Settings to mimic natural breathing?

[koy23]

I have a Resmed Aircurve 10 Vauto, I have it more than 2 years, I have never been able to use it to sleep soundly.

My problem is I think my nervous system is so sensitive to anything "touching airways,  as soon as I am collapsing I get awaken suddenly as in this video I recording showing moment of awakening:
(https://youtu.be/6cfOc8XC3fg)

So whenever I try to fix it with aircurve, my nervous system "awakens" me as soon as I drift asleep ( even before any collapse) I think because it senses the pressurized air. This has been happening for 3 years and no fix so far..

So I'm trying to set the machine maybe to mimic natural breathing as close as possible? There is cpap mode, but level mode and all the sensitivity triggers etc..

Could I sleep titrate also or do I have to have a titration study?

Could you help? 

Thanks

[Geer1]

Were you actually asleep during that video or was this a jerk while awake? Seems like it would be hard to sleep with a scope in and if awake there is no clinical relevance imo (unless you have a doctor saying otherwise).

Based on your previous thread it looks like you were having a handful of actual central apneas as well as what I will term central pauses (pauses between breaths looking central in nature but not long enough to be a central apnea). Do you have nights with lots of central apneas or only a few each night?

Your sleep study data posted always had apneas combined. How many were obstructive apnea and how many were central apnea?

An initial consideration for your settings would be using CPAP mode as that will stop pressure fluctuations. The one downside to this is the majority of your apnea in sleep study occurred during rem sleep so you might need higher pressure in rem sleep and lower in nrem and if on CPAP mode will need to set pressure to what you require during REM.

Another consideration is setting trigger sensitivity to very high, this has helped other members with central apneas so might match what your body wants better. Trigger and cycle sensitivities are specific to you alone so you need to methodically try the different settings and see which one seems more comfortable to you (and if there are any changes in your data).

Reducing PS may be helpful too. The higher the PS the greater the pressure swing each breath so if you are actually sensitive to this stuff then lower PS may help. The counter argument to this is if the PS is required to treat hypopnea/flow limitations.

Post some recent OSCAR data and setting details.

[koy23]

Were you actually asleep during that video or was this a jerk while awake? Seems like it would be hard to sleep with a scope in and if awake there is no clinical relevance imo (unless you have a doctor saying otherwise).

Based on your previous thread it looks like you were having a handful of actual central apneas as well as what I will term central pauses (pauses between breaths looking central in nature but not long enough to be a central apnea). Do you have nights with lots of central apneas or only a few each night?

Your sleep study data posted always had apneas combined. How many were obstructive apnea and how many were central apnea?

An initial consideration for your settings would be using CPAP mode as that will stop pressure fluctuations. The one downside to this is the majority of your apnea in sleep study occurred during rem sleep so you might need higher pressure in rem sleep and lower in nrem and if on CPAP mode will need to set pressure to what you require during REM.

Another consideration is setting trigger sensitivity to very high, this has helped other members with central apneas so might match what your body wants better. Trigger and cycle sensitivities are specific to you alone so you need to methodically try the different settings and see which one seems more comfortable to you (and if there are any changes in your data).

Reducing PS may be helpful too. The higher the PS the greater the pressure swing each breath so if you are actually sensitive to this stuff then lower PS may help. The counter argument to this is if the PS is required to treat hypopnea/flow limitations.

Post some recent OSCAR data and setting details.

Thanks! You are the FIRST person to ask this question from ALL the doctors I have seen about the video! 

I was not asleep neither awake, it took me around 24 hrs trying to sleep and my wife trying to get clear image with an ebay bought endoscope!
So when this image was captured I just drifted to sleep and was awaken right away. 

This keeps happening every single night

I have an updated sleep study here: New hypnogram
And data: Sleep study numbers

Most of the study was on my side and you can see number of arousals was around 30 in 6 hrs, but no obvious apnea..
I think what happens is my body doesn't "allow" apnea to happen by reacting right away before the 10 seconds of hypopnea happen..

I can't function still through the day and kinda gave up on PAP after sleep study said it's not breathing related arousals.. but my body is telling me otherwise..I wake up many times with snore that wakes me up.. so I keep saying uts breathing related bc what else ! 

That's why I'm trying to give like a 4th try to my BiPap just bc I failed miserably using it I was thinking maybe I should do titration study maybe the pressure needs to be higher .. my previous sleepyhead showed like 0.5 AHI with pressures around 5 and 6.. but again I wake up a lot.. that's why I think my body doesn't give time to machine registering apnea events..

[Geer1]

In that video I didn't see anything that would indicate a breathing issue.

The jerk was probably a hypnic jerk, they happen during sleep onset/transition and you would be even more prone to one sitting there with a scope in your throat. Everyone has them to some degree but in some people they can be excessive and cause sleep issues. Cause isn't really known but stress and anxiety definitely exaggerate them.

Your body does not anticipate a breathing issue before it happens. Your body reacts after your disturbed breathing affects body function. For example reacting to low oxygen levels, high or low carbon dioxide levels, and excessive breathing effort.

I assume that latest sleep study was done without CPAP. It shows no significant sleep disordered breathing. No significant apneas, hypopneas, RERA's (they didn't score them but your overall arousal index is reasonable so they can't have been bad) and no desaturation (blood oxygen levels were very good the entire study). You do have the previous sleep study data that did indicate apnea though so obviously can't say you don't have apnea, it might just not be present every night.

