Bilevel settings (and other factors) revisited

[dfunk]

Right, I understand what adjusting the trigger/cycle sensitivity does. But I think I'm unclear on how they interact with CA. Are CA's just harder for the machine to "hear" (to pull from my world as a working musician...)? So cranking the sensitivity up helps the machine "listen" harder for fainter signs of CA? And then theoretically the combination of Ti min/max and decreased cycle sensitivity helps you take a larger breath (big, slow singer lungs) and hold it long enough to extract an optimal amount of oxygen from it? 

Any suggestions for machine tweaks to try while I'm in the process of acquiring an ASV machine? Increased IPAP? Increased pressure support either by increasing IPAP or decreasing EPAP? The doctor seemed to think tons more pressure support was the way to go, but it made me miserable. Though I'm sure I could tolerate at least some more pressure support than 4. Could my lungs benefit from a little less resistance to empty out for the next breath? Is 4 just kind of the default that doctors use and tell you not to mess with just like everything else they tell you not to mess with? I've found that moving both pressures up past 19/15 while keeping the pressure support locked at 4 hasn't made a difference other than me waking up a little bloated with a belly full of air. (which I would've dealt with if it helped me feel better otherwise.) Do any of my graphs suggest bumping my EPAP pressure down a CM or 2 might be useful? 

I'm really starting to think there's something to all of this positional apnea stuff though. I tried a different cervical collar last night that seems to have kept my neck propped up a bit better. AHI last night was 0.7. I still don't think it's quite tall enough. I'm gonna try building it up with a t-shirt or something tonight.

[subconscious]

RE: Leak and Neck Pain

Nice work. Its impressive to see general folks make these types of gains and lobby for their care. 

In terms of the leak - yes, having leak issues can provide erroneous data due to compensations in the pressure as a result of apneas. I think it is easiest to think of it as, leaks should be removed entirely as possible, by any means necessary (e.g. changing mask, settings, or accessories), before attempting to modify settings to control ahi. because only one leaks are controlled, do you have a sealed system w reliable data feeds. 

i personally have found the phillips dreamwear nasal cushions much better than the resmed nasal cushion. In particular because the former figured out how to design it such that a vacuum is created around the nose thereby sealing itself once pressed against the nose. The resmed failed to achieve this. This change improved my leaks, and lead to a drop in pressure needed to keep my airway patent, and more comfort since i was thinking less about leaks. 


On the topic of neck pain - i've had a lot of experience. First of all, you need to define it. Determine where tenderness is located. Looking at a picture of "neck pain trigger points or headache trigger points", you will see the scalp, temporalis muscle, base of the skull on the back of the head, neck muscles on either side of the spine, the huge trapezius muscle which extends from skull base to shoulder to mid/lower back can all be tight. In my experience, muscle knots in the upper back will create tension that migrates upwards to the neck, then scalp, and jaw. If you or someone pokes w a finger your muscle across all these spots and they find it hard (compared to poking the muscle belly of the calves) and/or tender, then you have knots to address. This takes a strategic approach. People who fail here expect a single solution but that usually only works if you catch the knot early in its development (the next day after you strained that muscle group). Try the following:

1. Electric heating pad: place one on your upper back on low while you lay in bed and pass out. Do this each night and blood flow will dramatically increase. do not turn the heat up, you dont need to burn yourself, you just need to dilate the vessels to get flow. Hot showers arent too effective unless you wanna spend 30mins twice daily which is a huge waste of water. 

2. TENS unit. Place pads across each the stiff or tender spots. Make sure you have pads of varying sizes so you can target all the spots. Now the key w tens is to not get creative with the settings. Keep the pulse to be a consistent simple contraction. Then play with the intensity! If you place the pads to target the same muscles on both sides and set the same intensity, you'll find one group of muscle to contract better than the other. The poor contractor is your target. Turn up the intensity on that muscle until it starts contracting well, and then gradually keep decreasing until it contracts as well as the other side at the same setting. Then both should be optimally relaxed by having strong contractions while you continue decreasing intensity as low as possible. Rinse and repeat for as many muscles possible. Google images of tens placement for neck pain for guidance.

