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New to Therapy - Starting on BiLevel
#21
RE: New to Therapy - Starting on BiLevel
So I finished my first night of using the machine and suffice to say it wasn't a particularly good night. I'll attach the data, and I apologize if it's hard to read. I kept waking up due to the pressure getting too high and making it really hard for me to breathe. I also made a change to the cycle sensitivity partway through the night because I was having an awfully hard time moving from manual to automatic breathing with the cycle setting as it is by default. With it changed I had a much easier time of things. If this is an issue please let me know, but it seems much nicer to me.

With the overview, I included a closeup of some of the CAs and OAs I had. I don't know how useful it is, but it seemed interesting to me so maybe it's significant? I've never seen straight lines like that of little to no flow rate for such a long time. Could it be that I was breathing through my mouth during those?

Just to provide my own thought process so that it may be corrected if it's mistaken, I have mixed opinions. On one hand, I want to lower the pressure because it lead me to having pretty poor sleep. On the other hand, it seems like it's ramping up so high because I'm having a really rough time breathing during those event. I'm of the opinion that my PS need to be upped and considering how high the pressure was getting, maybe that could even do with increasing?

Also, @Gideon I did reset the setting before messing with anything. I appreciate the tip though!


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#22
RE: New to Therapy - Starting on BiLevel
A few things of note from me, others will have more to comment on...

Both Obstructive and Central events were high enough that they need addressed.

There's some clustering that indicates Positional Apnea, this is corrected by a change to low flatter pillow to reduce head and neck angle or a soft cervical collar. If I'm correct on the Positional issue, no amount of pressure or setting tweaks will overcome this.

Central Apnea need addressed either by lowering PS or increasing trigger and maybe both.

There's some mouth leak patterns at times.

I'd not advise all changes at once or you can't track what changed this or that. Limit it to one. On one hand Centrals are a big issue, but a case can also be made on addressing positional issues.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#23
RE: New to Therapy - Starting on BiLevel
Thanks for the insight Dave.

Do you have any idea what causes positional apneas? I went to an ENT on Tuesday, and they said everything looks fine so it seems weird to me that I'd have positional issues. Is it possible the clustering is just from my intermittent sleep last night? I woke up a lot and seemingly when the apneas occurred was pretty much just when I was asleep from what I can remember at least.

I've drawn some red lines over the flow rate chart. The lines indicate when I roughly remember being awake. From what I'm seeing, the only time I was really asleep and wasn't having issues would have been around 7 AM which strangely enough is the only time here that I don't remember putting the mask on and trying to sleep haha.


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#24
RE: New to Therapy - Starting on BiLevel
The context of positional apnea here is the angle of your neck while sleeping kinks the airway and makes an apnea. This positional apnea is not sleeping on your back or side, as in the positional metric within diagnostic or titration.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#25
RE: New to Therapy - Starting on BiLevel
Positional apnea as we see it is simply that you are tucking your chin to your chest. Doctors see positional as simply back, right, left, front. This is different.
Simply tuck your chin to your chest, think fetal position. Is it harder to breathe? If you are not feeling it place your hand on your chest with you neck in the vee between thumb and forefinger.

This cannot be fixed with any CPAP. It is similar to a garden hose, what happens when you link the hose a little? Flow slows. If you link it hard it stops.

On pressures, to give you a practical experience with the pressures involved.
Get a tall glass and a straw. A large soda from McDonald's will do. Insert the straw to near the bottom. Now the fun part, blow bubbles.



I'll bet you had no issues whatsoever. At 8 inches of depth you exhaled against the maximum pressure your CPAP is capable of, 20 cmw. The point here is for you to realize that all CPAP pressures are really low. This does not mean that you aren't having an issue.

Often times a comfort pressure can be fixed by increasing pressure.
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#26
RE: New to Therapy - Starting on BiLevel
I don't really notice remarkable decrease in airflow when I tuck my chin into my chest? I also don't ever really sleep like that unless it's something I only ever do when I'm unconscious and never wake up that way, which seems kinda unlikely, no?

