New to Therapy - Starting on BiLevel

[Gideon]

Realize the purpose of the FL's in the FL chart is to signal the need to raise pressure for obstructive events. It was not intended to be an indicator of all flow limits. I use it as an indicator that there may be more flow limits. A 95% value of 0.10 or less is what we like to see. We read zoomed images, typically 2 min views to evaluate flow limits.

The gradual increase after an event is usually indicative of central Apneas and not obstructive Apneas. Some, obstructive events, not all, are followed by a larger recovery breath which frequently tapers off to normal.
The l Forced Oscillation Technique (FOT), which is a 1-cm pressure oscillation at 4-times per second, is really good at identification of central Apneas.

Ideopathic central Apneas typically do not exhibit the waxing and waning that CO2 induced/treatment emergent central apnea has.

[Zeliox]

So I tried sleeping with CPAP mode and the pressure set to 4. I ended up taking the mask off in my sleep sadly, but the results so far seem pretty profoundly different. My AHI was only .87 and that was with a false-flag hypopnea before I fell asleep. I separated the "overview" into 2 parts because of the interruptions. One is when I had the mask on for part of the night and the other is a nap I took late this morning. I also included a zoomed view of the first of two CAs.

I'll definitely be doing this again tonight to try and get better results, but it seems really telling so far that the therapy at least on VAuto mode may just be making things worse. Do others think the same based on this? I know it's not enough data yet but it certainly seems to imply that so far to me.

@SevereApnea - Thanks for the tip about resizing charts. I had no idea that was a feature. I'm still kinda confused even after looking at it closer since it still looks more like I've seen from examples of CAs and nothing like OAs, but I'll try to do more reading today and maybe I'll find different examples.

[Dormeo]

Because your total sleep time is quite limited for this experiment, I wouldn't draw any conclusions from it.

At a fixed pressure of 4, I would feel completely starved of air. Is it comfortable for you? If yes, there's no particular harm in continuing your experiment. I have my own predictions about how it'll go, but you won't hurt yourself by generating more data with this setting.

At this point, I think it'd be good for you to work on using the machine for the whole night. To keep your mask on, you can try putting some adhesive strips across the straps where they touch your face so that the tug will alert you. You can also try wearing a hat that ties under your chin, in case you happen to have one.

[SarcasticDave94]

Just remember, this is a one night non-trend, with ok to good event results in minimal pressure.

Don't look at the chart when you answer this, how did you feel after this?

An if/then statement times 3: if your CA are idiopathic then ASV is needed, but if they're treatment emergent then either CPAP or BPAP can work with the right initial settings, if those clusters were positional then they must be addressed with a collar or different flat pillows.

And a bonus if/then, if 4 works to build a decent trend and you feel OK for it then you'll just use that. But given the fact with low pressure you pull the mask off, it's not too promising that you won't need more pressure.

[Zeliox]

@Dormeo - I felt totally fine at a pressure of 4. I'm not sure why you would feel starved of air? It obviously was a bit different from the experience with PS, but it was pretty easy to adjust to for me.

@Dave - I honestly felt pretty decent today especially compared with the last 2 days even with such limited sleep which is surprising to me. To be clear, I am still pretty tired but that's just normal for me. I've been dealing with severe chronic fatigue for many years at this point. I think the only reason I pulled the mask off is because I'm still adjust to the therapy. I don't think it's specifically due to the low pressure. If you look back at my other reports I have been doing this since the first night but I would catch myself, presumably because I was sleeping less soundly but that's just a hunch.

I'm gonna try this again tonight and see how it goes. I'm strongly suspecting that many of the OAs have been miscategorized CAs that are treatment-emergent or something along those lines but we'll see I guess how things go tonight.

[Dormeo]

It would be very unusual for large numbers of OAs to be misclassified as CAs, and I don’t follow your reasoning on the subject. But let’s table that and see how you do.

Just FYI, a setting of 4 is usually just for children or small adults, but again, let’s see how you do.

What will you be doing to keep your mask on at night?

[Zeliox]

I get that it's unusual, but I was basically awake when some of the events occurred last night that were logged as OAs and they certainly didn't feel obstructive. It was just a sense of not automatically breathing which seems to line up with the idea of CAs that I've heard. To be clear, I wasn't awake, but in very light sleep and the lack of breathing caused me to wake up shortly after.