3. Massage, now the tissue will be a lot more malleable. Get someone w strong hands. A soft handed masseuse might make you feel good but they aint gonna fix anything. Have them break throuhg all the remaining knots. You'll know you're making progress when a big hard muscle mass breaks into lots of small knots which then feel like crackling rice paper as they are kneading through the muscle. 

4. Hydration! You need 4L daily if dehydrated. Learn to start consuming that much w 1L in each part of your day broken into 4 equal sections. Thats the easiest way. 

5. If you have lost the natural curve of you C-spine and dont have physical trauma to it. Then you need to look at a picture of how you typically stand. If your ears typically sit in front, rather than over your shoulders, then your head is placing massive strain on your neck. People try to correct this but do so incorrectly. They think its an issue of neck exercises - its not. "Turtle heads" as i call them, are because the head-forward posture allows the low resting tongue to move out of the way of the airway, preventing obstruction. The only way that truly fixes this is to complete myofunctional therapy. Once the tongue is effectively strengthened, which can take 3-4 months of daily exercises, the head will keep moving further back and reduce its strain on the neck. 

6. Make your work/lounge space ergonomic. This does not mean buy expensive things. I actually haven't seen any product that truly accomplishes ergonomic. You need to be creative to create an ergonomic space. The top of your screen needs to be the natural height of the eyes. The keyboard needs to be the height of elbows when they are resting by your side. No wrist rest to prevent compression. And the feet should be flat on the floor. This will prevent your shoulder and head from coming forward w respect to your thorax which exacerbates the constant pull.

7. No pillow. My osteopath pointed out that the neck has never needed support until modern society selling beds realized it was a good accessory to sell. There's no good rationale for a pillow unless you are so medically compromised it is the better of 2 evils. If you have reflux, raise the head of the bed at the foot rests, not the pillow. The body was not designed unable to support its neck. After hundred of thousands of years of evolution, that makes no sense. Since I removed my pillow my neck problems have substantially improved. Likewise for the partner. Using the pillows always causes morning neck pain. And these are high end tempurpedic pillows. The body is meant to lay flat. Just like cpap, you will get used to it with practice. Time is needed for the muscles and ligaments to relax and lengthen when you stop using a pillow as they become contracted w prolonged use. A heating pad will help w the transition. 

8. If you have jaw/TMJ pain, you may need an orthotic splint. This is basically a mouthguard that provides vertical height so there's space between your jaws. This will decompress your TMJ which is critical because a nerve exists in the TMJ which sends sensory signals to the part of your brain that controls your sleep. That's why TMJ treatment is a known cause of fractured sleep. 

Hope this helps

[PeaceLoveAndPizza]

Dfunk, for now stick with the settings form 12/13. Things looked good and you said sleep was good, so keep those settings for a while. If something changes let us know.

[dfunk]

I haven't had any leak problems through my nose/mask since switching to the Bleep mask. Once my neck recovered enough, I got a Resmed nasal pillow for emergencies if I need something I can put on and take off easily like having a cold, or where the weather/humidity messes up the adhesive from the nose ports like if I'm camping. Been pretty satisfied with both. But I'll definitely keep the Phillips in mind if I start having leak problems with the Resmed.

The mask isn't the problem. I leak through my mouth. Taping took a lot of trial and error, but after some effort I got it dialed in and mostly have my leak under control, unless I have a monumentally drooly night for some reason. Even still, it's the best solution I've found. And I've tried a whole lot. 

As previously stated, I've already done a lot of working zeroing in on my neck pain. It's in my upper traps: sides of the neck and between my shoulder blades. I've made great strides in improving those parts of my body. I had some pain up on my head for a little bit but those were pretty easily resolved with some basic exercises and myofascial massage. I also had some problems with vertigo, which were also resolved pretty quickly. But the neck tightness persisted and I really only started to get that under control around the beginning of this year. 

