New to Therapy - Starting on BiLevel

[Zeliox]

I finally had decent adherence last night and it seems the results are again much better than they were with my previous settings.

My biggest problem now seems to be hypopneas. Many of the CAs logged to me appear to be miscategorized instances of either REM or aroused breathing. I don't know if treating the hypopneas would actually impact my energy, but I plan on trying VAuto mode again but with a min EPAP of 4 and max IPAP of 6 and a PS of 1 just to see if that is able to treat the hypopneas without bringing back what seem to have been a whole host of treatment-emergent problems. If I don't see improvement in my energy at these lower settings then I strongly suspect my issue may be more neurological, like idiopathic hypersomnia, and I'll have to stick with the device for a while to be able to showcase to a doctor that the therapy doesn't seem to be doing much I guess, but I really hope these setting will be capable of allowing me to lead a more normal life.

I also purchased an f30i to try out since I keep having problems with air leaking past my tongue into my mouth and waking me up as I fall asleep. I'm hoping this'll help with that and maybe imrpove my adherence.

[Dormeo]

"Many of the CAs logged to me appear to be miscategorized instances of either REM or aroused breathing." CAs are just a cessation of breathing for 10 seconds or longer without airway resistance. But you may certainly choose to ignore them if they follow arousal breathing or occur in some other special context.

Your hypopnea index is under 1. To the extent that we can draw conclusions from your limited treatment time during the night, I wouldn't describe that as a problem.

The "weird" breathing you noted in an earlier post is a bit of periodic breathing. Nothing to worry about. Some deeper breaths wash out some CO2, which results in smaller breaths, which then raise CO2, producing larger breaths. Rinse and repeat.

You haven't mentioned hypersomnia before. Why do you think you might have it?

I hope you'll learn to keep the mask on and give your current settings a decent trial before you start worrying about other possibilities. Unexplained arousals are difficult to deal with, because their cause is unknown, so this will take some patience.

[Zeliox]

There are hypopneas that aren't being logged. There are some examples attached and these are rather frequent throughout the night. From everything I've seen, the plateau shape of the curve as well as the dips in the middle of the peaks are fairly clear indications of hypopneas which could be indicative of something like UARs which can be hard to trigger detection on a machine such as this but still can lead to great consequences when it comes to restful sleep and daytime fatigue. This is why I want to increase pressure support minorly since that seems to be helpful in these cases.

I think it's fair to say they are miscategorized CAs, as in a clinical setting CAs such as these wouldn't be counted if they aren't causing an arousal or are part of otherwise normal breathing patterns during REM or otherwise aroused periods. It's normal for people who have already experienced an arousal or are in REM to have periods of breath cessation that aren't concerning. The only reason these things are a problem are if they're lowering your blood oxygen content or are causing an arousal at least as far as I'm aware so it doesn't really seem like an issue if the likelihood is that they aren't. This is a good video I found discussing this if you're interested. https://youtu.be/gR6o5XT3O6I

Hypersomnia and narcolepsy have been a concern of mine long before I began this treatment or had my sleep study done in August. I just didn't bring it up because I didn't think it was relevant here. I'm kinda just journaling my experience if nothing else at this point so I figured I'd mention it since it seems like I'm in semi-uncharted territory considering how much misinterpretation there was surrounding my issues in the beginning. I just want this up so maybe someone with a similar problem may find this in the future. I've been searching for the cause to my severe daytime fatigue and restless sleep for a long time now and have spoken with many doctors, and idiopathic hypersomnia and narcolepsy are a potential explanation given my history and symptoms but obviously something like UARs or sleep apnea would be preferable and worth exploring.

I think adhering to the mask for 6 hours with only a few interruptions is pretty decent. I also think 3 nights on it with clear patterns in flow rate in each is a good sample size to move forward. It's clear the treatment at a pressure of 4 isn't causing issues and positional apnea seems pretty clearly ruled out at this point. I don't see a reason to try to stick it out more when I can see problems that can be fixed. It's not like you start over on acclimation when you adjust some settings especially when it's such a minor change. That at least has not been my experience thus far. I've not even been using the machine for a week yet. It seems like pretty alright progress from what I've seen to be able to use it as consistently as I am.

