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

Keep in mind that EPR measures a drop from IPAP to EPAP, while PS measures a rise from EPAP to IPAP. So to emulate your CPAP settings, try this:

EPAP min: 6.8
IPAP max: 9.8
PS: 3.

This will also prevent pressure swings, which might help you sleep a little more soundly.

Let's make sure the aerophagia goes away with these settings. Then after taking stock, we can see whether there are other changes you might want to consider.

I see you have Trigger set to Very High. It's possible this is helping you avoid some CAs, though that doesn't address the underlying problem of arousals.

alemon wrote: ↑

Tue Sep 24, 2024 11:16 am

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.

What are HR values????

Sorry to hear about the aerophagia. More on that in a bit.

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

This data is for Sept. 21. Therapy settings are Min EPAP = 9.0, Max IPAP = 15, PS = 4.8. All those are significantly higher than your old CPAP settings of fixed pressure at 9.8 and EPR = 3. How did you decide to use these settings?

Given the drastic increase in pressure settings it's no wonder you gave yourself terrible aerophagia. And the aerophagia all by itself would explain the frequency of the spontaneous arousals during the night.

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

This data won't load for me. So I can't say anything about it. If I interpret your statement of "I'd tried 3.8/8.6-14", I would guess that you mean you tried Min EPAP = 8.6, Max IPAP = 14, PS = 3.8. Still way higher than your old settings on the CPAP were. Again, why did you decide to make such a drastic jump in your pressure settings when you went from plain CPAP at 9.8 with EPR = 3 to these settings on the Vauto?

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

This data is from Sept. 23, but it still represents a pressure increase from your APAP settings of min pressure = max pressure = 9.8 with EPR = 3.

Yes, the pressure swings do seem to be triggering a lot of spontaneous arousals. What's triggering those pressure swings are breathing patterns the machine has decided are "flow limitations". But some of those "flow limitations" just might be part of your normal sleep transitional breathing. In other words, as your brain tried to had the control of the respiration off to the autonomous part of the nervous system and change the CO2 trigger for "inhale now", the machine took the change in flow rate to be a "flow limitation" and bumped the pressure up, which then woke you back up.

So you might be better off using fixed bi-level pressures rather than an auto bi-level range. There are several ways to do that with your current AirCurve VAuto. More on that in a bit.

What you are thinking is "periodic breathing" is not significant enough to worry about in my opinion. It's not being labeled that way by the machine because the variation between the largest inhalations and the smallest inhalations is not large enough to be true periodic breathing.

In other words, what you still need to do is to fix the spontaneous arousals. And that's a whole lot harder than just "tweaking" the settings.

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.

As Miss Emerita points out: The corresponding settings to fixed 9.8 with EPR = 3 on the AirSense AutoSet would be to use: Min EPAP = 6.8, Max IPAP = 9.8, PS = 3.

Since aerophagia continues to plague you and since your obstructive stuff was well controlled on the AutoSet at 9.8 with EPR = 3, I would offer these settings as potentially useful settings to try on the AirCurve for the next 3-5 days:

Min EPAP = 6, Max IPAP = 10, PS = 4

The additional PS may make exhalation easier, which can help reduce the aerophagia. Choosing these settings will reduce the exhale pressure a bit over what you were used to on the AutoSet and increase the inhalation pressure a bit. But when PS = Max IPAP - Min EPAP, that will prevent the AirCurve from increasing the pressure in response to events, snoring, or flow limitations.

Now the small increase in PS along with the small decrease in min EPAP (from your AirSense AutoSet), may increase the number of CAs scored. But if the CAI remains well below 5.0 and the AHI remains below 5.0, the tradeoff of more CAs with less aerophagia may increase your comfort during the night. And increased comfort typically means less aerophagia and fewer spontaneous arousals and a better overall quality of sleep.

But the important thing is to stick with the settings for at least a few days. Don't let a sudden increase in the CAI from 0.23ish to 2.0ish spook you if it happens on the first day or two of using new settings with a larger PS.

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.

Again, dial wingin' (or settings-surfing) seldom fixes things unless you have a specific problem in mind.

