2-week mark and sleepy - help with high CA's and malformed flow??

Hi folks, I'm two weeks in and looking for advice on settings and something odd I'm seeing. After an up-and-down first week, I've settled at what I'd call "mediocre but consistent sleep" - which is an improvement on the day-to-day, but I still don't feel great - foggy, a little tired. I wouldn't mind except one day I had a FANTASTIC night, my third day of treatment, Aug 05 - I had energy ALL day, I felt so energized I could cry (my SD card hadn't arrived, settings 5-20 EPR 3, that's all I know). I've been chasing that night ever since.

Background: At-home sleep study. AHI 7 RDI 17. This study did not differentiate central apneas. The doctor did not prescribe a pressure, the machine was 4-20, EPR 3, all default settings. Feeling exhausted for a year or more, with really inconsistent sleep outcomes no matter how long I spent sleeping. CA's have been consistently going down over the course of two weeks, and AHI has dropped from 9 to ~2.8

I have two concerns: One is the high level of central apneas and general-daytime-sleepiness still, I've needed a nap after work all week again - but I'm scared of adjusting too much and not being able to function again. The other is that I've noticed my 'normal breathing' waveforms seem off, and looking at my flow rate over nights it feels very inconsistent with lots of flat-capped breaths and near-apneas, even if the machine isn't tagging flow limits - my charts seem all over the place compared to a lot of people. Not sure how to handle that alongside the CA's. I see my mask has been leaking a bit (this is new), but I really hadn't noticed it at all - it feels completely sealed to me.

What I've tried: Gradually raising the minimum pressure to 5 to 6 to 7 to 7.4 (which seems to have flattened out my pressure lines). Changed EPR from 3 to 2 on the 7th due to two awful nights after my VERY good day to see if it might help, as was suggested to cut down on CA's. Pillow beneath chin and neck/shoulder to cut down on positional apneas (helped a ton in terms of AHI events, not as comfortable lol) This week I've been at 7.4 all week, and I've had consistently moderate nights.

Edit to add some links:
https://sleephq.com/public/4ff85559-943 ... a675b2ac37
https://sleephq.com/public/79153d36-c59 ... 89273ac4de

Welcome! At two weeks in, you're still fairly early in the process of adjusting to CPAP. Yes, there are a few lucky souls who have a wonderful first night and never look back, but for most of us, better outcomes take more time. You've clearly done a great job of educating yourself on how to use data to fine-tune your settings, so you're way ahead of the game there. A few thoughts.

If your leaks aren't waking you up, don't worry about them. They are all well within the machine's ability to compensate.

I appreciate your including the Sleep HQ links. That enabled me to spot-check your CAs, and just as I suspected, almost all of them come after arousal breathing. You can identify arousal breathing readily; it is deeper and messier-looking than regular asleep breathing. There are several theories about the physiological reason people tend to get CAs after arousals, but they key point is that for you, with a pretty low CA index, the real problem isn't the CAs but the arousals.

It's normal to experience multiple arousals per hour; we tend to have more of them when we're older and fewer when we're younger. It's also normal to have some full wake-ups off and on during the night; if they're short, we don't remember them. So your goal shouldn't be to eliminate arousals or wake-ups.

But from your reports on your day-time feelings of sleepiness, I would guess your arousals are to some extent messing with your sleep architecture. That's the progression from one sleep stage to another that you go through multiple times per night. Arousals may be interrupting deep sleep or preventing you from getting enough REM sleep, for example.

So my focus would be on what will help you sleep more soundly, with fewer arousals. Here are a few ideas.

* If you found EPR of 3 comfortable, I would suggest that you try it again. I think you can leave your minimum where it is, given how few obstructive events you're having.

* Try your best not to nap.

* Try setting your machine up outside your bedroom and using it during the day or evening while you read, watch TV, or use your devices. This will speed your brain along the path toward accepting the new sleep experience.

A few more topics:

Flow limitations. Do you have a stuffy nose? If you do, work on unstuffing it. If you don't, your FLs probably originate further down in your airway. The return to EPR of 3 may help a bit, but I should add that some people are bothered by FLs and others aren't. So having more rounded inspiratory curves may or may not make a difference to you. And you're right, the ResMed algorithms don't pick up all FLs, and you do have a fair amount of FL that is unflagged.

