Finally had a proper sleep study - Please help interpret results

[Gideon]

These original diagnostic values do indicate that you would not qualify for a BiLevel with Backup or an ASV.
The VAuto is the best. At worst it will only be as bad as the AS11

[nearenough]

That's correct, and why the original script was for an auto-titrating cpap.  My primary care ordered a bi-level test because of the ongoing chronic fatigue which did not exist prior to therapy.  He believed bi-level would require less effort to exhale and limit arousals which, he believed, would result in better sleep.

[Dormeo]

I just wanted to mention that the OP lives in Denver, at a high altitude. Nearenough, were you also tested at a high altitude?

And I'm curious whether your doctor has done any screening tests for other possible causes of your daytime sleepiness or fatigue. Examples might include thyroid, Lyme, autoimmune, testosterone, iron.

[nearenough]

Good questions.  I was tested at the same altitude I live at.  As far as tests, no nothing has been tested.  My fatigue started about 1 month after starting therapy when I finally got my pressure dialed in to stop the OA/H events, so my PC is assuming the fatigue onset is related to poor sleep and adjusting to CPAP.  He ordered bi-level since my current device only has very primitive pressure support (ResMed calls it EPR.  It goes from 1 to 3cm, mine is set to 2cm).  

It would probably be worth broaching the other possible issues, though.  Sadly, my insurance is basically a high deductible plan, so it costs me quite a bit to get tested.  It's the same reason I've not been able to get connected with a sleep specialist and instead use my PC for what little I've done with apnea therapy so far.

[Dormeo]

I think it would be unusual to feel fatigue AFTER a month on PAP, when settings finally resolved obstructive events. Can you think of anything else that happened right around, or just before, the time you began to feel fatigued? A hike in a tick-infested area? A change in diet? A bout of flu or some other flu-like disease? A change in medications?

[nearenough]

That's the odd thing - none of the above.  I've gone through an exhaustive list of possible lifestyle and environmental changes, but nothing is different.

Oddly, most days I wake up at around 5:00 am, still tired, and if I've had 7 hours of PAP therapy I'll take the mask off.  Some days I fall back asleep for another 60 to 90 minutes, and it feels like the best, deepest sleep.  Sadly, in that hour I probably end up with a high AHI as a result, so I try to avoid the temptation.

[nearenough]

I like to look for linearity in results through titration, and there is a huge red-flag here where your highest AHI was just 1-cm pressure higher 14/8 than your titrated pressure. CA events related to pressure support tend to be random and I think that was the case here. It may be a coincidence that your best results occur at 13/7 rather than any relationship to efficacy.

Here's an example that I believe may confirm your red flag suspicion.  This phenomenon happens every more nights than not.  Breathing is cruising along normally and then there's a series of CA events with some sort of patterned breathing.  At lower pressures when I first began therapy, it would be prevalent enough that ResMed would flag them as CSR breathing.  I would agree with you that 14cm in my study is probably circumstantial.  

Hopefully I can find a way to titrate those away - BiPAP ResMed VAuto arrives tomorrow.