[Treatment] Need help for self titration (DS Auto BiPAP) - CA's waking me up while falling asleep

[Tayy]

Hello, I hope I get some help here.

I've written about my past situation in another forum, but I think you can help me more.

The past situation:

I often wake up during the night and I never feel refreshed after sleeping. The last time I felt refreshed was after waking up from the narcosis after a surgery.
Before the surgery I also slept lightly and didn't feel refreshed. I had a hard time breathing through the nose and thought I had sleep apnea and tried to fix it by getting my nasal septum (and so on) corrected. My thought was (before surgery) confirmed by a home sleep study. In this night, I did not sleep like I would normally do. The AHI was 7.1 and I had 54 apneas, 2 hypopneas and 12 oxygen desaturations (the lowest oxygen saturation was 86%) through the night. The longest mixed apnea was about 75 seconds.
I did not receive a machine for this, because it this was considered a mild case. I had to work on my sleep hygiene (which I was already following, without results). This was in 2018. After that, I had the surgery and I hoped that it would make me feel more refreshed. It did not.
The moment after I woke up from the narcosis felt really refreshing for me, my theory is that I was well supplied with oxygen. While I was in the hospital, I noticed that I would wake up gasping for air, it felt like my throat closed.
About 6 months later, I had to be two nights at an in lab sleep study (not two consecutive days). I am pretty sure that I did not sleep much because I was "excited" and felt being watched. I could also not go to the toilet in the middle of the night, because I was wired to the measuring device. I felt like I was awake both whole nights, that is why I think that the results are wrong.
The results from the first day were: Sleep efficiency good, my dream sleep was reduced, I had 4 short sleep cycles, arousals were lightly disturbed, but I had just an AHI of 3.4/hour with the lowest oxygen saturation of 91%.
The results from the second day were: Sleep efficiency good, frequent short waking phases, deep sleep reduced (6.2%), dream sleep normal, immediate appearance of dream sleep at the end of the night, macro structure of the sleep disturbed, micro structure (arousals) lighty disturbed, AHI of 3.0/hour with the lowest oxygen saturation of 92%.
Because of how my sleep looked in the lab, they said that I might have narcolepsy. I don't sleep during the day and this theory was refuted by another sleep lab I went to.
Another 6 months later, I went to a neurological sleep lab. I had to be two nights there, but this time they were two consecutive days. Unfortunately I only have the results from the first night: "sleep profile with reduced sleep efficiency, slightly reduced REM and deep sleep as well as three sleep cycles slightly to moderately disturbed. Light breathing rate". The AHI was just 3.0/h with a minimal SpO2 of 77%. The doctor said that I might get my sleep fixed by going to a therapist.
I know that an AHI <7 is not considered as sleep apnea. But I am 100% sure that I was not really asleep while in both sleep labs. That's why I didn't have enough deep sleep -> less sleep apneas(?).I have difficulties to sleep while being watched.
Also interesting is that the therapist prescribed me promethazine (did not help) and then seroquel. Seroquel helped me fall asleep faster but I also woke up often during the nights. I just fell asleep faster again. It did not really help because I felt even more foggy and tired troughout the day.
I can't tell if I snore because I live alone. I tried to use an app to record me while sleeping and it sounded like I would breath loud (maybe light snoring) and then suddenly stop breathing.
I often wake up with a headache. Almost every night I wake up with a dry mouth and I have daytime sleepiness all the time. It is not that severe that I would just fall asleep (or maybe this is not happening because I drink like 5-6 coffees per day), more like feeling fatigue the whole day .
Still after surgery, my nose feels closed sometimes while lying in bed. In the past I would also wake up sometimes feeling drowsy, with the urge to breath. I also wake up sometimes in the night and then I am sweating. Since a few weeks I wake up with acid reflux, feeling nauseas. Since my last sleep study I also gained about 10kg (22lbs) because I feel too exhausted to do sports. I have trouble focusing and learning (this is the main reason why I want this to stop because I am a university student and also have to work). 3 months ago I got diagnosed with ADD (because of my suggestion to get medication so I can focus better) and it really could be that I have it but I think my sleep is the main factor for this.
I am male, 25 years old and slightly overweight. A few years ago, I was really fit, also while having the sleep studies. I tried measuring my SpO2 with a garmin watch (no medical device) while sleeping for a for weeks: on many nights the lowest SpO2 is about 80-85%, one night it was at 74%. Unfortunately this device just captures about 4 hours and not the whole night.
I tried many supplements, magnesium glycinate, taurine, theanine, several sleep blends, and so on. Nothing helps me with staying asleep and getting a restful night.