[SarcasticDave94]

Your assumption that CA don't count if an arousal isn't present is not entirely accurate. On any other machine than a BPAP with backup rate, I'll have CA frequently. Same on a diagnostic. And mine don't always include arousals, in fact most of mine don't. I'm still waiting on my new detailed diagnosic from last week, so I have to refer back to one in '17. 124 CA but few if any arousal. On the Obstructive events, yes I had arousals then.

If you're concerned about Hypopnea, to address them, pressure goes up. I'm not saying your levels require it, but that's how PAP works on Hypopnea. I say pressure because at 4, the only direction is up.

As for Positional, I see a cluster of Hypopnea. OK it's just one in this latest OSCAR.

[Dormeo]

From the wiki: hypopnea involves "overly shallow breathing on the order of 30-50% of normal respiration or an abnormally low respiratory rate. This differs from apnea in that there remains some flow of air. Hypopnea events may happen while asleep or while awake." So for context we'd need to see what your normal respiration rate or flow rate was before determining whether something was an hypopnea. If this is an abnormality of your sleep, we'd also need to know whether you were awake or asleep during the periods of time you provided the zoom-ins for.

The experts on this forum often recommend an increase in pressure support for hypopnea as well as for flow limitation.

[Zeliox]

I know that pressure increase and pressure support is recommended, which is why I said I will be increasing PS to 1 and upping the pressure slightly to a max of 6. Since it seems that at 8 I begin to experience a significant degree of treatment-emergent problems it seems like a bad idea to go much higher for now. Also, I posted a glimpse of my sleep study in one of my initial posts. I have a history of hypopneas so I feel fairly confident in saying that these are those. I sadly wasn't provided with a flow rate chart from my sleep study, but I don't know that that's really necessary when these look like fairly textbook hypopneas from what I can tell.

@Dave - I'm not sure where you're seeing the clustered hypopneas? The machine is logging very few the last 3 nights in general. Otherwise, if I look through the report myself, the ones that I see which aren't being logged are spaced pretty regularly throughout my sleep so I'm unsure what you're referencing but I'm open to hearing it in case I'm missing something. This seems much more indicative of something like UARs vs positional apnea to me though from everything that I've seen about both.

Also, I didn't say CAs were only problematic with arousals, but also oxygen desaturation. If I'm wrong I'd be happy to hear what the exact diagnostic reasoning is, but the source that I provided backs up what I said as far as I'm aware. It's my understanding that something can technically be flagged as a CA if you just breathe deeply while you're experiencing REM for instance, which leads you to not breathe for a significant amount of time. This wouldn't cause oxygen desaturation nor an arousal and would also be considered normal behavior; thus, it wouldn't be considered diagnostically significant. When I look at the flow rate before these CAs that were logged, there is behaviour potentially indicative of REM or aroused breathing meaning that this would likely be normal and not concerning which was my whole point. This on top of the fact that both the in-lab study and the at-home test I had done show no centrals at all causes me to believe these aren't concerning. If I'm wrong I'd really love to know why.

[SarcasticDave94]

Your last not zoomed chart has 2 Hypopnea next to each other. Yeah maybe it's just a cluster of 2 events, but there it is.

[attachment=36228]

[Zeliox]

I feel like you must be joking. I don't think anyone would seriously look at that and consider that as diagnostically significant for positional apnea.

[SarcasticDave94]

That's fine, ok this is only 2 events, one after the other, it's barely a cluster of any shape or form, ok great.

I do think the trend showing on this thread, however, is nothing from PAP is going to help you very much. Pressure that's higher than 8 bothers you, then low pressure isn't doing much to help either. For some, there's other health causes for poor sleep that should be pursued.

[Zeliox]

I recognize that PAP therapy may not be effective and I even discussed this before. I also get where you were coming from before when I had all those apneas at a higher setting but I respectfully disagree in light of the more recent findings and I believe I've explained why well previously. There are conditions that can be treated with lower pressure settings and PS values so I think it's valuable to explore those settings before moving on.