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[Pressure] Lower Pressure, Lower Obstructive Apneas?
#1
Lower Pressure, Lower Obstructive Apneas?
Hello,

Why does lowering the IPAP decrease Obstructive Apnea events?? How do I reduce periodic breathing related hyponeas?

I have been using an Auto BiPap for two and a half months. It is a SleepStation Auto-BiPap with Humidifer and a DreamWear Full Face Mask. While I was in AFIB for most of the time (now out), I don't have any other heart issues.

For the first month I used the Sleep Clinic's settings of 6" to 16" with it set to operate only as a Auto CPAP -- no bi-level functionally. Once I got used to the system I found I rarely an AHI of less than 10 and averaged around 15. I usually woke up whenever the pressures hit above 12.5 so it rarely got higher that that.

After studying online data and this board I started adjusting the settings on the CPAP. First I lowered the max pressure to 12.5 -- if it woke me up it wasn't going to work.

A that point I was sleeping better but still having a lot of obstructive apneas along with a huge amount of periodic breathing. During the pauses of the periodic breathing I was experience large numbers of hypopneas and a few central apeneas (it seems almost random what is assigned which). I still was well above an AHI of 10.

Then I moved the minimum pressure up from 6" to 8.5". Using OSCAR it seemed that seemed to be the sweet spot to prevent starting an apnea series. With that changed I ended up with an average AHI below 10 and often hitting and AHI of 5-7 but sometimes hitting 12. Obstructive apneas were lower, but still prevalent, and CA/HP events were high.

The results were all over the place. Some nights around and AHI of 5, other nights around 20.

Finally I set it up to operate in true BiPAP mode. Here I found something that was very different from the typical tritation protocols -- my OAs dropped substantially when I LOWERED IPAP. I started regularly achieving an AHI under 5 -- although hypotenuses during periodic breathing often pushed it into the mid teens. In fact I dropped my IPAP to 5" and experience very only a couple of OAs a night.

At this point OAs were well under control, but periodic breathing hypopneas were vary different night to night.

At this point I'm at a minimum of 5.5IPAP and a minimum 8.5EPAP. Rarely does the auto setting increase either, but sometimes the EPAP is increased up to a 90% of 10" with the IPAP staying at minimum.

So, the questions I have is this:

Why did lowering IPAP reduce OAs contrary to every tritation protocol?

How do I lower my periodic breathing and related Hypotenuses? These really change from night to night. Sometimes almost non-existent and proving an AHI of 0.7-2.5, other times I see a HUGE increase in periodic breathing and realted hypopneas/CAs that pushes my AHI to 10-15.

My SPO2 rarely goes below 90% and averages 94%-95%.

Is the periodic breathing and related hypotenuses actually a problem? Are they position related or might they have to do with other things as they vary so much from night to night?
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#2
RE: Lower Pressure, Lower Obstructive Apneas?
Welcome to the forum



Let's see what it looks like. Post some Daily charts so we can see what is happening, closeups of the PB also.

It is EPAP pressures that manage OA, and we need to see your charts to see what is happening.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Soft Cervical Collar
Mask Primer
Dealing with a DME
Organize Charts
Attaching Charts

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#3
RE: Lower Pressure, Lower Obstructive Apneas?
Well I totally botched that post but swapping IPEP and EPAP. Below is the corrected version.

Net-net, lowing EPAP decreased Obstructive Apneas while I'm still battling hypopneas realated to pauses in periodic breathing.

I'll post some images shortly.

Current settings are:

Machine Settings
 
     PAP Mode:Auto Bi-Level (Variable PS)
     Min EPAP:5.00 cmH2O
     Max IPAP:12.00 cmH2O
     PS Min: 3.50 cmH2O
     PS Max: 7.00 cmH2O

Lower Pressure, Lower Obstructive Apneas?
Hello,

Why does lowering the EPAP decrease Obstructive Apnea events?? How do I reduce periodic breathing related hyponeas?

I have been using an Auto BiPap for two and a half months. It is a SleepStation Auto-BiPap with Humidifer and a DreamWear Full Face Mask. While I was in AFIB for most of the time (now out), I don't have any other heart issues.

For the first month I used the Sleep Clinic's settings of 6" to 16" with it set to operate only as a Auto CPAP -- no bi-level functionally. Once I got used to the system I found I rarely an AHI of less than 10 and averaged around 15. I usually woke up whenever the pressures hit above 12.5 so it rarely got higher that that.

After studying online data and this board I started adjusting the settings on the CPAP. First I lowered the max pressure to 12.5 -- if it woke me up it wasn't going to work.

A that point I was sleeping better but still having a lot of obstructive apneas along with a huge amount of periodic breathing. During the pauses of the periodic breathing I was experience large numbers of hypopneas and a few central apeneas (it seems almost random what is assigned which). I still was well above an AHI of 10.

Then I moved the minimum pressure up from 6" to 8.5". Using OSCAR it seemed that seemed to be the sweet spot to prevent starting an apnea series. With that changed I ended up with an average AHI below 10 and often hitting and AHI of 5-7 but sometimes hitting 12. Obstructive apneas were lower, but still prevalent, and CA/HP events were high.

The results were all over the place. Some nights around and AHI of 5, other nights around 20.