Sleep posture. Try a soft cervical collar to keep your neck, and thus your airway, in a good alignment. Here's some information about size and fit: https://www.apneaboard.com/wiki/index.p ... cal_Collar Also, do you sleep on your sides, your back, your stomach, or some of each?

Omg, thank you SO much for the detailed response!! You've already made me feel so much better as I try to navigate this whole maze of a condition, especially just in spotting what I thought I was seeing as well in flow limits. I'll try the EPR of 3 again. Do you think a higher pressure might help with clearing them? I was wondering if the machine doesn't flag them, maybe I just need to try something consistently-higher that might clear them.

For your questions:

1. Yes, haha, I do absolutely have congestion. I have nasal sprays I use for it which help a little, one is prescription, but I'm seeing an ENT to try to help out more with that. Some nights I can breathe through my nose, some I can't so well - with the full-face, it puts pressure on my sinuses, so I've noticed I breathe through my nose less, and my mouth a lot. Nasal strips both work great and do not work for me as I (of course!) have super sensitive skin, I break out immediately and you can see the shape of a nasal strip right on there all through the next day. Heavenly, and sometimes I say it's worth it, but I just can't use them every day. Maybe I'll give one a go though, see if that helps.

2. I almost entirely sleep on my side. Sometimes I'll be a little on my back in the early mornings I've noticed, but usually it's more my head is still sideways on the pillow. I've been tucking a pillow beneath my chin, and it WAS helping, but I think it gets dislodged during the night as I move. I'll try the soft cervical collar.

And actually, I did order a P10 to try. I took a doze earlier on Saturday (after mistakenly trying a lower EPR to help CA's and having an awful day of it), and I noticed the flows look different: https://sleephq.com/public/b858aaa1-690 ... c7cdbbc4a6
(Note too, last night I was breathing through my nose a lot as well.)

A little gunshy to try the new mask right away, because at this point a poor night makes me literally nonfunctional, but I was considering it maybe this coming weekend, or if I'm feeling brave

It's good you're working with an ENT on your congestion issues. I'm not sure solving them will suddenly make you sleep more soundly, but congestion is certainly something to check off the list of possible culprits.

I should have asked a couple more questions: What meds do you take? And did your sleep study include data for restless leg syndrome, periodic limb movements, or spontaneous arousals?

Do try a well-fitted cervical collar, in case that's part of the puzzle too.

And don't forget to use your machine during the day or evening, outside your bedroom, while you read, watch TV or do something else mildly diverting. This can really help your brain settle down about having air blown up your nose all night.

No medicines outside of Flonase/Azelastine. Vitamin D, Iron supplement when I remember it, B12 in the early afternoon when I remember it. Not much else! I'm slated to begin ADHD meds at some point, but I'm trying to get this whole situation to a relatively-stable place first.

Unfortunately my study did not include movement data, but my partner and I have never noticed me moving excessively - just to get comfy. I've never noticed it. They say "a bit of tossing and turning but not excessive" (which I believe, they have RLS to compare to).

Cervical collar was supposed to arrive today, but alas, I doubt it at this point, I agree I think it's going to help - I'm not even going to post last night's OSCAR data, I must have gotten into a weird position because it was awful. I've started using the machine in the evening, hopefully it will help.

I have been noticing some pressure in my throat as it raises to beyond ~7.4, is that normal? It's not quite painful, just like I can feel a stretch all the way down. I was feeling it a bit the other day as well, mostly against the front of my throat.

Edit to add, continued thanks for the engagement, I as ever am extremely grateful.

Thanks for the information. No tell-tale clues except for ADHD, which has a complex relationship with poor sleep. Complex, because it isn’t clear what direction causality runs.

I don’t know what is causing the throat sensation, but given how few obstructive events you have, I’d suggest experimenting with min = max = 7.4. Your pressure goes up mostly in response to FLs, and especially if those are due to nasal congestion, the higher pressures may be pointless.

