My journeey with CPAP and Bilevel

[GoodSleepHunting]

   
Hello everyone,

I'm starting this thread to share my concerns and insights from analyzing my flow charts. I began my therapy with a Philips Respironics CPAP machine and tried various settings and pressures, but I never felt fully rested. I can count on one hand the number of times I felt really good after a night, and those instances were usually at lower pressures. The C-Flex feature wasn't effective in fully lowering the pressure, and A-Flex would cut off my inhales, which was frustrating. Setting pressures at 7-9 without any pressure relief made it hard to breathe out fully, causing shortness of breath during the day.

The best results I had were with a setting of 6 with C-Flex at 1, but the IPAP was still too low as my nose would clog during the night, and i had significant flow limitations and flat tops. Now, I have a Lowenstein bilevel machine, which I bought used at a great price. I suspect I would have been better off with a ResMed auto CPAP machine, as I'm seeing many central apneas pop up.

For instance, with a 10.5 IPAP and 4 EPAP (PDIFF of 6.5), I see periods of great breathing , with more rounded tops, but also many straight lines indicating periods where I stop breathing, possibly due to excessive oxygen intake. I'll experiment more with my CPAP settings on the Lowenstein, as SoftPAP might be better than C-Flex at lowering pressure but it seems the same to me, lowering preassure only at the top of my exhale.

on the CPAP respironics I didn't see too much CA's, but rather a lot of RERA's and waxing and waning breathing patterns as well as flat tops.
With the bilevel settings, I wake up very alert after few hours, suggesting that the rounded breaths and good breathing streaks are beneficial, but still insufficient- it seems it will be harder for me to sleep with these setting for more then 4 hours. I would like to get a V-Com but idk where to buy it (I'm from Europe), ordering it from America I would end up paying near 100$ for a piece of plastic with holes lol.  Also idk what the difference would be with V-com or just changing the ramp setting from 2 to 3 and so on.

I do tape my mouth and use a dual-bridge chinstrap or a collar as well - sometimes when i want to sleep on my sides alone i use a backpack for slee positional apnea,
now i'm sleeping at a very inclined position, trying only to sleep on my back, i mix it up here and than but i think side sleeping might be better overall but i'ts harder to control my jaw from not droping that way, the chinstraps comes loose and the collar isn't the best as well even with added padding to raise to to my chin = so these are also combinations i'm dealing with.

Oscar is not showing many things since i't not compatible with my Lowenstein bilevel, so i can only pull flow charts from it, Lownesteins own program is really trash and difficult to navigate.

Some of the setting I intend on trying next 7-8 days, to see where I stand and will be uploading full flow charts, currently i need to collect more data with full nights  where my leakage is under control:

9.5IPAP 4EPAP ramp 2 Ti 35%
10.5 IPAP 4EPAP 6.5PDIFF ramp 3 Ti 35%
10.5 IPAP 4EPAP 6.5PDIFF ramp 2 Ti 35%
11.5 IPAP 5EPAP soft pap1 ramp 2 Ti 34%
11.5 IPAP 6EPAP soft pap2 ramp 2 Ti 34%  5.5 IPAP EPAP 7.5

CPAP
7IPAP softpap 3
7.5IPAP softpap 3

[SarcasticDave94]

Possible help is found in using the free OSCAR program to see all the data. Second, Philips Respironics machines are notorious for bringing pressure up too slow to catch some events, for most users. In other words, the pressure changes slowly, which may hinder therapy a bit. These Respironics machines are reactionary devices, changes to therapy latter stages during or after the need to change, while a ResMed device responds to needs more predictive, changes predicting it'll happen and meeting things head on.

[Macka]

Hi GoodSleepHunting,
If you really want to get to the bottom of things I would advise getting either Torena or Somnopose app for your phone, and a running belt, or some other way to secure the phone to your torso. Also a decent pulse oximeter like a CMS50f, that will load data to Oscar. The extra data virtually allows you to conduct a fairly useful nightly sleep study. Makes it much easier to 'read' your nights and know where to attribute blame or release other things from suspicion and concern.

The Prisma software can be a bit overwhelming, but it is actually exceptionally good for nightly statistics. We all know Oscar is best for looking quickly at all your waveforms. Will make it much easier if you use the link in my signature to set Oscar for Lowenstein data.

PrismaTS software is on ver 5.13.0.13 and make sure you have the latest Oscar version. In the configuration menu of PrismaTS, set therapy overview to 'last therapy day'. That way it will open to the day you want by default, instead of a period which gives period averages for everything. You will want to use these stats to learn about your breathing rhythm and the stability your settings are generating. Lowenstein uses your relative minute volumes to determine breathing and sleeping stability, by checking your resp rate and tidal volumes are stable and within good range. It seems to me a very good indicator. You try move a ramp setting or something else and upset your timing, it will usually show in deep sleep number and stability score.

       
The first screen has all your average timings figured out by the machine which helps to set them, the second stats screen is accessed by clicking on expanded statistics button near the bottom of the page. You will learn to use the pressure stats to fine tune the pressures.