With this extra information my recommendation if giving CPAP another try my recommendation would be minimal settings. EPAP 4 cm, PS 2 cm (so pressure of 6 cm). Fixed pressure, not auto adjusting. Play with sensitivity settings to find what feels more comfortable to you, people usually lean to higher on trigger and lower on cycle. Then we can see what occurs for apnea, hypopnea etc, if apnea or hypopnea is a significant issue should get some signs on OSCAR when using these minimal settings. If no signs then I would say it supports these most recent sleep study findings and only to continue using CPAP if you feel better on it. If you haven't been using CPAP in a long time then make sure you give it a good couple weeks at least to allow body to adapt to it.

There are phone aps you can use that track noise and record snoring. Using something like that would be better than believing it is the snore that wakes you up. Apnea related snoring is usually pretty obvious (just ask your wife, she will know lol).

Just based on the sleep study data and your old charts I looked at it doesn't really appear that breathing would be the obvious cause but it could be part of the issue mixed with hypnic jerks, insomnia etc. If you aren't already aware of these concepts look up sleep hygiene and CBT for insomnia for some good sleep practices that will improve sleep quality.

[koy23]

Thanks for the thorough explanation,  just wanted to add that between first sleep study and second were 3 apnea surgeries including genioglosus advancement.  
The arousal index of 7.9/hr is not normal for my body, I haven't had it before, I can't tolerate it,  maybe some people have higher tolerance but for me it makes me sleepy/zombie like. So the question is what is the cause of those "spontaneous arousals" ? What is making me stuck in rem and keep sleeping/waking cycle as the hypnogram? 

For the video it's a jerk for sure but not only when drifting to sleep, even though in that particular video I was drifting to sleep. But at the time of first study, I "felt" this jerk many times through the night and every single time I took a nap. 

Now after surgeries. I wake up without feeling this jerk, I feel "vibrating" at the base of my tongue, and many of the times I wake up "hearing" the snore. It's a split second between sleep and awake where I could hear the snore or feel the vibrating of my tongue base
I also recorded myself snoring lightly then waking up with a bugger snore. 

No doctor so far could have explanation or find what's happening, but again arousals are proven in both studies. Maybe my body reacts very "violently" to narrowing of airway ? Maybe as soon as it happens ? 

I tried my PAP at 4 pressure  on cpap mode like 2 months ago, what happens is each time I fall asleep I jerk awake, like 3 times on a row till I Removed the mask and finally could fall asleep. 
I don't know how to "overcome" this initial obstacle to try to see if the PAP will help.. 

I'm just trying to find help maybe with the machine bc I can't see other options from doctors..

[Geer1]

Arousal index of 7.9 is not an issue, it is actually on the low side. 10-20 is normal range. Everything about your sleep results looks normal to me (I am guessing doctors said the same). The only real issue present is some insomnia but that is to be expected in an in clinic test as no one sleeps well in that environment.

The reason you have trouble with PAP now is likely the reason every new user struggles with PAP (especially those with minor SDB like yours now). It takes many people weeks to finally start getting better sleep with PAP then without it, the reason PAP negatively affects those with minor SDB is because the disturbances it causes while your body adapts is worse than the benefit gained from the better breathing. Eventually the body adapts and isn't negatively affected by PAP anymore and then slowly you start to notice improvements from the improved breathing. If you believe breathing is still an issue then all you can do is force yourself to adapt to it. Don't remove it if you are having trouble sleeping and if you do remove it then go do something else and put it back on before you try to go to sleep again. If you can't sleep the first night you will sleep the next night or the night after that. Eventually your body will adapt and then if breathing is still an issue eventually symptoms will improve, if you don't improve rest easy knowing you tried it and confirmed that breathing is no longer an issue.

If using CPAP again I would use the minimal settings I recommended above, less is more when it comes to PAP therapy. The higher the pressure, the higher the PS the worse your sleep will be unless you need that higher pressure/PS. There are no indications you need high pressure/PS and the only thing that might indicate changes would be OSCAR data supporting such a change. I can't give you any better/more PAP advice until you give those settings a good hard try and post some results.

Out of curiosity do you have digestive symptoms? Bloating, reflux, constipation, diarrhea etc? IBS as the doctors call it.

[koy23]

Thank you for explaining,  should I try to leave it on auto first night and check my pressure on Oscar ? 
Like ps 2 and max iPap 15 and see what's the 95% pressure will be ? 
Or try 4 cpap mode directly as you said? 

I had reflux but it is now much better ( last 2 years)

[Geer1]

I would use fixed pressure if you believe you are sensitive to the pressure changes. If it isn't effective then we will see signs of apnea/hypopnea and can raise pressure. If it is only not effective at certain times (like REM sleep) then might consider auto again.

[Crimson Nape]

Geer1 makes a very good point. I'm extremely sensitive to pressure changes. My AHI doesn't change, but my quality of sleep is effected. I'm aware the next day of the arousals caused during the night by a pressure change. Meaning that it wakes me up enough to remember it. Using a fixed pressure allows me to sleep through the night undisturbed. Also, because of using a static pressure, I don't have to tension my mask for the maximum pressure in the range.

With all I said above, I'm probably the only one on this board that has this problem though.

- Red

[koy23]

I would use fixed pressure if you believe you are sensitive to the pressure changes. If it isn't effective then we will see signs of apnea/hypopnea and can raise pressure. If it is only not effective at certain times (like REM sleep) then might consider auto again.

Ok thanks a lot for tour help