Keep us posted!

Back with some more data! First day with cervical collar - tbh I should have figured out how to sleep with it BEFORE going to bed, it took me awhile, and I definitely unfortunately was up in the middle of the night. There's a ton of junk data at the start of this - that was me trying to get comfy and well-positioned, and same after I woke up. I got a SPO2 monitor mostly working though! The past few days were pretty poor, and I can't actually tell how I'm feeling yet - I woke up feeling like my head was full of static, but I'm not 100% if it was bad-night or sleep momentum yet, there's a positive edge that's making me think it might be a decent day! I'm feeling hopeful.

I didn't yet take your suggestion of setting min/max to the 7.4, but I super appreciate it, just trying to get some data first. I definitely think the pressure increase are solely due to CA's, which seem to be mostly positional - I'm going to try to get a few more good days before playing with more settings

Two charts attached, mostly because they have data - the 18th, in which I woke up feeling HORRIBLE, just, *awful* without any great clarity as to why (outside events ofc) - I feel like I just never fell asleep. And today, WITH the cervical collar, where I'm not quite sure yet! Both have O2 data now, but I kept it from the flow rate chart because the drops were overwhelming

https://sleephq.com/public/6d950a29-f55 ... 4d931f11d2
https://sleephq.com/public/cab58afb-78b ... b403a11cb6

Also have some sleep stage data - I'm not sure if their benchmarks are to my own (nonexistent) previous or to expected values - but I compared it to some sleep data from January before I lost my fitbit, and my average for REM tended to be 1:30, if that, about 14% of sleep-time. So it looks like maybe I got way more REM than my previous average (Also, I think I lied, I think I'm feeling good today! Took me a while to wake up!)

alemon wrote: ↑

Wed Aug 21, 2024 9:12 am

I definitely think the pressure increase are solely due to CA's,

Well get that thought right out of your head.

These machine will NOT ever increase the pressure in response to CAs/centrals. It's the one thing it absolutely won't respond to and that is by design. More pressure won't "fix" centrals nor will it reduce them so the machine simply won't increase the pressure and one of the reasons is that more pressure could potentially make the centrals worse.

Now you might have had something else going at the same time of the CA/central that would indeed cause and increase in pressure (that would be snores, FLs, OAs, hyponeas) but it was just a coincidence. The centrals/CAs themselves will never cause a pressure increase.

Huh, TIL! Thank you Pugsy - I felt as though when I looked at my charts it was corresponding to pressure increases, but if that's the case it must have been due to flow limits. Still have a lot to learn, appreciate the info!

Hi all,

Back with some perplexing data. I feel like every time I try something new, it works really well for two days, and then just stops working and my numbers skyrocket. Night dated 22 in OSCAR I felt just awful for reasons I'm not certain of, but the 21 was really good, second night with cervical collar, 20th was the first. I was tired at 9PM(!??) yesterday so just went to bed - I feel "fine" in the morning, not a bad night, but I suspect that's from the 12 hours of sleep more than the quality, the centrals are super high - I think a few of them I was awake, I had bumped my humidity and temp and kept getting rainout in the machine, but overall it's a bummer to see the upwards AHI trend. First two nights with the collar I didn't have issues, but the last couple nights it has been bothering me a bit more and I'm finding it hard to get comfortable on my side. I don't know why it wasn't a problem earlier.

Changes I made.
1. Started using nasal strips alongside the cervical collar. Continued to do so the past several nights, present in good and bad ones.
2. Swapped mask to the F40, which I just got. Couple leak issues, but I find it VERY comfortable - at first I didn't want to try it and introduce another variable, but as I tested it earlier in the evening it was SO comfortable I wanted to use it right away ^^;
3. Tanked the room temp from 72 to 68. I think this definitely helped some. Tube temp is way higher to compensate, 86 degrees.