I have found when starting out, if you give a range to the machine and see where it takes you. Then in conjunction with intelligent reading of your signals, you can start tightening the range. Once you regularly match median and P85 across all pressures, you will be near where you should be with pressures and can then decide if you want to add a bit of extra range to keep 95% under control or not.
On a good night all 4 stats columns will be the same and stability score high 90's. Deep sleep periods can be accurately inferred from rMv as well. Lowenstein claims to have lab verified the accuracy of this.

I find it helpful to keep really good notes of all your settings and then highlight any changes in Oscar. I just copy from one day to the next and highlight any changes in bold. I do test a lot of stuff out though. Sometimes I will go to test something and then with a quick search through notes I might find I already tried it 3 months ago, and was a disaster!
   

Looking at your pressures, I am immediately thinking your epap is way too low for that size pressure support. See this a lot with people on too low an epap and using too much epr or pressure support down at these low pressures. Is particularly exasperated if you have flow limitations and low tidal volumes. You will often see the big breaths right before the central, triggering the cycle.

[GoodSleepHunting]

Thank you for helping out!

First, I want to say that I have Prisma 25S-C machines that only have fixed bilevel options (the S and CPAP options). I can't use ranges and see medians over time, and so on.
I remember Lankylefty saying that O2 levels aren't as important as people think because just by looking at the flow limitations and the points in the flow chart where I stop breathing, we can know that the oxygen drops at those places, almost always corresponding 1/1. However, I'm open to buying new equipment that could provide more data, but I'm already overwhelmed as it is, to be honest, with all the uploading every morning, tracing, changing, etc.

I have two nights' data here and a few simple questions. After this, I will try some more settings for longer and then come back with the results.
But i kind of know gerealy what i need to look for, I will slowly increase IPAP till i come to the point of high CA score, to know my limits, 9.5 with ramp2 already gave me more of them than 9 with ramp 3. Also, it seems to me that Oscar is showing me EPAP of 4.5 when it should be 5 which makes me wonder.

In pic 1 - I set IPAP to 9 and EPAP to 4, with a ramp of 3. The flow rate would look good to most people, and AHI shows a very low score. But if you zoom in, you will see a lot of messy patterns. For example, with settings like this, it seems I can sleep for 8-9 hours and still wake up tired as hell. I don't know why. It seems to me that when IPAP isn't too high, like 11 or 12, if I wake up during the night, I will not wake up alert. I will feel drained. Sometimes with higher IPAPs, I will wake up after 4 hours, and I will take the mask and chinstrap off because they bother me much more. This shows me I'm not as drained, but I still want to sleep more. However, it's harder to go back to bed with all the gear, so compliance is an issue for me. You know, having tape over your mouth, a chinstrap, a mask, and sometimes a backpack can be too much.
   

In pic 2, I uploaded the settings from the Prisma TS program. I don't know why, but if I miss a day of uploading, it will not upload previous nights' data, only the night before, which annoys me.
   


I want to ask about the pointy ends in my breathing. I know that flat tops indicate flow limitations and that I probably need more pressure. I also know that when I have 2-3 points, it might indicate snoring. But I don't know what a single spike, rather than a rounded top, means when it's consistent in my breaths. Is it something about Ti being too high or too low?

Thank you for your help!

[SarcasticDave94]

I know regardless of machine, most adults will feel air starved and feel that therapy was less successful when starting at 4 or so. You might consider moving that up to 5 or somewhat higher, just to get a better airflow base. I'm getting this 4 from the data, of which OSCAR charts only displays what the machine recorded, and it did include a short span of 4 at the startup. 5 may be even too low for you.

I'm always a bit skeptical of those that disregard O2 info as being totally useless, because it can be an indicator of issues. LeftyLanky has good info, and there's some I'll disagree with as well. It's your therapy, so if you want to include O2 info, that's fine by me.

I'll let others comment on other aspects, like the chart pattern.

[Macka]

Will be helpful if you can collapse the calendar and rig Oscar to display more signals like tidal volume and resp rate. If you wanted to share your prisma file through dropbox or google drive can have a detailed look.

Your charts look pretty good but I can see you have a bit of a mess during likely EM periods. This is where S mode is hurting you. Your only option in this mode, is to increase pressure to cover those periods. I also believe the centrals and periodic breathing are often caused by too much pressure support with low epap. Often exasperated by flow limitations. I think you need more epap or peep. Have you tried bisoft 1 or 2? They allow you to keep the low epap but apply a gentle rise up to eepap before inhalation which can keep the alveolar airways from collapsing and help greatly with oxygenation.

Cannot tell how the inhalation shapes are being affected by your timing choices or the flowrates, from that zoom level. Need a clip of about 1:15 min of breathing from a nice flat section.
See if you can show more signal charts by shrinking them up a bit like this example below

[Deborah K.]

It will help us help you if you set your Oscar up to show the following items, in the order listed:

Event Flags
Flow Rate
Pressure
Leak Rate
Flow Limits

We need to see to the very bottom of the Flow Limits, and nothing more on that page.  As someone else indicated, remove the calendar.  That allows us to see more important things shown below.