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Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?
#1
Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?
26 y.o. male. 160lb
Over the past year I have noticed my sleep is not as restful and generally tired. My AHI after starting CPAP for almost a decade was very low (Pressure ~10) and feeling good. Last year I was put on an APAP after not feeling well rested on CPAP.
I started looking through my data the past year and have 2 concerns; 
Rising AHI (Centrals & hypopneas) and possible periodic breathing

Rising AHI
My AHI has risen to about 4 with frequent days >5 and the higher the number the worse I feel next day. Mostly Centrals and Hypopneas
Hypopneas: They always come with a flow limitation (pics incl). I noticed a good portion of them are preceeded with erratic breathing, I think these are from rolling onto my stomach after filming myself one night and with movement data. Can these be anything else? (Pics included)
Centrals: Always show up when falling asleep or before waking, some during the night. A decent amount come in clusters (pic incl)
(Pics included)
Periodic breathing:
I noticed my flow rate doesn't look like normal data and has a periodic pattern (sometimes more sometimes less pronounced). Rarely do the valleys reach zero but the pattern is visible alot. A couple times the pattern had central apneas at the nodes back to back but its rare. 
(pics included)
Is this periodic breathing? Anyone have an idea whats going on and what can be done to help reduce my AHI and feel better rested?

PICS OF ALL EVENTS: https://imgur.com/gallery/ECO9qN8https://imgur.com/gallery/ECO9qN8ttps://imgur.com/gallery/ECO9qN8

APAP 10-11.6 (For Her Algorithm)
EPR Off
Airsense 10 with Amara View Full Face (mouth breather)
SPo2 avg ~96 most of the night
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#2
RE: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?
For the hypopneas, I usually find that's due to not having enough pressure. So what I would do is look over the history of the past week and check your calculated 95% pressure readings on each of those days. Whatever is your lowest reading, set your minimum pressure to -1.0 below that, so let's say your lowest 95% reading was 8.5, then set your minimum to 7.5. Similarly, for the highest 95% reading you got, then set your max +1.0 above that, say the 95% was 11.0, then set your max to 12.0. Then keep monitoring it over the next week, and if the 95% readings trended higher than before, then keep increasing the max pressure; or if it trended lower, then keep decreasing min pressure; if the both trends happened, then decrease min and increase max pressures. End the changes, once you get to an AHI of less than 5 consistently.

As for the Centrals, that's a bit harder to fix with pressure. As far as I am concerned CA's happen just because your body forgot to breathe, or something prevented it from breathing. If as you observed it could be as a result of you rolling over onto your stomach. Maybe get yourself a body pillow to make the roll over softer? Or you may have other ideas about this.

As for periodic breathing, I wouldn't know what to do about that. I also have periodic breathing occasionally. I don't think it's important enough to worry about. I'd concentrate on fixing the Hyps and CA's first.
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#3
RE: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?
You are having a lot of arousals, most are preceded by flow limits,
You have EPR OFF, Why?
Yo fight the arousal we need the EPR

Set EPR = 2, fulltime.

I expect to see increased CA events and decreased arousal. This is a balancing act.
Your flow rate often shows signs of CO2 induced breathing, this leads me to expect an increase in CA. right now it is the arousal we need to get a handle on.
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#4
RE: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?
most of your events are central so imo it's better to leave epr off, at least until you determine if these are treatment emergent/pressure induced. did you have a sleep study? if so, were your events mostly ca?

some of your charts suggest the possibility of periodic limb movements. your detailed sleep study results (not necessarily the summary) might tell us something about that. otherwise keep it in the back of your mind; if you continue to see similar repetitive patterns in your flow rate, especially after minimizing your ca, you might look into it. you won't be aware of it so audio/video recordings and/or witness reports are necessary to determine if movement is affecting you.

edited to add: after re-reading Gideon's reply, no harm in trying epr, knowing it will likely raise your ca. however, there's a chance the flow limitations are caused by movement, in which case epr won't reduce those.
  Shy   I have no particular qualifications or expertise with respect to the apnea/cpap/sleep related content of my posts beyond my own user experiences and what I've learned from others on this site. Each of us bears the burden of evaluating the validity and applicability of what we read here before acting on it.  
 
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#5
RE: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?
Hi Gideon,

My problem is definitely arousals and I dont notice many true Obstructive or Centrals this past month. Just sh**ty fragmented sleep. My original sleep study noted this too with only hypopneas + RERAS. 

Key point I forgot to mention is when I was a child I had severe asthma, I don't have the best lungs on the market (data shows low to mid 300s tidal volume). 
A few months back when the sh**ty sleep started I had a week where I had severe shortness of breath & a resting HR ~90-100. My doctor thought it was COVID but my test came back inconclusive since it leaked and I was better by the time I got retested as negative so we dont know what happened. A1c blood test for diabetes came as 5.9% which is normal but the max of the normal range before prediabetic, improved my diet.