Also, I'm aware that a setting of 4 isn't usually prescribed. The only reason I'm doing it is to get a baseline for how my condition is because I'm heavily considering that the therapy is causing problems far more than it's fixing them at least at the settings I had it at previously. No test that I've ever done, in-lab or otherwise has ever shown anywhere near the apneas that have been occurring and the idea of positional apnea just really doesn't line up at all with my knowledge of my sleeping habits and anatomy. If it is positional then it should still occur at these low pressures, if it's CAs then presumably it would be much lessened if not eliminated at these low pressures. This is my thought process at least and if anyone thinks I'm mistaken then please chime in. I'm just trying to rule things out.

I may try taping part of the mask to my face, but I'm not sure.

[cathyf]

You might find this thread useful (and if not, at least amusing )
  http://www.apneaboard.com/forums/Thread-...pid=391082
It's the OSCAR chart of me singing the Star Spangled Banner while masked up. What's interesting to me is that singing -- at least while awake -- is very short fast inhales and long, drawn out, vibrating exhales. When I breathe while asleep it is totally different -- very short fast exhales followed by a short rest, followed by a struggling long inhale.

Like I said in my comment, I was surprised that the long held note at the end scored as obstructive, and it helped me understand that a central isn't holding my breath -- holding is work and centrals are a relaxation.

The way that I understand treatment-emergent centrals is that when your body that has spent years fighting for every breath gets a machine that is fighting alongside you, you don't stop fighting. Instead you grab the extra air with all your fight and breathe "too well" and then you just stop for a bit, kind of at loose ends.

You know those moving walkways in an airport? So you are late for your connection and are walking/running as fast as you can. Then you come upon one of those moving walkways and you walk really fast on it and you are just flying down the hallway. And you realize that you are not as late as you think because you moved so much faster than you thought that you could. So you stop and look at that interesting piece of art that you are passing.

My normal breathing on cpap I take little 2-5 second breaks between breaths. Every so often that extends to 10-11 seconds -- a central apnea. While I can have 30-40-50 second obstructives my centrals don't do that.

Ok, I have very high levels of flow limits but only when I am asleep. On autoset, it is a perfect flag of me being asleep. The first 51 years of my life I breathed all night every night against significant flow limits. I'm really good at it! Give me a machine that helps out, and I'm even better at it!

(Note about operating OSCAR. If you right-click on any y-axis, a menu comes up. The one labelled y-axis allows you to override the settings for the min and max on the y-axis. The auto set works to show all of the curve for the whole night, and when you are zoomed in you often want to narrow that down to reflect the values in your zoom.)

[Zeliox]

That's a pretty funny experiment! It's also interesting to note what you did in your post regarding OAs. I also appreciate the explanation of treatment-emergent centrals. I would assume that they would arise in anyone and not just those who have been struggling with sleep disordered breathing considering that the machine gives a boost regardless, but I could certainly see how in some instances it may be worse in those who have suffered worse and are dealing with large improvements through PAP therapy.

What you mentioned about centrals, at least to me, seems to corroborate my idea that at least some of the OAs being detected are actually centrals, since what I experienced while presumably in N1 sleep last night was no amount of breathing for an extended period leading to an arousal bringing me out of sleep. This is similar to the example you provided where I'm breathing "too well" I suppose and my body is wanting to stop for a bit.

[Zeliox]

I just had my second night with CPAP mode and a pressure of 4. It looks pretty similar to last night. Very few events and a few that are clearly false-flags while I was either awake or presumably in REM. Regardless, my AHI was 1.68 which is significantly better than before. Sadly, I wasn't able to adhere to the mask the entire night again. I did attempt to tape it to my face, but I woke up early this morning to the tape folded on my night stand and my mask neatly hung on my bed where I normally put it so that was kind of funny. Regardless, I did manage to sleep with it for about 4 hours which is certainly an improvement and I think fairly significant. It's roughly in accordance with how much I was using it on the old setting so to me it seems enough to begin drawing some comparisons. I will still continue to use it to get a clearer pattern but I believe this is pretty telling that my sleep issue either isn't really breathing related or just isn't being picked up by the device.

I attached the overview of last night along with a period where my breathing seemed really weird. Any ideas on what that could be are appreciated. The thing that's weird to me about the second picture is how the flow rate is rising and falling rather smoothly plus the hypopneas. I've never seen that anywhere are it seems like it would maybe be a problem? I'm not sure what it may mean though.