I just recalled I've yet to make the change of setting straight pressure to 7.4 with EPR 3. Let me know if you think that's still the move here, or if you have any suggestions based on updated data. Thankfully I've had more good days than bad the past four nights or so (though you wouldn't know it from the data!), but I'm really hoping for more consistency - I just don't get why my CA's are skyrocketing when I'm working so hard on sleeping position.

https://sleephq.com/public/e401d5ab-729 ... 0c2003b277
https://sleephq.com/public/cc3cb500-b01 ... 0a8149862a
https://sleephq.com/public/a0c55b39-be6 ... 3595b922eb

It's great you found a comfortable mask, and encouraging that you're having some good days. I'll be curious what happens if you try using a constant pressure.

Your CAs continue to appear after arousals. Sometimes you'll have a series of them. Let me mention the two theories about how this kind of CA occurs.

One is that the deeper breathing characteristic of arousals slightly lowers the CO2 level in your blood, which slightly reduces the 'breath now" neurochemical impulses in your brain. Another is that sensors in your chest wall stop you from breathing for a little bit when your chest has expanded more than usual during a stretch of deeper breathing.

Either way, a series of CAs can get going if you then have some deeper recovery breathing after the CA pause. The recovery breathing sets off another CA, and so forth. Sometimes there isn't quite another CA after the recovery breathing, but instead there's some shallower breathing. Either way, this is a stretch of unstable breathing.

I continue to think that the real problem is the arousals rather than the CAs themselves. So I'm hoping very much that we can find some ways to help your sleep become sounder.

BTW, you were smart to lower the temperature of your bedroom. You might review this list of standard recommendations for better sleep to see whether there are some other changes you could make:

• Keep a consistent sleep schedule. Get up at the same time every day, even on weekends or during vacations.
• Set a bedtime that is early enough for you to get at least 7 hours of sleep.
• Don’t go to bed unless you are sleepy.
• If you don’t fall asleep after 20 minutes, get out of bed.
• Establish a relaxing bedtime routine.
• Use your bed only for sleep and sex.
• Make your bedroom quiet and relaxing. Keep the room at a comfortable, cool temperature.
• Limit exposure to bright light in the evenings.
• Turn off electronic devices at least 30 minutes before bedtime.
• Don’t eat a large meal before bedtime. If you are hungry at night, eat a light, healthy snack.
• Exercise regularly and maintain a healthy diet.
• Avoid consuming caffeine in the late afternoon or evening.
• Avoid consuming alcohol before bedtime.
• Reduce your fluid intake before bedtime.

Thanks so much for your input! I've spent a solid week at continuous pressure, and definitely has helped quite a bit. I do unfortunately follow a lot of the given suggestions about sleep health already, partly as I've had so many issues.

Currently I've had a couple bad days after a 5-day good streak since starting straight-pressure, so I'm wondering if I acclimated to my settings changes and they need more tweaking, wanted to see what suggestions folks might have. My numbers look half-decent in comparison to my previous, but I wish they were better. I noticed last night especially I had periods of that cyclical breathing you were speaking of: https://sleephq.com/public/4722b3aa-c98 ... e605f3d2af

Here's a full account-share link to supplement screenshots: https://sleephq.com/public/teams/share_ ... d74a2806f5

User Flags are set to 8 seconds of 50% flow restriction, of which I had a very large amount last night as well. Ugh.

It looks like I had a period of really nasty CA's and cyclical breathing starting at about 2:15 until about 3:30. Is there a way to resolve this? As you noted, many of my CA's seem to be post-arousal breathing, but a couple times it looks like they were post-hypopnea. I'm thinking maybe I just need to keep slowly raising min pressure to try to eliminate those near-hypopneas? As ever, bummed to have a good stretch and a couple bad days again. Any other insights/suggestions? Should I be thinking about bi-level?

Much appreciation for any insight anyone can offer!

alemon wrote: ↑

Wed Sep 04, 2024 1:05 pm

Currently I've had a couple bad days after a 5-day good streak since starting straight-pressure, so I'm wondering if I acclimated to my settings changes and they need more tweaking, wanted to see what suggestions folks might have.

A couple of bad days is not always a sign that you need to adjust the settings yet again. When you are genuinely acclimated to xPAP, you'll realize that we all have some bad nights, but as we get further and further into our therapy, the percentage of bad nights goes down.

