my machine yet as I have only had it for about 5 weeks. I can’t even see the actual sleep neurologist until January 2025. The medical equipment supplier refuse to change the settings without a new prescription (I changed it myself) so there is no way they will give me a different machine so early in the journey.

OK... worth a try I guess. The night below was very different anyway.

Last night, I changed the low pressure to 12 and the high pressure to 18. I woke about 3am and the AHI was 2.9. I went back to sleep then started to have issues between 4:30-5:30am. The mask was leaking a lot (sleeping on my side) and my ears felt like they were filled with pressure/hurt a little. The AHI was 4.4 when I shut the machine off for good. So, an improvement but maybe the high pressure needs to go down to 17? I had zero leaks at 16 and my ears did not hurt. Thoughts?

https://sleephq.com/public/52413236-36b ... 0b65c379c4

The graphs show minimal leaks during the 5am pressure ride... took you to Mars! If you'd had a higher limit it would have taken you there. At no time during the night were your leaks over the limit.

The waveforms don't show flat tops... the machine was responding to what it thought were OA's... there was no Snore or FL's recorded. If you zoom into the start of the 5am Ride you can really see the cardio-ballistic effects during the events... the machine is seeing these and recording them as OA. I think the machine is wrong about this, your heartbeat is confusing it.

I'm changing my opinion... you don't need that high pressure, mostly. Were you going on your back before, and now avoiding it? This would support what I'm seeing, the difference then and now. My theory is when you're on your back you really do need much higher pressures... but when on your side your heartbeat is fooling the machine. The cardioballistic is happening all the time, but only during events does the machine get fooled... you're having a CA and the machine thinks is an OA... it responds with high pressure... this is the wrong thing to do for CA's... so they get worse... and the machine goes nuts flying you to Mars.

I'd like to see a night with a low range... I'm betting you would too! Just set 11-13 EPR 1 or 12-13 EPR 2 and let's see what that brings. You definitely did not benefit from that pressure excursion on your last report. I'm used to high pressures so I can run 21/17 and sleep on my back whenever.

Vandownbytheriver: Thank you for your thoughts. When I was on my side around 4:30-5:30am I heard the mask leaking out of the side of my mouth. Maybe the machine didn’t pick it up. I am trying to learn how to hang my face over the edge of the pillow.

When you say “ Just set 11-13 EPR 1 or 12-13 EPR 2” does that mean I do not set a high pressure? If I do set a high pressure what do you suggest. Still learning about all the settings.

vandownbytheriver wrote: ↑

Thu Aug 08, 2024 10:16 am

you can really see the cardio-ballistic effects during the events... the machine is seeing these and recording them as OA. I think the machine is wrong about this, your heartbeat is confusing it.

Can you please provide documentation for how/why the machine responds to cardioballistic artifacts with more pressure?
Or was this comment you made just your own opinion?

Looks to me like the OP never really had much sound sleep after the 4:55 restart. The bulk of all those flagged events are arousal/awake related and I don't even see much cardioballistic effect unless I really go out on a long skinny limb.

These machines will increase the pressure for what it thinks is an OA....whether awake or asleep. I have never heard (or seen) cardioballistic artifacts cause OA flagging or pressure increases.

Pugsy: Based on my link to last nights charts how would you change my pressure settings?

Gagne wrote: ↑

Thu Aug 08, 2024 12:52 pm

Pugsy: Based on my link to last nights charts how would you change my pressure settings?

I don't know that I would change anything at this time.

1....One or two nights after a change does NOT a trend make. Need more nights at the new settings IMHO before we can say much and I for sure don't ever change anything based on one night's data unless the results were a disaster. The ear discomfort....might be a problem we want to prevent though. It does make me wonder just how much of an impact that time with higher pressures (after 4:55) may have impacted the ear problem. Would you have had it anyway even without the big climb in pressures???? Dunno...it's a maybe.

2....the bulk of your flagged events you weren't asleep...you were awake or half awake and staying sound asleep is your problem...not real asleep apnea events

The stuff after 4:55....you weren't really sound asleep so I wouldn't put much thought into using that data as a marker. Remove that session from the report and I think you will be a lot happier with the overall AHI.
Do you know how to turn off a sleep session so that it is omitted from the calculations?
Using OSCAR (I think you can also do it using SleepHQ but I don't know how) and the daily report...look over on the left side and scroll down to the sleep sessions and remove the check mark for the session beginning at roughly 4:50 or so.