The current situation:
I ordered a Dreamstation Auto BiPAP and received it on thursday.
Since I don't know which type of sleep disorder I have, I've chosen this device because I've read that a bipap device would be good against OSA and UARS. I also don't have enough money to first buy a cpap/apap which might not work for me and then buy a bipap.
Now I've tried to sleep with it and I absolutely can't fall asleep. It feels like I'm about to fall asleep but then I wake up again immediately because it feels like I have to gasp for air. I get an adrenaline rush and have to remove the mask or turn off the device. I still tried to fall asleep for a few hours but it wasn't working.
I've checked OSCAR and now I see that I have an AHI of 19.97 for the hours I tried, most events are CA's (17.33).
I've read in other posts that CA's can occur in the first days/weeks of using a device and that they will most likely go away.
There are also some people that get CA's when the are about to fall asleep, I guess I am one of them(/forums/Thread-Sleep-wake-transition-central-apnea - sorry I can't post links yet but this is from apneaboard).
I really hope that these CA's would go away with some changes in the settings where I hope some of you can help me.
I am not sure how accurate the marked CA's are because sometimes I had to hold my breath for a few seconds when I woke up again because it was too much for me.
I also hope that I don't have CA's while being asleep because I can't afford an ASV out of my own pocket.

In this thread forums/Thread-Struggling-with-BiPAP-AutoCurve-VAUTO-Central-Apneas (apneaboard thread) someone suggested:
"-Trigger =Very High
-Cycle = Very High"
Are there similar settings for the Dreamstation auto bipap as this advice was for a resmed device?
I think I will try to take seroquel tonight while using the device, to get some sleep as I slept too less the last two days, but this might also "fake" the actual needed settings, I guess.
I will attach a screenshot of OSCAR data from the whole night and one screenhot zoomed in where some CA's happened. In the zoomed in, I will also scroll down the left bar for more information about the settings I used.

If needed, I can make photos of the sleep study results but they are 1. in German and 2. a few years old (and 3. I think didn't sleep at all).

Sorry for the long post, but I hope someone has advice for me.
I also apologize if this is not written in good english as I am no native speaker.

[Gideon]

Go to the top of this page and click on CPAP setup manuals, follow the instructions and request the clinical manual for your machine. you may need the serial number from the bottom of your machine, be sure to remove the humidifier tank before flipping the machine over to read it. This will say if you have trigger or cycle settings.
Trigger is to initiate breathing faster, Also we don't know if that will work on a PR machine, but we can try it. Start with "Trigger" on "High"

If this is a used machine, (check the Run or Blowerours) then do a factory reset, just to make sure that all settings are at default, then reset your pressure and PS settings.

First change. set Min PS = Max PS =1 as we want to minimize PS in an attempt to minimize central apnea. This typically works for treatment-emergemt central apnea. To evaluate the character of centrals we need a 10-15 minute segment, not the 4 minute you posted.

Set your min EPAP = 8 to help with the gasping for air. apparently, you don't need this therapeutically but the comfort definitely matters.

[Tayy]

Hello Gideon,

thank you for your reply.

I've received the manuals but it seems like there are no trigger settings for my DreamStation Auto BiPAP.
It is a new machine, so the settings should be at default, except the ones I set up.

I changed the settings to Min PS = Max PS = 1 and EPAP = 8 before sleep yesterday.
I actually could fall asleep but I woke up a few times although I took a seroquel before sleep.
After 4 hours, I took the mask off (subconsciously), because I felt uncomfortable.

OSCAR shows an AHI of 1.50 but I had a few events in these 4 hours:
6 RERAs, 4 OSAs, 2 hypopneas and 3 flow limitations.

I think I woke up everytime after I had a RERA because I took the mask off after I had one at 02:39.
I've read that RERAs trigger awakenings, but it should be subconsciously, but I feel like I am aware of them and wake up (for a few minutes).


You've written that you need a 10-15 minute segment of the centrals, but I guess it isn't needed anymore.
I'll add screenshots of last night though.
One with the overview of the whole night, one with a 18 minute segment and one with a 6 minute segment.

I would actually say that an AHI of 1.5 isn't bad but my sleep quality still isn't good because I wake up too often and it feels like I have a very light sleep.
With the RERAs it actually looks more like UARS, doesn't it? But I am not sure how many events I'd get without the machine.
I hope you can still help me here.

[Gideon]

A couple things
1. please zip a copy of your entire SD card and copy it to my drop box. You have an "unknown model" and we would like to add that to OSCAR and eliminate that message, it will be gone in the next OSCAR release.

https://www.dropbox.com/request/6VeFzBXa4qZ37EgphL5b

On comfort, let's try min EPAP = 9
On RERAs, PS is the best tool to treat them so we increase Min PS = Max PS = 2

we are searching for a sweet spot, a trade off where you feel good and we have both obstructive (RERAs) and central well balanced.