It's also worth noting that other things can cause problems with spontaneous arousals, which can lead to post-arousal CAs being scored and that post-arousal CAs would not be scored as a sleep disrupted breathing event on an in-lab sleep test: They're just a small glitch as the handoff of the control of respiration is done as you fall back asleep.

If this were my data, I would not (yet) be thinking about changing the therapeutic settings just because of a couple of "bad" nights with a higher CAI than you think you should have. Worth noting: Your CAI and total AHI is still under 5.0, indicating that your therapy is pretty much "working" since we don't really know how many of those CAs are post arousal "false positive" events that would not be scored on an in-lab sleep test. More on this in a bit.

My numbers look half-decent in comparison to my previous, but I wish they were better.

Chasing a 0.0 AHI is a fool's errand. Likewise chasing a perfect "flow limitation graph" is a fool's errand. And it can be counter-productive if the efforts to eliminate the very last of the events or the flow limitations wind up causing other sleep problems.

I've scrolled through the data you posted at https://sleephq.com/public/teams/share_ ... d74a2806f5. You had a total of 24 CAs scored that night. And yes, on the surface that sounds like a lot, even though your total AHI = 2.78 and your CAI = 2.49, both well under the proverbial 5.0 used to define "effective" therapy.

Notably in scrolling through your data, it looks to me like at 19 of those CA are clear "post arousal false positive" CAs---i.e. these are events your machine scored, but you were likely awake when they happened: Evidence of an arousal appears in the flow rate graph immediately before these events, and it's reasonable they are events caused by your transitioning back to sleep, albeit in some cases it does not look like you had a smooth transition back to real sleep. And at least 2 or 3 of the other CAs look like they are probably post-arousal false positives or scored when you were trying to transition back to sleep.

In other words, it looks to me like your "real" AHI for this night would be darn close to 0.0 after you delete all those spurious CAs from the calculation.

I noticed last night especially I had periods of that cyclical breathing you were speaking of: https://sleephq.com/public/4722b3aa-c98 ... e605f3d2af

This is not real periodic breathing that you need to worry about in the sense of their being something physically wrong. Rather, I think this bit of breathing is evidence that you were not sleeping particularly well---as in I think you may very well have been drifting in and out of light sleep without being able to fall fully asleep and stay fully asleep. You may not even remember being restless, but overall I think that you probably had a whole bunch of spontaneous arousals during this night, and probably enough spontaneous arousals to lead to you feeling like you got a bad night of sleep.

The thing is: Spontaneous arousals are not caused by sleep disordered breathing events. In other words, trying to make them go away by tweaking the pressure settings is not likely to work.

So---anything going on in your life that has increased your stress levels? (That includes worrying about the quality of your sleep if it leads to you lying awake in bed at any point in the night worrying about how little sleep you seem to be getting or how bad your sleep seems to be.)

Also worth pointing out that your time in bed window is a whopping 10 1/2 hours. You may just need to spend less time in bed while working on teaching your body to sleep better when you are in bed.

Here's a full account-share link to supplement screenshots: https://sleephq.com/public/teams/share_ ... d74a2806f5

User Flags are set to 8 seconds of 50% flow restriction, of which I had a very large amount last night as well. Ugh.

I think you are overreacting to the data. The low limitations are no where near as bad as you are making them out to be.

First of all, on this night your flow limitation never reached the level of .5 on the graph. Indeed, the highest points on the flow limitation graph that I can find are .33. Also, it's worth noting that the vertical scale on the flow limitation graph does not necessarily indicate how much the airway was collapsed. Rather, it is a measure of how "distorted" the machine thinks the inspiration part of the flow rate curve looks as compared to normal sleep breathing inspirations. Many of your flow limitations appear to my eyes to be scored right after you appear to have aroused and may represent the machine mistaking normal ragged wake inspirations for flow limited sleep inspirations.

In carefully scrolling through your data, I can find no more than 6 places where there is some evidence that a flow limitation might have caused an arousal. Lots of the places where flow limitations are scored in places that the flow rate curve appears to indicate that you were attempting to transition back to sleep after an arousal already occurred.

