Long Time PAPer Trying to Dial It In again!

[dlbzone]

First, thank you to ApneaBoard.org and all the knowledgeable contributors!
 
I was diagnosed with Severe OSA in 2009 and began therapy with Respironics M Series Auto.  The machine still works fine and I keep it as a travel machine if I am going to be more than a few hours away from home just in case I get stuck somewhere or need to sleep for some reason.
 
I was able to obtain a Respironics System One 950 ASV machine in 2012 and a Respironics Dreamstation ASV in 2019.  I registered the Dreamstation ASV for the recall in 2021 and obtained a Resmed AirCurve 10 Vauto since I couldn't afford the ASV out of pocket, and finally received a replacement Dreamstation ASV from Respironics in 2024.
 
I had some difficulty moving from Dreamstation ASV to the AirCurve 10 Vauto and then again am having difficulty going back to the Dreamstation ASV.  Actually I am back to using the Resmed AirCurve 10 Vauto for now.
 
My specific difficulties are associated with increased CA, OA, SpO2 desaturations, headaches, fatigue and cognitive decline.
 
I also lost about 45 pounds over the last 6 months, but still about 100 pounds that I need to lose.  Patience is key.  I gained about 5 pounds a year over about 30 years.  There was definitely a lot of yo-yoing in between.  I keep reminding myself that it's ok if it takes me a few years to lose the weight, I just need to keep heading in the right direction.
 
I sleep in an adjustable bed now, on my back, with my torso at a 30 degree incline.  I previously had been sleeping in a recliner at about a 45 degree incline for probably a year or more.
 
I use a 3" soft collar which keeps my mouth closed during the night.  I started using this shortly after I began sleeping in the recliner and discovered I was mouth breathing.  I immediately began feeling a lot better.
 
I spent the last few weeks trying to figure out why I was waking up with headaches almost daily, or sometimes developing them midafternoon, and struggling with fatigue and brain fog.  I attempted to be fairly methodical with trying to understand the source of the issue.  I went so far as to go back to CPAP mode and adjust my EPAP to where AHI was under 1.0 for multiple days, but I was still waking with headaches and if anything felt worse.  I was also still getting some CAs, OAs, Hs, and still having some desaturations during some of these events.  I further reduced EPAP until I had a couple nights with no CAs.  My AHI went up a little, but still under 2.0 and I didn't wake with headache and began feeling better overall. 
 
Now I'm in the mode of trying to fine-tune my settings a little bit more if I can with a small EPAP auto range to address changes throughout the night and from night to night and also adding a little bit of PS for a little bit of comfort and for the Flow Limitations, while not causing CA to increase any meaningful amount.
 
Here is my last full night, and a sampling of some events.  I am curious to hear opinions about EPAP range and PS range associated with the events and flow limitations I am seeing and open to your inputs.  Thanks in advance!
Full Night     
CA     
OA    

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Here a a couple more charts:
FL + H     
FL     

[PeaceLoveAndPizza]

I think your analysis is spot on and the slowly increasing pressure support approach is a sound one. I suggest setting PS to 1 as a starting point would tell you a lot, but do what you are comfortable regarding increasing it.

[dlbzone]

I doubled IPAP from 0.4 to 0.8.  I reduced EPAPmin to 10.6 so that IPAPmax was still at 12.4 as I want to avoid CA.

I don't feel that great today, developing headache and fatigue early afternoon.

I now realize that Resmed prioritizes the fixed PS setting over the auto EPAP range to stay within the IPAPmax limit.  In other words, with IPAPmax=12.4 and PS=0.8, then EPAPmax=11.6, whereas I thought it would allow EPAP to increase to 12.4 and reduce PS to stay under the IPAPmax limit.  I guess it is logical since it is a BiPAP auto and not an ASV machine.

I think on the Philips ASV, it will prioritize EPAP, so if EPAP+IPAP hits the limit, the IPAP is decreased to allow the EPAP to continue to rise as needed up to the limit, assuming the EPAPmax and IPAPmax settings are the same. 

Anyway, I had increased flow limitation, especially for about 50minutes from 4:15am.  Looks like RERA and UARS to me.  ???

I ordered a WYZE V3 camera for $20 from Amazon to film my sleep to try and understand what is happening, since my O2Ring is registering a lot of motion throughout the night.

For now, I am definitely going to return EPAPmin to at least 11 and maybe a little higher.

Anyone have any comments on the charts?

Thanks!