1. It didn't occur to me to try a heating pad! I might give that a go. 

2. I think you might be confusing TENS with EMS, which is understandable since most units do both. Tens stimulates the nerve to reduce pain while EMS activates the muscles to contract. Anyway, I've been using EMS for a few months now and it's definitely made a difference. I do dry needling with electro-stimulation at my PT's office and the EMS is a very similar experience. My PT helped me develop a plan for placement of the pads. And you're absolutely right. The trick is to target the muscles that don't contract as easily. My experience with dry needling with me PT gave me a good baseline of how it should feel to make sure the treatment at home is therapeutic and effective. It's not easy to catch a family member who's got time to help me put on the pads since we're all so busy and work on different schedules. But I do it as frequently as I can. I splurged on the four-channel unit so I can target pretty much every offending muscle at once! :-)

3. I did massage for a while and it helped some. But even though my massage therapist was great at myofascial/deep tissue massage, it definitely wasn't as effective as PT. And it was a lot more expensive since massage therapists don't take insurance. But manual traction at my PT has a pretty similar feel to massage. And mechanical traction especially has a similar effect to massage, except a lot more effective. At some point I'll schedule a massage after a PT appointment. I think you're right that it'd be good to do massage to kind of fine tune things right after a PT appointment handles the heavy lifting. And don't worry, my massage therapist doesn't hold back. She knows I'm there for therapy instead of relaxation. :-)

4. The whole 4L (or more in some cases) thing is old science that has since been debunked. Current research suggests that you should just hydrate when you're thirsty, with maybe a little extra if you're about to engage in activity that's going to make you sweat a bunch. But I suspect that plenty of folks ignore their thirst, so setting an amount and a schedule might help those folks who are ignoring when their bodies are telling them it's time to hydrate. And of course it's very personalized from person to person. Somebody like me who's 5'6" and 170 lbs isn't going to need the same amount of water as somebody who's 6'6" and 220 lbs. 

5. It's true that my posture is not great, which is a product of both heredity and my line of work. I do my best to be conscious of it though. And I know I should do more tongue exercises but, y'know, life. I suspect I'll have more spoons to focus on this as my sleep continues to improve my functionality. Life with an AHI under 3 is a lot easier to manage, and under 2/1 even more so.

6. Yup. I was already optimizing my posture throughout my life before all this mess with my neck went down, and I doubled down on it once my neck went haywire. I even went so far as building a (simple) desk that's the right height to accommodate my short torso. Especially since poor body position in my sleep was the cause of all of this in the first place, I keep a close eye on anything that my stress out my neck. 

7. I've tried the no-pillow thing a few times and it's just not right for me. It causes my neck to collapse forward into the position that got me in all this trouble. Right now I sleep with a couple flat, simple, down pillows mostly resting under my shoulders, tilting my head back ever so slightly, which I suspect counterbalances the remaining tension in my neck. After much trial and error, that seems to be the best thing for keeping things aligned and keeping my airway open. I tend to prefer a more science-based approach so I usually avoid folks like chiropractors and osteopaths. But my PC is a doctor of osteopathy and things improved considerably when I started taking his advice on finding specialists who will actually listen to me, such as my awesome PT. His holistic approach to medicine has been great.

8. Nope, no clenching/TMJ here. Like I said, my leak problem is through my mouth, not my nose. It really just wants to fall open. My jaw problems come from when I try out drastic measures to keep my mouth shut. It's why I can't wear a chin strap. Just now, after wearing this cervical collar these past couple weeks, my jaw started hurting in the same way. But I suspended it a couple days ago and it's slowly starting to feel better. I'll probably be back to normal in another couple days. Not excited about having to sing for work between now and then, but I'll be ok. I actually tried different mouth guards when I was trying to control mouth leaking. They were either ineffective or caused the same kind of jaw problems. I even tried a custom molded prescription oral appliance and it was probably the thing that caused the most jaw pain out of everything I've tried. And of course using it without BiPAP played havoc on my central apnea. With the machine, it was great at keeping my leak under control and my AHI down. But the jaw pain from it was a non-starter.

Thanks so much for your perspective! I really appreciate you taking the time. <3

[dfunk]

One thing I forgot to mention about 12/13 is that I spent a considerable amount of time awake and not using my machine in the middle of the night trying to deal with a persistent runny nose. I think something in one of my sinuses got irritated for a couple days or something. But I suspected the 2.5-hour break in the middle of the night might've thrown things off. (see attached.)

On a hunch, I bumped up my EPAP pressure by 1cm last night and the TI min by just .2 seconds. It's hard to explain, but when I thought about it, it seemed to me that it felt a little too easy to exhale. I wondered if slightly more EPAP pressure might feel a little more natural. I also gave my muscle relaxer a try again for the first time in a while, to try to help my jaw. (See original post for details on why I had to quit taking it for a while.) And, well, see for yourself. :-D And no grogginess from the muscle relaxer! I think that's the best *regular* night's sleep I've had in a very long time. A couple very short obstructives, 1 very short large leak, and a few hypopneas at the beginning of the night which could potentially be false positives as I was still awake/falling asleep! Respiratory rate never dropped to zero. 