Over the last few weeks I tried various different pressures and levels of EPR, also tried straight CPAP and analyzed each day after doing research on scoring PSG's.

Last nights settings/regimen gave me the best sleep in weeks!
Changes:
-400mg Magnesium Bisglycinate instead of just 200mg nightly
-Took 3.5mg of Zopiclone (been having to rely on it a couple times a week due to insomnia (sleep onset & after awakenings)
-12-15cmH2O, EPR: Max (3),  Regular Autoset Algorithm

TAKEAWAYS FROM THE LAST MONTHS DATA
-Last night I had about 10 arousals I scored (movements with a break in regular flow pattern) out which became 3 awakenings (2 of them to pee which makes me think theres more that can be optimized)
-Sleep Onset looks a bit delayed, but didnt notice personally last night
-Median flow limit only 0.01 last night, usually around .1 to .15 where higher makes me feel worse
-Minute vent improved & stabilized last night, was usually between low 5's to 6. More unstable minute vent the shittier I feel
-I had 2 periods last night where the breathing was erratic/not regular (Ive noticed these periods throughout the past few weeks (the least last night) and during them my heart rate and Spo2 fluctuate)
-The more periods of stable breathing and Spo2/HR I have in the night the better I feel the next day is what I notice in my overall data
-Before arousals many times I notice flow rate shapes with flatter tops or the inhale/exhale bounces. No snores picked up during these anomalies

I uploaded a gallery of last nights data. A closeup of a good normal breathing pattern, all the arousals & the 2 periods of weird breathing (maybe REM?). The description of each screenshot is in the name. All these pictures are from last night

https://imgur.com/a/9DiDEWb

Can you check the screen shots and suggest what I can do to make my therapy better? 
Do I need a new type of machine such as a BiPAP (consider lung isses)? 
Is UARS a possibility? What should I look out for when looking for UARS?
Any possibility of unknown heart issues causing my sleep issues? 
I had some skipped beats while exercising so my doctor ordered a 48hr holter (My BP is normal most days 120/80, 75bpm, but higher on days my sleep is bad)

Sorry for the long post but Ive found alot of useful data this past month!
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#6
RE: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?
Anyone got any suggestions of whats going on and what I can do to improve my sleep?
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#7
RE: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?
I would say you're probably right on the REM side of things.

I don't see anything that would suggest a need (at this stage) for BiPAP, and any heart issues, that's something you'll have to speak to the cardio about (those 48hrs are not too bad... but having your blood pressure taken every 20 minutes for 24 hours? 0/10 >.< ).

Really, I think you need to give yourself a few days on one specific set of settings, let your system adjust to that, and then carry out the comparison. One night is just one night, and apnea (especially centrals) can be inconsistent in the short term. Your FLs look pretty good, but your movement is all over the place, and I'd possibly want to be looking at if something movement-y is causing your exhaustion.


See my comparison of Viatom/Wellue and CMS50F oximeters here.

Not a doctor, definitely not your doctor, all advice is given as-is and represents simply my own understanding as a fellow patient and OSCAR user.
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#8
RE: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?
The flow limits are looking good and I don't see UARS as being an issue. Neither do I see a cause for your arousals.
I would like to see a trial at a higher PS to see if it will help but your machine is not capable. Any chance you have one you can borrow.
While your pressure is fairly stable all APAPs vary pressure and often change pressure when sending anything. Please include pressure in your charts and flow limits too.
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#9
RE: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?
Given the centrals and oscillating flow rates in the early post, I'm impressed with how much better you did at EPR 3. Pressure seems very stable and there is not much I see that should be done any differently.
Sleeprider
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#10
RE: Is this Periodic Breathing & How can I Improve AHI (Centrals & Hypopneas)?
your flow limitation stats are very good but some people are more sensitive to them than others and some or all of your arousals are preceded by them. we all have arousals though and those in your screenshots aren't clearly awakenings (no mask-offs for example). still, they're enough to prompt you to ask about them. in the absence of other explanations, while it's not definitive, your last screenshot (possible 3rd rem period?) might be showing subtle leg movements at about 30 second intervals. I notice your charts include 'movement' at 9 for the 95%tile and 48 for the 99%tile. where does the 'movement' measurement come from, what's it measuring exactly and how significant are the 9 and 48 values?
  Shy   I have no particular qualifications or expertise with respect to the apnea/cpap/sleep related content of my posts beyond my own user experiences and what I've learned from others on this site. Each of us bears the burden of evaluating the validity and applicability of what we read here before acting on it.  
 
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