If you feel that the ear problem is from the higher pressure (above 16) then you can always limit the max back to 16.
The ear issue may be a bigger problem than having the machine max out the pressure so sometimes we have to make compromises.

I do think that earlier in the night when you were for sure asleep that there were some cardioballistic artifacts and we didn't see much of an increase in pressure so I doubt that the artifacts caused the higher pressures after 4:55.

Maybe try 12 minimum and 16 max and not worry about maxing the pressure out at this time.

BTW....when you post a report like last night...always include a subjective report on how you feel you slept and how you feel today. It's good you mentioned the ear thing but I need more than just that.
Like how many wake ups do you remember from last night?

Pugsy: I forgot that you asked for a subjective report in addition to the link to the data. I remember waking up about 3-3:30am and went to the bathroom. Then around 4:30-5:30am I was in and out of sleep. I kept feeling the ear pressure and a few times I felt the mask leak on my cheek. When I got of bed for good about 6am I had a bad headache and I felt tired. It also took an hour or so for my ears to stop feeling sort of plugged up. In the day I feel less tired than before starting the machine but definitely not well rested.

I see what you are saying about maybe ignoring the events in that morning period when I was in and out of sleep. Before that session the AHI was 2.9 when I got up to use the bathroom about 3am ish so that would be a great improvement.

I think I may try the 12/18 one more night just to see if I still have the ear pain. Vandownbytheriver mentioned the ERP. I see it has settings of 1,2 3. I don’t understand that that actually means. What setting should I have that on? I think it was on 2.

Thank you for your help.

Gagne wrote: ↑

Thu Aug 08, 2024 2:28 pm

Vandownbytheriver mentioned the ERP. I see it has settings of 1,2 3. I don’t understand that that actually means. What setting should I have that on? I think it was on 2.

EPR is Exhale Pressure Relief. The pressure drops upon exhale by whatever setting you have chosen....a setting of 1 is a 1 cm drop upon exhale...setting of 2 is a 2 cm drop during exhale and a setting of 3 is a 3 cm drop upon exhale.
It can make for more comfort the higher it is and it also might help if the pressure is causing the ear discomfort.
It can also sometimes help with reducing flow limitations.
It can also help if someone is battling aerophagia.

You had EPR set to 2 last night.

I like EPR myself but others don't and in a small percentage of people it can cause some unstable breathing resulting in central apneas BUT I don't think you are one of those people. You aren't having enough real asleep centrals to make me think that your centrals are triggered by EPR. I think that the bulk of your centrals are awake/arousal related.
At some point you might want to try EPR set to 3. I don't like doing more than one change at a time unless I don't have a choice because if you have a really good result (or really bad result) and you changed more than one thing then you don't know which change caused the whatever result to either blame it on or be happy with.

You might take a look at this thread as I have some examples of asleep flagged events as well as awake/arousal flagged events.
viewtopic.php?f=1&t=187767&p=1451526#p1451526
I have some other examples somewhere but can't find them right at this moment.

Pugsy: Thank you for the EPR explanation. It makes sense now. I will leave it at 2 for now because I understand what you mean about only changing one thing at a time and needing more than one night of data to decide if the change was helpful. It is clear that the change of low pressure to 12 helped me and I didn’t have any trouble falling asleep with it at 12 so will keep it there. I am going to go back to the high pressure of 16 for a few days and see what that brings. If I am not getting lower AHI numbers then I will try 12/17 for a few days then 12/18 if needed. Learning all the details and the trial and error clearly takes time. I keep reminding myself that 4.3 AHI per hour is WAY better than the 41 AHI I was having 5 weeks ago!

Remember that more pressure (or less for that matter) isn't going to impact any flagged events that you aren't asleep when they get flagged. Instead you have to try to target whatever it is that is causing the arousals or awakenings and I don't think it is airway issues. These machines can only fix airway issues pertaining to obstructive apnea. They can't/won't do a damn thing about any other reason for wake ups.