I'm really pleased with this. I'm gonna stick with it like this for a few days. I might suspend the muscle relaxer once my jaw feels better, just to see. But any effect of that should be pretty immediately obvious.

Woohoo!

[PeaceLoveAndPizza]

Most excellent news about your good nights rest and taking control of your own settings. Bravo!

I know nothing about the effects of different medications on sleep, so will leave that to others.

[dfunk]

Ok, one more post today and I'll stop clogging the board:

I keep thinking about every possible factor and machine setting that could affect my sleep. My AHI is low by normal standards (especially after a consult with YouTuber Lanky Lefty, and a bit of additional tinkering on my own) but I still wake up feeling pretty crummy. Here's what's on my mind today:

• I naturally want to take short, shallow breaths, even while using BiPAP. While asleep, I seem to naturally inhale for about a second, give or take. If I let myself do this, my AHI is through the roof, including tons of central apneas. The best settings I've found use a Ti min of 2.2(!), regardless of pressure.
  
• If I use easybreathe, it naturally wants to track those short breaths, resulting in less time at prescribed pressure and decreased airflow, right? Instead of a square wave or a wide, gentle curve, it's a very tall, narrow curve.
  
• If I'm reading my flow rate and mask pressure graphs correctly in OSCAR, if I use a static rise time without EasyBreathe, I spend more time at IPAP pressure, right?
  
• For a given pressure setting, using EasyBreathe is certainly more comfortable while falling asleep than using a static rise time. 
  
• My AHI at a given prescribed pressure tends to be higher with a static rise time than with EasyBreathe, but both include central central apneas.
  
• However, on EasyBreathe mode, my AHI improved by adjusting the Ti min/max and Trigger/Cycle sensitivity. It completely eliminated central apneas, at least according to OSCAR, and significantly reduces obstructives as well.
  
• After my most recent sleep study, the doc had me try out an S/T machine, thinking the backup respiratory rate would help. It was awful. Sky high AHI no matter what I adjusted. Going back to my normal BiPAP with EasyBreathe, I was back to feeling tired but not 100% useless, which was my normal at the time. Even on nights when my minimum respiratory rate was less than 5, or even 0, it was still better than the S/T machine set with the backup rates I tried in the 8-15 range. 
  

So all that said: 

• Might I need that higher pressure, increased Ti min, high trigger sensitivity, and low cycle sensitivity *because* I use EasyBreathe? 
  
• Could the tradeoff of these drastic settings curbing my apneas be my rampant periodic breathing, resulting in me still waking up tired even if I don't have that additional apnea feeling of brain fog and like my head was crushed in a vise? 
  
• (I also tend to wake up super gassy but I don't care. Happy to cope with mild side effects if it means I can get a decent night's sleep.)
  
• Could I theoretically use lower pressure without EasyBreathe? Would I be able to reset everything else back to default without it?
  
• Could skipping EasyBreathe also do good things for my respiratory rate, which even on good nights can be erratic, drop below 10, or even completely bottom out?
  
• I really suspect a good bit of my remaining exhaustion is due to this periodic breathing. Could backing down pressures and ditching EasyBreathe be a possible means of improvement?
  
• Or is ASV a possible solution? I saw a new sleep doc for the first time yesterday who wants to bring me in for yet another sleep study to see if we can use it to fight insurance to get me an ASV machine. 
  

All of this is theoretical right now. I don't even want to begin messing with my pressures again for a bit. But would welcome other people's observations.

[Sleeprider]

Using a graph or two might help to make the point better. From what I'm hearing, you should return your TiMin to the default 0.3 sec or 0.8 seconds at the upper end. I would then change cycle time to low. You are using a spontaneous bilevel to try to manipulate respiration time, and the truth is your therapy thread is the place to discuss this so we have more background and can build on that history. I'm going to merge the threads, read what is going on and get back to this.

[dfunk]

Thank you for merging and reducing the clutter! I'll pull together some recent graphs.

[dfunk]

The past 3 nights.