Since aerophagia IS an issue, some dial wingin' to fix the aerophagia is in order. Since your obstructive stuff was well controlled on the AutoSet with a pressure of 9.8 and EPR = 3, that means you can set the min EPAP to 9.8-3 = 6.8 and get the same pressure level you had on the AutoSet. But again: Since your obstructive stuff is so well controlled with an effective EPAP = 6.8 and aerophagia is a problem and you have the AirCurve, it is worth trying:

Min EPAP = 6
Max IPAP = 10
PS = 4

for a few nights. This will give your stomach more exhalation relief (less aerophagia) and the increased PS may make everything feel more comfortable. By setting PS = Max IPAP - Min EPAP, you prevent the AirCurve from doing the pressure swings.

Good luck

Hi all,

I'm back after a long absence to say: Everyone here was right, and I was so confident in my own understanding but I was just wrong. Thank you for being so patient with me and for offering such grounded advice anyway! I kept trying to push the pressure up higher, and only had issues upon issues.

Now, I still feel quite poor, wake up quite sleepy on the day to day - but after finally lowering my pressure in desperation (and some stern words from a brand-new sleep doctor), I've found 6-10 makes my charts look almost the same as my higher pressures. So maybe making the pressure higher wasn't needed, and the aerophagia was perhaps just messing with my sleep as well. At this point I just don't know.

Now that I've said the above - I still am feeling quite poor, and given everyone on this forum has been ridiculously spot-on with their advice, I'd love if anyone could spot check me. I believe I'm having tons of RERA's still, but my AHI is now regularly far below 1. We're looking into other options on the doctor side - low iron, narcolepsy, etc, but I still believe all hope is not lost for PAP. One thing I have noticed is, by my own recording in OSCAR, I feel generally worse on the day to day since starting bilevel, even though my numbers are better than ever. I don't have a great explanation for that unfortunately. I'm sleeping longer and falling asleep faster since about September when I started bilevel, and generally feeling worse (but with a few VERY good days) - but I can't tell if it's "recovery" time, or if I respond to it worse for some reason, or get shallower sleep, or some completely separate phenomenon.

I did recently have an in-lab sleep study, but I'm suspicious of the results - it was so I could get an "official" bilevel prescription, but I guess by their logic I had to "fail" it to get the prescription. They titrated me to straight-8 pressure, wherein I "only have one event per hour", but I also had 30 "mysterious arousals" per hour. I suspect RERA's, though, I can't look at the data myself - they don't score those. I've also wondered if bilevel isn't falsely reducing my AHI, with the pressure support disguising moments that would have registered as an apnea due to pressure support causing 'smaller' breaths. I'm not sure.

I've attached a few days from recently. I had an illness in there, thus the sporadic days. Neither the 17th nor the 18th did I feel rested, probably about a 4/10. I admit my last very good day when I was dial-swinging was when I tried a PS of 5, 7-12 - but like everything, that didn't last, that was back on November 13th, and the aerophagia continued.

Here is also an account share link as well: https://sleephq.com/public/teams/share_ ... 6ff6aaa3c2

I don't know whether your arousals are related to respiratory effort (RERAs) or not, but you do have a lot of them. Did the sleep test show your sleep stages? If yes, how much time (or percentage of total sleep) in each stage did you get?

I'm glad your doctor is following up on other possible causes for your daytime sleepiness/tiredness. I forget if this already came up in this thread, but in addition to tests for iron, your doctor might want to do tests for testosterone (if you're a man), thyroid, Lyme disease, vitamin D, B vitamins, and autoimmune disease, especially in the connective-tissue-disease family. Any chance you have long Covid? Has your brain been imaged?

You know, that's a good point, I'm really not sure if I had Covid or not - I definitely got very sick early in 2020, but it was early March, well before Covid was widespread. I've never known, there weren't tests at the time - I've had issues with sleep my whole life though, I think just recently they've become untenable, but certainly could explain it getting worse. Immunocompromised-situation is definitely on the books to test as well, I've had thyroid panels and they've all come back "normal" (though I've always thought my issues might resemble poor thyroid function in general). My ferritin when last tested was quite low - I'm going to be getting that re-tested soon, maybe see a hematologist. Female, so no need to test testosterone, though that's a good call. I'm taking all these down for when I see my PCP in a couple weeks.

Actually looking at my sleep study I slightly misremembered - I had a high PLM index, which a registered polysomnographer thought might be respiratory-related. It's certainly true if you look at my breathing waveforms they look quite poor, and the arousal index was 14 when "fully treated", but it's hard to tell. It seems as though they found my sleep stages to be relatively normal, which is a bit surprising.