[Tayy]

Thanks again for your fast reply!

I uploaded a ZIP container called "DEX700S13" - that's how it was called on the page where I ordered it from.
If you need more information about it, just let me know.

I will try EPAP = 9 and Min and Max PS = 2 tonight, I will report tomorrow.

[Tayy]

I tried the settings as mentioned above, but still woke up a few times in the 2.5 hours usage yesterday.
It seems like the RERAs reduced but I still had some hypopneas.
Of course it is not that much (AHI 1.94), but it seems like I wake up after I have events (hypopneas/reras).
Could I just be too sensitive?

Should I first try to keep the mask on at night, before other changes in settings should be done?

Maybe I have to get used to the therapy first, to get more information about my sleep (especially more hours of sleep).

I'll still attach two screenshots:
- the "whole night" (2.5 hours)
- one where I woke up after I had a hypopnea (turned the machine off after that, but turned it on again after 4 minutes)

Edit:
The reason why I keep taking the mask off after a few hours is because it feels like I am not sleeping at all, but I have to wake up at around 6 - 7 am, so I take it off to get atleast some sleep.

[Tayy]

...3 weeks later:
I am no longer using the BiPAP auto mode. This helped me to get used to the therapy.
I also switched to Resmed P10 nasal pillows and I feel way better with them compared to when I used the full face mask.
I noticed that I get a dry mouth every night, so I started to tape my mouth, as this caused me to wake up. This still caused my mouth to "inflate" because my jaw drops at night.
After that, I ordered the Knightsbridge Dual Band, which I now combine with mouth taping.
This was the "missing key" to reduce the CA events. It seems like almost all of my CA events actually happen when I'm falling asleep and not (at least for now) when PS is too high.

My current settings are:
EPAP 9.5
IPAP 14
= PS 4.5
BiFlex 2

The first night  I used the chin strap (4 days ago), I only woke up for like 1-3 times. This is way better than in years.
The last two days though, I woke up several times again. I even took off my mask and chin strap a few times, two days ago, not remembering this when I woke up. Does this indicate that I have a deeper sleep now? I normally would notice everything and wouldn't remove anything. I must say, that I had a congested nose that day, I guess that was the reason I did this.
I also didn't have to go to the toilet in the night.
BUT I woke up and was way more tired, even more tired than before starting the treatment. Today, I feel the same.

Last night I had an AHI of only 0.66. Is my body "adjusting" to sleep better or am I using wrong settings?
I think I still have some untreated flow limitations. I still have a lot of arousals. I woke up a few times again this night.
Should I increase IPAP more?

A few more questions:
1. My 95% pressure is 10.7. How can this be?
I ask because this is more than EPAP but way less than IPAP.
9.5 (EPAP) + 4.5 (PS) would be more than 10.7 (14, IPAP).

2. Why are some of my breathings shaped "spikey"?
I've never seen this in other threads.

3. Should I try Auto BiPAP mode again since I reduced my CAs with the chin strap?

I'll post more screenshots in another reply.

Thanks in advance.

---

More screenshots

[Sleeprider]

At PS 4.5 and fixed BiPAP pressure your AHI is excellent. There is no need to move to variable pressure, and not much in your charts suggests the machine would change pressure anyway. None of the close-up charts suggests flow limitation that I would pursue, if it is there at all. There is some variable breathing volume in the areas flagged for periodic breathing, but I don't think this is of any significance to your therapy. I would turn off VS2 flags as they are not meaningful and just a distraction. We see VS2 event flagged for things like the tube rubbing on a bedside table or edge of the bed. There are a number of flow spikes such as 03:08, 04:40, 05:20 that may be arousals, however we really can't speculate on a cause. It would be actually unusual to see perfectly even respiration through the night.

[Tayy]

Thank you for your reply.
I disabled VS2 events.

While it is great to hear that it looks good, I'm still wondering why I feel more tired now.

I'll add some more screenshots of arousals and of the other periodic breathing event.

I'd actually agree with you Sleeprider. It looks good, but maybe there is something I'm not aware of.
The only other thing is, that my body just wants to sleep more, since I am getting more quality sleep(?), but then on the other hand, I wouldn't wake up a few times in the night.

---

One more screenshot

[Gideon]

First your numbers are beyond good they are excellent, so remember these settings and writ them down, they are a safe place. if/when you change settings and they don't feel right change them to your safe settings, and your safe settings may change over time.
Next, do not chase numbers, you are beyond that. It is ok to have worse numbers if you feel ok, if it is more comfortable. We are looking for a more comfortable sleep.

That said I suggest some experimentation. Make a change in settings, then see which feels better, the current settings or the changed settings. Note I did not say look at the settings.

first trial, increase both IPAP and EPAP by 1 cmw. Then evaluate by feel, which is better and why?