Also worth noting: Not all flow limitations respond to increased pressure by "smoothing out". Sometimes flow limitations are related to congestion problems. Sometimes they get scored during wake breathing. Sometimes they get scored as we're transitioning back to real sleep and real sleep breathing.

It looks like I had a period of really nasty CA's and cyclical breathing starting at about 2:15 until about 3:30. Is there a way to resolve this? As you noted, many of my CA's seem to be post-arousal breathing, but a couple times it looks like they were post-hypopnea.

Here's what that data looks like:

And here's my interpretation of what happened:

A short lived small leak appears to have woken you up around 2:20. And you sort of get back to sleep, but for some reason, you wind up getting trapped in a cycle of what is sometimes called sleep-wake-junk or SWJ for short. Meaning, you're bouncing back and forth between very short arousals/wakes and very light sleep, but you are unable to get back into a real light sleep that then progresses through a full sleep cycle.

Now you may or may not remember being restless for this 75 minute period. But I can count at least 8-12 places where arousal breathing appears to be present, and for almost all of them, there is no flow limitation present, or the flow limitations start after the arousal when you are trying to get back to sleep. I'll post detailed times later this evening so you can see what I'm talking about.

I'm thinking maybe I just need to keep slowly raising min pressure to try to eliminate those near-hypopneas? As ever, bummed to have a good stretch and a couple bad days again.

If this were my data, I'd be reluctant to increase the pressure for what I'm seeing here. But then I have a history of severe aerophagia and before I increase pressure, I want to be damn sure there's a valid reason for doing so. And I'm just not seeing it.

I think you just need to be more patient. You had a good stretch. Now you've had a couple of bad days. Give it more time. See what happens in the next 5 or 6 days. Do the good days outnumber the bad ones at the end of that stretch? If so, then these are just a couple of bad days with visits from Pugsy's aliens.

If, however, the bad days outnumber the good ones after giving these settings another week or so, then you'll have additional data that may point to what to do next.

Any other insights/suggestions? Should I be thinking about bi-level?

I see nothing in this data that a sleep doctor could use to justify writing a script for a bi-level machine or recommend a bi-level titration study.

Do you have any problems with severe aerophagia? That can sometimes be used to justify switching a person to bi-level. (That was how I wound up on bi-level.)

Or are you thinking of buying a bi-level machine on the gray market without a prescription and self-titrating? If that's your idea, then the question becomes how much money you want to throw at the problem: Bi-levels are about twice as expensive as an AutoSet. And in your case, it is not clear at all whether having a higher PS will give you any better results. Sometimes a PS greater than 3 can trigger real CAs, and EPR=3 means you are using a PS = 3 right now.

That said, using PS = 4 on a bi-level (i.e. a Resmed VPAP) might increase your comfort enough to potentially reduce some of your spontaneous arousals. But if you are not dealing with aerophagia, it could just be that using your AirSense 10 AutoSet with these settings for several more weeks will allow your body to get really comfortable sleeping with the machine and over the course of several weeks the number of spontaneous arousals may disappear without any need to tweak the settings or switch machines.

Finally, it is worth noting: Every time you change the settings your body does have to get used to sleeping with the new settings. And that can trigger additional spontaneous arousals if you are just sensitive to the sensory stimuli coming from the machine.

Hi robysue --

I want to thank you SO much for all the effort you put into reviewing my data. Truly, I so appreciate it, and your insights - I'm precisely a month in, which isn't no time, but I have so much left to learn, and details like this are SO SO helpful, I cannot express how much I appreciate it, especially as dialing in settings is such a frustrating process, one night at a time.

Just to quickly explain to the wider point, why I get so nervous after a bad day or two (AND why I'm spending 10.5 hours in bed haha) is for me, it's not just that the numbers are bad (if I feel okay, I really don't care too much!), at this point a poor night's sleep leaves me literally inoperable. I can't concentrate, I can't think, I can't do my job or work, I can't do anything around the house, brain fog, etc.... This has been growing, the past two years, but really reached a head this year, to the point where I've been unable to participate in hobbies, almost unable to work, and my entire career is on incredibly thin ice, just because I can't concentrate. It's truly, incredibly debilitating.