Example.....I have a higher number than normal arousals/awakenings because of back/pelvic pain.
Probably 75% of any AHI that I see are related to arousals and not real asleep apneas.
And yes...the machine can get it wrong sometimes but remember that it only measures air flow and it has zero way to know if we are asleep or not.

So....learn to spot awake/arousal breathing on your flow rate graphs and learn to not obsess over that "less than 5 AHI" because it can be misleading if we have a lot of arousals. On that first part of last night you still had some false positive flagging so not all of that 2.9 AHI is worth worrying about either. Your real asleep AHI was probably closer to 1.0.

Pugsy wrote: ↑

Thu Aug 08, 2024 12:00 pm

Can you please provide documentation for how/why the machine responds to cardioballistic artifacts with more pressure?
Or was this comment you made just your own opinion?

Here's my previous post on the matter... unfortunately the SleepHQ links have expired. I was able to help this person by putting them on CPAP instead of APAP.

viewtopic.php?f=1&t=188209&p=1455188&hi ... c#p1455188

Another initiate to the Cult Of Lanky!

vandownbytheriver wrote: ↑

Thu Aug 08, 2024 8:33 pm

Pugsy wrote: ↑

Thu Aug 08, 2024 12:00 pm

Can you please provide documentation for how/why the machine responds to cardioballistic artifacts with more pressure?
Or was this comment you made just your own opinion?

Here's my previous post on the matter... unfortunately the SleepHQ links have expired. I was able to help this person by putting them on CPAP instead of APAP.

viewtopic.php?f=1&t=188209&p=1455188&hi ... c#p1455188

Another initiate to the Cult Of Lanky!

Ahhh....your opinion. Doesn't surprise me.

I meant published documented studies but you knew that and you don't have documentation to share with anyone.
Your posts or thoughts is NOT documentation.
BTW those links are dead but don't bother redoing them. If you can't give me anything other than your opinion I don't want it.
I want real scientific study kind of proof. Your thoughts don't qualify as scientific proof.

Have a nice day.

Pugsy wrote: ↑

Thu Aug 08, 2024 8:41 pm

vandownbytheriver wrote: ↑

Thu Aug 08, 2024 8:33 pm

Pugsy wrote: ↑

Thu Aug 08, 2024 12:00 pm

Can you please provide documentation for how/why the machine responds to cardioballistic artifacts with more pressure?
Or was this comment you made just your own opinion?

Here's my previous post on the matter... unfortunately the SleepHQ links have expired. I was able to help this person by putting them on CPAP instead of APAP.

viewtopic.php?f=1&t=188209&p=1455188&hi ... c#p1455188

Another initiate to the Cult Of Lanky!

Ahhh....your opinion. Doesn't surprise me.

I meant published documented studies but you knew that and you don't have documentation to share with anyone.
Your posts or thoughts is NOT documentation.
BTW those links are dead but don't bother redoing them. If you can't give me anything other than your opinion I don't want it.
I want real scientific study kind of proof. Your thoughts don't qualify as scientific proof.

Have a nice day.

I helped the person. They expired the links. I published them with permission. You didn't read them at the time? Not my fault.

Here's some Rubicon for you:

What I've said a million times (OK maybe 4) is that you don't know it's CBA unless you have a synced EKG. Everybody who's coming in has those pulses at ~1.2 Hz (we gotta talk Hz cause FOT is measured in Hz so when we (you guys) call up ResMed and say they're pulsations and they say Oh it's FOT you can respond No it's not cause this is 1.2 Hz and FOT is 4 Hz and besides FOT doesn't kick in till about 8 seconds into expiration and this starts immediately).

Now that we have a wake guy saying WTF! pulsations! I think this lends credibility that it's machine fault. My working theory is that it's having trouble maintaining baseline. Here in Rizzo's waveform magnified like crazy, pressure should be 8.26 but it's actually wandering all over the place.

viewtopic/t187118/My-CPAP-machine-wakes ... l#p1444931

We got off on the wrong foot, you and I. Since you're the boss of this place I probably should just give up and leave. But I'm not going to, you're going to have to be the SuperSleeper of CpapTalk and kick me out. Is this a discussion forum or Pugsy's Place? You decide.