[Pressure] central sleep apnea because of high Bipap pressure??

[Gideon]

Higher PS has a greater impact both on increased Centrals and improved obstructive events. You are looking for a comfortable balance between the two.

Pillow mods may be as simple as Reducing from 2 pillows to one or going from a firm foam to a feather pillow or something like that. You are looking for comfort with less head lift. I personally like something firm on the back of my neck. If can come up with something else that works great, just let us know what it is.

[Geer1]

These recent results are looking more obstructive and definitely looks like there is a positional aspect.

Your head should be fairly flat so that your neck/airway are not kinked, this usually means using one thin pillow. If you are using thick or multiple pillows it is easy for you to shift forward a bit during sleep which tilts your head forward "tucking" your chin. This restricts the airway causing positional apnea. Improving pillow selection can help as can using a cervical collar as Gideon mentioned.

Before I get into more details obviously the most important aspect to this self titration is getting good OSCAR data. Putting SD card back in machine is critical as is always posting a zoomed out view showing the whole night of OSCAR data with the details tab visible. This allows us to see patterns throughout the night, how you reacted to increasing/decreasing pressures etc. You can also post some zoomed in shots like your recent ones if there is something you think may help understand details but remember that we always need an overview shot as well.

Now to correct some misconceptions on your part.

"While using Pressure Support values i considered the following two points.
1. Higher EPAP value triggers more centrals so lesser EPAP is preferred because i seem to have therapy induced CSA.
2. Higher IPAP value is necessary for reducing OSAs and Hypopneas."

EPAP can cause centrals but higher PS is usually the bigger issue and IPAP does not reduce OSAs.

EPAP is the lowest pressure the machine produces during exhalation. EPAP is what stints (holds) your airway open allowing the next breath to occur normally. EPAP is what treats obstructive apneas. If you are having obstructive apnea increasing EPAP will usually help. However pressure isn't always enough to overcome obstructive apnea and one common example is positional apnea. If your chin is tucking and restricting airways it takes a lot of pressure to overcome that and finding a pressure that will work to do so is unlikely and even if you do then it will be too high when you are not tucking chin. So what do you do? Stop the chin tucking as much as possible to avoid the positional apnea to begin with. As mentioned changing pillow arrangement and using a cervical collar are most effective. You can also try different sleeping positions if they are comfortable but one change at a time to know if it is helping.

Pressure support is what helps improve flow rate through a restricted airway. This helps to treat flow limitations and hypopneas because the change in pressure from EPAP and IPAP speeds up the flow rate of breathing in/out moving more air through a restricted airway. You have to find the sweet spot for pressure support. If you use too low of a pressure support you might not get enough flow, if you use too high of a pressure support you get too much flow, wash out your CO2 and cause central apneas. First you need to treat obstructive apnea as well as possible with EPAP/treating positional apnea then you can determine what level of pressure support is advantageous.

In your case I am thinking positional apnea is an issue. This is supported by the recent clustering of events, worsening at lower EPAP and your better results the night you propped yourself up with pillows to sleep on side rather than back. You also appear to have a central apnea issue at times which may be treatment emergent apnea, mixed apnea or misinterpretation by machine. We can't try and treat everything at once right now so the first goal is to try and resolve obstructive apneas.

Fix your pillow arrangement as best as possible. Use vauto mode with min EPAP of 8 cm and max IPAP of 16 cm. Leave PS at 3. This will allow your machine to run between EPAP of 8-13 automatically. If you are still seeing signs of positional apnea then try either side sleeping or a cervical collar to confirm/resolve them. We will deal with central apnea last unless it is out of control.

[SarcasticDave94]

I've found that on a BPAP, the EPAP has very little to nothing to do with CA. PS does very much though. In large part because PS gives a difference between exhale to inhale and flushes out CO2 and increases breath efficiency.

[sanemonk1]

Thanks everyone. I am excited now that i am learning a lot about my issue and getting some help to tackle the mysteries. I was starting to loose hope with PAPs and complexity of my apneas just like before.

1. Screenshot overview attached. Please let me know if you find out more about my condition.
2. Memory Card put in the machine
3. Will use only one hard flat pillow. I was using two pillows. I am floored by how you guys can point that out just by seeing oscar data. Would have never though about that one.
4. Will use vauto mode with min EPAP of 8 cm and max IPAP of 16 cm. Will Leave PS at 3 as suggested by Geer1 and post result tomorrow. 
5. Will use cervical collar, may be tomorrow.

[Sleeprider]

I will use the collar. Will set ps 3 Epap 6 and Ipap9 tonight and update.
So, higher PS and higher EPap both increases/triggers central in my understanding. 
Pillow mods are sleep apnea pillows?

The collar will assist with positional apnea, and PS 3 will help avoid centrals. Your settings were EPAP min 8.0, IPAP max 14.0 and PS 5.0. The ONLY thing Gideon suggested you change was the PS from 5.0 to 3.0.  Please don't reduce EPAP to 6.0 as this will not help or IPAP to 9 as this will be counter-productive.  Your settings should be:
Mode Vauto
EPAP min 8.0
IPAP max 14.0
PS 3.0
I want to add one more thing, set your trigger sensitivity to high..

[Geer1]

3. Will use only one hard flat pillow. I was using two pillows. I am floored by how you guys can point that out just by seeing oscar data. Would have never though about that one.