[dlbzone]

Special Thanks to Stevew77 for the Wyze Sleep Camera suggestion in this post. Cameras to Observe Sleep

Why is this a good option?  
1) Very inexpensive
2) Not overly complicated
3) Integrated IR LEDs for night vision so that room can be pitch dark and still record good quality video
4) flexible mounting options
5) Good quality video for understanding what you are doing before, during, and after apnea events and when you are awake vs sleeping.

Potential challenges?
1) Requires WiFi and iPhone or Android phone with Bluetooth.
2) Requires registering for free Wyze account.
3) Requires user to supply microSD card, and microSD card reader.
4) Requires user to perform a little bit of video file manipulation using additional applications to combine and view the videos efficiently.

I picked up a Wyze Cam v3 from the A etailer for $20.  It comes with a 6 foot cable and power supply.  It does not come with microSD card, which is required for direct continuous recording overnight.  An entire night of 1080P recording takes about 4GB.  I think 64-128GB microSD cards with SD Adapters are roughly $20 and there are some options that come bundled with USB readers for around the same price.  It requires downloading their Apple or Android App and registering a free account to control the camera functions.  You have to put the camera on the same network as your phone at least during setup.  I used a Guest Network that blocks devices from seeing each other for security purposes and it still worked fine.

Once I had a night of recording on the card, I took the card out, put it in my reader and copied all of the video to my computer drive.  Don't be tempted to try and merge files directly from the micro SD Card.  Your computer's HDD/SSD is much faster and more reliable so you want to minimize accessing those files from the card.  It is much better to copy everything to the computer hard drive.  Then Merge them.  Then check that the merge file is working and complete.  Then delete all the clips to save that space and empty your trash.  Again, you need ~ 4GB free for one night worth of video and double that for a short period of time to merge the clips..  I was surprised to see the video was recorded in one minute clips.  So that's 480 clips for 8 hours spread into one hour per folder.  It took me several hours of trial and error testing freeware applications on my Windows PC to find the perfect tool to join the entire night into a single file without reencoding the video or giving me errors.  The tool I used is called LosslessCut.  All you need to do after installing the software is to drag and drop all the files into the application window where is says DROP FILE(S).  You can add them one directory at a time, which is up to 60 clips.  I don't think you can add multiple folders at once, but I haven't tried so not sure. After adding the first files, a Batch File list is created.  Keep adding until all the clips have been added.  Make sure you add them in order of time.  There is an icon 2nd to the right of where it says Batch File List is the Merge/Concatenate files button.  Click on that.  A window will open.  To the left of the blue Merge! button click on the box that says mov - Quicktime and click matroska instead. You can optionally change the Output file name, but make sure to leave the extension .mkv .   Then press the blue Merge! button when you are ready and the program will go to work.  The time that it takes to complete depends on the speed of you computer and your storage.  I think it took 3 or 4 minutes on my machine, but it's pretty fast.  Be patient.  The beauty of this method is that none of the video or audio is being reencoded, but rather it is packaging all of the original clips in a single file container.  

Q: Why did I select matroska .mkv container format?
A: When I tried mp4, I kept getting errors, because Wyze did something non-standard with their .mp4 files.  The Matroska .mkv container format is designed to be more flexible and allow a wider range of video and audio file formats than the .mp4 container.

There are many freeware programs available to view video files.  I use MPC-HC x64 (Media Player Classic Home Cinema x64 edition) for Windows and have for many years. I use this because it can scan large video files very fast with simple Hot-Key controls.  There is a control bar and slider available for those that don't want to use the hot keys, but at a minimum you will want to use the arrows and the space bar for play/pause control.  This program is super stable and very efficient.

After typing this, I think I should probably have made this it's own thread and spent more time on it, but maybe I will later if there is enough interest.

[SarcasticDave94]

You probably already know this, but the therapy differences aren't going to be just between Respironics and ResMed, there's that aspect of SV Auto to VAuto thing. SV Auto or ASV are designed to treat Central Apnea, while the VAuto is still mainly for obstructive events, despite the timing controls. The Respironics SV Auto and the ResMed VAuto aren't their respective lineup equals.

If the Central component becomes difficult, which it inevitably will at some point, you'll need to pursue getting a ResMed AirCurve 10 ASV. And this Central Apnea component will typically be consistently inconsistent, jumping up and down randomly despite therapy settings unless on ASV.

[dlbzone]

Thanks SarcasticDave94.  Yes, I understand the differences between the machines and to a pretty good extent the therapy that each is capable of providing. But I appreciate the inputs because I am always learning and trying to optimize my therapy.

