[CPAP] New user, still having severe apnea except for one hour?

[mutantlog]

I was recently diagnosed with severe sleep apnea (AHI > 100, blood oxygen ~69% during the first study) and was prescribed a BiPAP after the titration study. I haven't seen the results or the prescription directly yet myself, but I have received a loaner S9 VPAP Auto to use as a trial. While it's dropped from the >100 that it was during the first study, my average AHI has still been ~55 which means it's still severe. I've been looking at the data with SleepyHead for any hints on how to improve things, but it's still new to me, so I'm not sure how to interpret the data. The one interesting thing I noticed is that a few nights ago, I had about one hour of what looked like ideal sleep, but of course being asleep, I have no idea what was going on that caused this. I've captured my sleep data ( https://imgur [dot] com/a/xG1Yr ) from that evening, with the hope that someone can look at this and give me suggestions of what may have occurred at that time to improve the sleep. I'm still trying some different masks, as I've been having issues with loud leakage at my cheeks waking me up in the mornings, but any recommendations to help improve my sleep would be greatly appreciated.

[Sleeprider]

Okay, this is not what I was hoping to see.  You are using fixed bilevel pressures of 17/11 (PS 6), and life pretty much sucks like this.  I'd like to see you change the settings to Vauto mode, EPAP min 11.0, IPAP max 20, PS 4.  It's a shot in the dark, but we need to start somewhere.  The basis of these settings is that you have a lot of central apnea, and FWIW, it may all be central or all obstructive given the accuracy of the machine when event rate is this high.  The best thing we can do is reduce pressure support (PS) to deal with that aspect.  If the OA is accurate, you may need a much higher EPAP pressure to keep the airway open. Finally, there may be a positional component to all of this mess.  I think you should dry a soft cervical collar that prevents you from tucking your chin toward your chest, and that keeps the head an neck aligned better.  The fact you have clean periods in this chart points strongly to positional apnea.

To size a soft cervical collar allow 2-inches of additional circumference to your neck, and an inch or so in height.  This needs to be a loose comfortable fit that maintains proper position.  Soft collars are available at most drug stores and Amazon for $10 to $20. Stay positive, this might be easy to fix with the right tools.

[srlevine1]

I concur with Sleeprider as to letting the machine do its thing to determine a starting point. As for the gap, it is suggestive of "twilighting" -- very light sleep where not much happens.

[trish6hundred]

Hi mutantlog,
WELCOME! to the forum.!
Good luck to you on your CPAP journey and also with getting your settings dialed in to meet your needs, hang in there for more responses to your post.

[mutantlog]

Thanks for the information everyone. I'm still working through mask fit issues as well, so a couple of nights have been a write-off for data purposes, but last night seemed better, although I'm a bit confused by the data. ( https://imgur [dot] com/a/jBt6N ). AHI was lower in the morning which was good, but I'm not sure what caused the gaps in the data throughout the night. Did the mask not fit as well as I thought? I know I woke up a few times throughout the night, but didn't notice any excessive leakage issues, etc.

Still need to go pick up a collar to try that out. I'm also restarting an acid reducer to see if I might be suffering from GERD, as I did have ulcer issues back in December.

[Sleeprider]

The gaps appear to be times you shut down the machine or it shut-off due to being on AutoStart. If you are not aware of doing this you need to turn off the Autostart function. I do see a spike of leak at the end of each session, so that may be what is going on. the machine restarts and begins at minimum pressure when it detects your breathing, again because you're using autostart.

Every time your machine restarts, your events drop off. Unless I'm really missing something I think you need completely different settings. Can you tell me how these settings were determined for you? You are using PS 4 over 12 to 20. This means your pressure settings are EPAP min 8, IPAP max 20 and PS 4.0.
Your pressure starts at 12/8 and generally increases to 16/12. In every case, the events appear to stop at the minimum pressure of 12/8. We can show you how to access settings, but I think you need to set EPAP min to 8 and IPAP max 14 with PS at 4.0. this will limit the pressure to a range from 12/8 to 14/10. I also think you have complex apnea or central apnea and are on a completely wrong machine, and should be on adaptive servo ventilation ASV. Again, how were these pressures or this machine determined to be appropriate?

[mutantlog]

Hi Sleeprider,

My original prescription was for a BiPAP at 17/11 which was sent to my vendor after a titration study at a sleep clinic. I haven't seen a copy of the report for the sleep clinic myself, and the tech at the vendor was going to up it to 18/12 in response to the first week's data.

I didn't have the autostart issues when running in VPAP mode. I did have about a 1:50 nap this afternoon (data at https://imgur [dot] com/a/GF2s6 ) and didn't have any autostart issues, and a good period without events, but it was a shorter nap. I added a second pillow to keep me elevated during this nap, and I'm going to try the cervical collar this evening and keep you posted.

[Sleeprider]

Thanks for the update. Please make the effort to obtain printed copies of your sleep study and titration study from the clinic. These are medical records you are entitled to receive under the HIPAA (Health Insurance Portability and Accountability Act of 1996). It is important to have these records to fully understand your condition, and to use in the future to avoid additional studies, or request a second opinion. I strongly suspect that you have complex apnea, which is a mixture of central and obstructive apnea, and that pressure support was used to encourage ventilation when central or central hypopnea occurred during titration. This would explain the rather high pressure support (18/12 is a PS of 6). Having the test would let us see if the titration was actually successful or a kludge.

For complex apnea, the better treatment is usually ASV which provides higher pressure support on a breath by breath basis, at the time, and in the amount needed to prevent apnea and hypopnea. ASV and similar machine have what is known as a backup rate to cause you to breath when central apnea occurs. Patients typically are issued CPAP or BiPAP and must demonstrate they cannot be successfully treated on these devices before they are authorized to receive the more expensive ASV. Sometimes, the amount of apnea can be reduced using bilevel, but with your AHI running 20-30 events per hour, I think you need to start studying ASV, and the insurance procedures for approval of a bilevel with backup rate. You are currently using a device with the HCPCS code E0470. You need a device with code E0471. Some basics of approval are discussed in this article https://www.resmed.com/us/dam/documents/...F_RADs.pdf