I understand the assertion that the pressure is low, but I can speak with certainty that it is uncomfortable for me when the pressure gets so high. It is also extremely hard for me to not focus on my breath without a decent degree of pressure support. The big problem I was having was that it wasn't responding to my exhalations well which was making my airway feel restricted and my ears pressured. Once I changed the cycle sensitivity it mostly went away but when I woke up with the pressure at the higher settings it felt like I was being forced to hyperventilate with how much air it was forcing into me which is what I was getting at with the pressure being too high at times causing me to wake up. I would try to fall back asleep but the machine was forcing me to breathe at a really unnatural rate that wasn't allowing me to relax.

I'm still left not really knowing what needs to be adjusted. I'm inclined to decrease the max pressure or increase PS in the hopes that I will be able to remain asleep longer, but that seems contrary to what Dave was mentioning before.
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#27
RE: New to Therapy - Starting on BiLevel
I would not advise increasing pressure support or the CA will increase. You think you're uncomfortable now, but wait till CA get even worse by this ill-advised move. I also think you'd benefit by getting used to PAP therapy during the day when reading, watching TV, or something similar.

Revisit on the Positional Apnea, how tall are your pillows? Using 2 or more? If this is thick, this can be the source.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#28
RE: New to Therapy - Starting on BiLevel
I've used it for a few hours outside of sleep, and I feel pretty comfortable with the settings at their starting point and the cycle sensitivity where it is at this point. It's just when the pressure gets higher during sleep that it seems to become a problem. Should I ramp it up while I'm awake to try and get used to it there too?

I'm not exactly sure the best way to measure the thickness of a pillow, but mine seem to be between 3 and 4 inches without my head on them, so I'd assume with compression they'd be about 2-3 inches? I only ever sleep with one.

Also, I don't think I ever got an explanation on why I have such long periods of little to no flow rate. Is it possible that could be me breathing through my mouth or something? I've seen some other's who have a similar pattern but I don't believe I've seen any last so long. I recognize those are being logged as apneas, but it just seems quite long to me, like I'm seeing some last up to 23 seconds.

Also also, should I be worried that my AHI and stuff are way higher than I've ever seen them? In my in-lab study it was 5.9 and on an at-home WatchPAT it was like 1.7. Would this indicate that the machine is making these worse?
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#29
RE: New to Therapy - Starting on BiLevel
I don't think changing settings for daytime use to get used to a nighttime therapy device make good sense.

A 23 second Apnea isn't unheard of, however I'm not saying you are or are not having a 23 second Apnea. FWIW I had a 90 second Apnea on a diagnostic study. It is possible it's mouth breathing, but I don't remember seeing large areas of mouth breathing pattern on the leak chart.

Are you using smart start? This could be the cause of the blank spaces on the flow rate. If this is on, try turning it off and see if that makes a change.

Likely part of the event increase while on PAP is the Positional and treatment emergent Centrals. You could try a thinner pillow or consider the soft collar.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#30
RE: New to Therapy - Starting on BiLevel
I am using smart start. You're thinking it's turning off in the middle of use or something? That doesn't seem to make sense considering it's still reading a pressure setting during these periods. It also isn't just one that's 23ish seconds. Most of these events look like that from what I'm seeing. The shortest ones I see are roughly 10 seconds long.

I attached a closeup of one of these apnea clusters. You can see that they're all at least 10 seconds or so with longer ones of about 20 seconds. The IPAP is at 10-11 throughout which would imply that the machine is on, right?

Is there no recommendation for adjusting the machine at all? Wouldn't treatment emergent centrals imply that the pressure is too high or that there's too much PS? Maybe I should lower PS to 2? It also doesn't really seem to have helped centrals at all considering it's at 6.24 which is also higher than I've ever had it recorded.


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