The only way I've found to help is by sleeping when I feel tired and putting in the long sleep hours, thus the very long hours in bed. Ugh! Who wants that though, right? I got a 'normal' 8 hours the other day and felt like I was drunk, or had the flu, it was just awful. Thus why I'm thinking so much about settings - if my settings are dialed in, I hope, I won't need to spend so much time in bed I also KNOW it's sleep related, because the days when I have a good night I feel totally, completely fine. Just, 'normal', and MORE normal than before I ever had the machine. I can go about my day, do the things I need, go to bed normally, I have energy. I've had a few of those, and many more lately, which is why I'm hopeful, but I really need that to be almost every night, and even two days of an off night means I've lost half my workweek.

I'm totally with you, I definitely don't want to be tweaking any settings without thinking, and I have noticed perhaps a bit of aerophagia at these current settings (I had some success with a min around 7 as well, before, but on APAP, and it was still hitting medians in the 9.* range). My biggest concern has definitely been that my nightly breathing seems to be ALL over the place, including significant pulse spikes at the CA events, and I've been hoping to find something that makes it far more regular - had some folks advise BiPAP might help with that. And at this point, I really need literally anything to work, and unfortunately to work very regularly. Even if I had to fund it myself, I'd be willing to, as my livelihood is on the line, and it would be worth it to be able to live life again. (Of course, ONLY if it worked, which I recognize we really don't know yet [though perhaps with a trial I'd have more info]). With your encouragement I'll leave it be and hope for the best in the next week.

I really appreciate you're not too concerned looking things over. That's very encouraging for me, that I might just need to continue to give it more time and push through.

Also, I really like the term "Pugsy's Aliens". I'll be snagging that from now on I think!

Thank you again

Hi all! I'm back again!

After a lot of struggling and bad nights again, I booked a consult with a respiratory therapist and they recommended bilevel. I've done a great job of getting my AHI events relatively low, but was still having very poor sleep. I'm giving bilevel a try, and having a few issues, mostly around aerophagia - my HR values look much better on this, though. Previously I was on CPAP-EPR-3 at 9.8cms, and that seemed to be doing all right, I've been trying to translate that over to bilevel.

Account Share link:

https://sleephq.com/public/teams/share_ ... feff23607e


Two days back, I woke up with terrible aerophagia, and had to swap back to the CPAP, clearly too high, I think I accidentally set each too high though:

https://sleephq.com/public/39305b4c-67e ... f80524fece

Yesterday I'd tried 3.8/8.6-14, just trying to cut down on the pressures a little, again woken by terrible aerophagia in the early AM and swapped back to the CPAP - for that, I felt pretty good! I slept past my alarm completely.

https://sleephq.com/account/teams/vVNLB ... _id=JzoXBj

Today I tried cutting the settings down, 7EPAP 11 IPAP PS 3. I definitely slept quite poorly, even though my numbers look great, with tons of wakeups in the early morning - not sure if it was pressure swings or if it was breathing, but I know pressure swings were wrecking my sleep on APAP, so I'm starting to suspect the same. I do not feel nearly as rested - though of course, I recognize it's the first full night. Still seeing lots of that periodic breathing.
*Addendum, I saw it recommended I not put on the mask til I'm about to sleep, and by doing so last night I kept the pressure from swinging way high to try to fix my awake-breathing before I was sleeping. That also may have helped.

https://sleephq.com/public/651c85b6-52a ... e6ca2e5002

What I'm trying to understand is how to translate the 9.8cms/EPR-3 to a useful bilevel analogue without getting horrific aerophagia, (I think EPAP 9.8 might be too much for me with any amount of PS) and how to potentially set relatively more-stable pressures. I know sometimes aerophagia can just require some time to adjust, but until I'm adjusted I need my sleep! I'm not trying to settings-surf, just find something that seems it is remaining effective through the night without the major wakeups by pressure-swings. I was thinking tonight I'll keep the 8 EPAP, seems to be a bit more effective, IPAP 11~12, PS 3 or 4? Grateful for any insights at all.