I have Complex Sleep Apnea as described here: What is central sleep apnea?
I get CA when transitioning to sleep.
I get CA when my pressure is too high, EPAP and/or IPAP.  
If CA is short enough and not overly repetitive, I often don't get arousal.  The higher the pressure, the more repetitive my CA events and the bigger the resulting SpO2 drop.  
I get OA when EPAP too low.  I always or nearly always get arousal from OA.  

What am I learning from my video experiment?
I am seeing 20+ arousals per night.  They align with large spikes in flow and heart rate.
As long as my pressure is not too high, my CAs don't cause arousal and are often limited to a single CA at at time, if I have them at all.
I often after normal breathing take a large breath while waking up, hold that breath while I stretch or adjust my position scoring an OA and then let it out followed by large recovery breaths returning to normal within a few breaths.  

Here is one of the nights that I recorded video and a collection of waveforms with some description of what I saw on the video.  I would be grateful for inputs, either confirmations or debate.  Thanks.

   
   

[dlbzone]

I think I just about have it dialed in again.  Here are some questions and some charts and some waveforms with embedded questions.  Thanks in advance to sharing your wisdom!

I know these first two questions are a bit broad given there are so many variables.  Consider the context of the two full night charts I post here where I think I pretty much have it dialed in.

Q1: How do I know when EPAP is too low, too high, just right?
A1:

Q2: How do I know when PS is too low, too high, just right?
A2:

Q3: When I know most or all of my remaining obstructive events are self-induced by me holding my breath while repositioning, yawning, etc., and auto algorithms respond by boosting pressure that exacerbate arousals and leaks, I am better off using fixed settings?
A3:

Q4: Is there any chance that the continuous pressure change oscillation from using BiPAP can weaken or otherwise harm the airway?
A4: 

Q5: Does having ventilation support though PS on BiPAP therapy further weaken breathing muscles, which could lead to more severe issues in the future?
A5: 

   
   
   

[Jay51]

I just wanted to give an answer to your question #5.  I have used this ventilator about a year and a half now and notice zero difference in my day time breathing.  Zero. 

But possibly, I have noticed 2 improvements.  Possibly.  1st is that somehow my body has adapted to even tolerating the ventilator at night during sleep, which is an improvement for me IMO.  2nd.  I notice a slight difference when I take a nap without the ventilator (or even my s9 adapt ASV).  My breathing has become a bit quicker and deeper just before I fall asleep.  I think I had to make this adaptation in order to be able to fall asleep with it.  This may have changed for the better.  Once I am unconscious I would think I revert back to my original style of breathing.  Possibly it has been altered a bit for the better by the ventilator?  

Only negative has been some aerophagia, but tolerable. 

Maybe others will post about your questions 1-4.

[dlbzone]

Thanks Jay, I spent the last three hours reading your saga.  Sorry you had to go through all that, but happy you have found your way!

I also have a deviated septum and enlarged turbinates that my ENT wants to perform surgery on.  I am a bit of a chicken at this point afraid of how I am going to breath and sleep during recovery so haven't scheduled yet.

I have tried flonase and antihistamines, but the only thing that seems to help is oxymetalizone nasal spray.  I try not to use more often then necessary, often alternating nostrils during allergy season in attempt to avoid dependency and rebound.

At your low pressures, I would try the Resmed Airfit P10 nasal pillows mask.  It is amazing, small, lightweight, and oh so quiet.  I have never been able to use a FFM and have tried several. 

It was a little scary to hear about the lung damage that breath stacking can cause.  I get some multiple triggering/breath stacking if I set the Trigger=veryhigh on my machine so have slowly adapted back to default trigger and cycle settings and try not to let me pressures get too high.

[SarcasticDave94]

Q 1 & 2 will be somewhat based on trial and error, however there are going to be indicators for both these. Such as feeling like there's not enough air, or air starved, is likely to be min EPAP needs to go up in my experience. Too low PS Min manifests when the support is low on inhale. It's possible that both too low Min EPAP and PS feel similar, but there's some subtle differences.

Q 3: fixed settings are in my opinion a very limited use case for certain specific factors, such as extreme intolerant to pressure change. Otherwise I feel pressure ranges make it easier to get good therapy over more variables.

Q 4, 5: No because in part these CPAP class machines aren't nearly as powerful as ventilators. ASV has V for ventilation, OK but it's not nearly capable of taking away your respiratory drive. The one area it may hinder is if one sets very high min PS for no reason. But even then you're not going to be dependent on the machine, where you're walking around Wally World dragging along a CPAP. No offense, however some people that don't know think this is just one tiny little mistake away in settings from happening.

Fun bit of info: Max IPAP with ASV at 25 cmH2O is 0.355584 PSI.