It shows up as repetitive obstructive apneas but only at certain times, it is one of the easier patterns to notice once you get more experience with this. 

For example when you look at the overview data you just posted you can see how you had two periods of repetitive apneas separated by an hour of better breathing. The difference was likely your position changing. At 1:40ish you probably shifted position fixing the positional apnea then around 2:45 probably shifted again and started having the positional apnea again.

You have two options with IPAP. 

Option 1: Max IPAP as Sleeprider just posted. This will mean you are operating at fixed pressures of EPAP = 8 and IPAP = 11. This would be helpful to see if changing pillows, positions, collar etc help with positional apnea. 

Option 2: Max IPAP = 16 as I had recommended. My idea behind that was to see if the higher pressure (which will be driven up by machine) helps resolve any of these issues. Although higher pressure usually doesn't stop positional apnea it can help (it can also just mean that the machine stays pegged at max pressure though). 

Both have merit. If you want to more clearly see the effects that changing pillow orientation etc has then stick with Option 1 then switch to Option 2 once you are think you have done as much as you can. It is always easiest to interpret the difference in results if you only make one change at a time although it sometimes takes a little longer to find ideal settings doing so.

[mesenteria]

 
...
However, there was still 4 CA events, 1 Hypopnea and 5 OSA events around the same time frame.
I was praying not to see CA events. 
...

A couple of things:

While your machine flags what it thinks are CAs, and very well might be, they also might only be of such short duration that they are largely innocuous;  you might as well just monitor them for duration for the next 15-20 reports to see if you can detect any directionality.  What I mean is, if they're in the 12-15 second range, they're not likely to be deleterious, except that they come often, or bunch during a brief interval.  If they are spaced out, one per hour even, that's not going to be a problem...not by itself.  Not unless there are also several hypopneas and obstructive events to add to that number.  What I'm urging is context, including if you're sleeping reasonably well, getting some REM, and not nodding off at meetings or at track events (whether a spectator or a participant  ).  The daily AHI is just a metric, if useful, but it doesn't necessarily give a comprehensive and analytical view of the previous night's events, and nor does it tell you that what did happen was harmful necessarily.

My AHI is always less than 0.8, which truthfully is rather spectacular.  However, if I do have a noteworthy 'event', it is going to be the odd CA.  I never, EVER...get an obstructive, but I do get the rare hypopnea or flow limitation.  What shows up 85% of the time when I'm up around 0.8 AHI is the odd CA.  When I go to look, cursor over the vertical coloured line, it is in the 10-15 second range.  Heck, with my weight and height, I do that just bending over to put on my shoes!

So, the advice to also pay attention to how you feel about your sleep, and if you can function hour-to-hour during the day, is sound advice.  An AHI well under 4.9 is a win.

[sanemonk1]

I am posting two Oscar sleep data from last night.
First one was for about one and half hour with AHI of 18.14. I had used single soft flat pillow with collar. I woke up finding it very hard to breathe and gasping for air.
Second one was for about 4 and half our with AHI of 10.22. I used single hard pillow with collar- It was more comfortable than the soft flat pillow and the result shows it being more effective also. I woke up again gasping for air so took off the mask and slept about an hour more. Both the time the setting was the same PS 3.0 over 8.0-16.0 (cmH2O).

However, both time I woke up because of having difficulty breathing and gasping for more air. I felt weak and sleepy. It was the same previous nights also on Bipap and APAP. Is it because i am in the process of getting used to the treatment or something needs to be changed?  

I definitely feel little more rested than other nights when i wake up very tired though. I am also relieved that only few CSAs are being induced which I attribute to the low PS of 3 like many of you stated before. My OSAs are also down to 10.22. 

Looking at the overviews data of 10.22 AHI period, I see that the flow rate was broken twice. Leak rate and other data were also not available so it was not because of leak? What happened there please let me know.
Please also let me know other possible areas for improvements.

[Geer1]

That first bit of data is perfect example of RERA's. See how the breathing gets smaller and smaller and then you have an arousal, take a bunch of deep recovery breaths then do it again. This is a positional issue, the higher pressure seemed to help a bit (which is why they were hypopneas instead of apnea) but when having these issues you can see how the pressure maxes at 16 cm. Higher pressure is only going to be minimal assistance, trying to fine tune position, pillow, collar etc is going to be your best way to improve.

The breaks are most likely you turning the machine off.

[sanemonk1]

That first bit of data is perfect example of RERA's.
So you mean I also have a lots of undocumented RERAs beside having lots of OSAs and hypopneas from my initial sleep test report? What kind of treatment what would you suggest from here?

See how the breathing gets smaller and smaller and then you have an arousal, take a bunch of deep recovery breaths then do it again.This is a positional issue, the higher pressure seemed to help a bit (which is why they were hypopneas instead of apnea) but when having these issues you can see how the pressure maxes at 16 cm. Higher pressure is only going to be minimal assistance, trying to fine tune position, pillow, collar etc is going to be your best way to improve.

I already have collar and pillow adjusted.
So positional issue meaning I keep using bipap plus adjust not to sleep on my back ever? I dont have problem with bipap as it seems to reduce my AHI but I already have shoulder issues sleeping on my sides. No matter what I do I always end up sleeping on my back because of side shoulder pain.