Finally I set it up to operate in true BiPAP mode. Here I found something that was very different from the typical tritation protocols -- my OAs dropped substantially when I LOWERED EPAP. I started regularly achieving an AHI under 5 -- although hypotenuses during periodic breathing often pushed it into the mid teens. In fact I dropped my EPAP to 5" and experience very only a couple of OAs a night.

At this point OAs were well under control, but periodic breathing hypopneas were very different night to night.

At this point I'm at a minimum of 5.5EPAP and a minimum 8.5IPAP. Rarely does the auto setting increase either, but sometimes the EPAP is increased up to a 90% of 10" with the IPAP staying at minimum.

So, the questions I have is this:

Why did lowering EPAP reduce OAs contrary to every tritation protocol?

How do I lower my periodic breathing and related Hypotenuses? These really change from night to night. Sometimes almost non-existent and proving an AHI of 0.7-2.5, other times I see a HUGE increase in periodic breathing and realted hypopneas/CAs that pushes my AHI to 10-15.

My SPO2 rarely goes below 90% and averages 94%-95%.

Is the periodic breathing and related hypotenuses actually a problem? Are they position related or might they have to do with other things as they vary so much from night to night?
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#4
RE: Lower Pressure, Lower Obstructive Apneas?
Here is Last night:



   

A sample of the periodic breathing with Centeral hypopneas, sometimes they are labled Hypopneas. These are really driving up my AHI. I can't seem to control them. Most of the time these come out as



   

Here is the prior night with the same settings. It was almost a perfect night while last night was very different.

   

Here is the BIG picture

[attachment=16163]


Attached Files Thumbnail(s)
   
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#5
RE: Lower Pressure, Lower Obstructive Apneas?
The left Sidebar contains very important information.  See what the Organization link in my signature says.

The overview chart shows a great deal of variability in both obstructive as well as Central numbers.  

The closeup of the periodic breathing episode does show CSR, Cheyne-Stokes respiration.  The common association with CSR is with CHF Congestive Heart Failure.  This does not mean that you have CHF, It does mean that you should make this condition known to your cardiac, sleep, and general doctors.  Does this pattern occur on many nights?  Do you have any heart and/or lung conditions?

This is typically is caused by your pCO2 cycling around your body's trigger point for breathing.  Your bodies chemoreceptors reacting to this control your bodies major drive to breathe.  When your pCO2 goes high your breathing drive increases. when your pCO2 goes low your breathing drive decreases eventually resulting in a Central Apnea, in this pattern, this happens gradually resulting in the waxing and waning characteristic of CSR.  What caused this to happen? I don't know.  

Because you chose to isolate all the other charts I cannot tell what is happening to pressure here.  I want to see Mask Pressure and pressure (OK your pressure settings were constant) because what is happening to pressure support may be important. I also would like to see what is happening wit both tidal volume and minute vent. Always include all the charts in the closeup views because they provide context.
Standard charts include Events, Flow Rate, Pressure, Leak Rate, Snore.
Advanced charts include Events, Flow Rate, Mask Pressure, Minute Vent, Tidal Volume, Respiration Rate.

Treatment is typically with an ASV machine, the only member of the CPAP family that actually treats Central Apnea.  The ResMed ASV manages Minute vent to maintain your average minute vent to manage this which it does with modifying the PS on every breath modifying the current minute vent.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Soft Cervical Collar
Mask Primer
Dealing with a DME
Organize Charts
Attaching Charts

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#6
RE: Lower Pressure, Lower Obstructive Apneas?
Also your sleep studies could be important especialy with your Centrals and CSR. Please post redacted full copies of both your diagnostic and titration studies, not just the summaries, so we can see what indications of centrals existed during those studies.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Soft Cervical Collar
Mask Primer
Dealing with a DME
Organize Charts
Attaching Charts

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#7
RE: Lower Pressure, Lower Obstructive Apneas?
Hello,

Thank you for you comments. I'll try to answer all your questions:

The only sleep study I had was an at-home study --  the insurance wouldn't cover an in-clinic session. I did not have a specific clinical tritation done. They put me on the auto CPAP with settings of 6-16 and let the machine tritrate me.

Past that, I have not yet had a follow-up visit yet. They scheduled on at six weeks but I had to reschedule it and the next wasn't available for another six weeks (they're booked solid). That one won't fall for another few weeks yet.  Because of that delay I started to adjust the machine as the initial results were poor and I needed it leveled before I got out of AFIB... as apnea is believed to be the root of what sent me into AFIB.

Now I'm hesitant to see the doctor because I've been tritrating myself.

There are no known  heart or lung issues. My heart has been pretty thoroughly examined and they say it looks really good -- other than the AFIB and the fact that I have a naturally very low heart rate. They may yet do a stress test, but I know from my personal trainer and training that I haven't had any obvious issues at sustained high workloads.

I have been in treatment for AFIB for since June, which caused me to get the sleep study done. Finally last week, with a ten day hospital stay, they managed to get me back in normal rhythm with a cardioversion and on a medication to hopefully keep me that way for a while.



Here are the results of the at-home study:

   

   

   
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#8
RE: Lower Pressure, Lower Obstructive Apneas?
Here are two days back-to-back. One great day and the next not. There seems so little consistency in the results despite all the settings being the same.

I think that is everything you asked for. If not let me know.

   

   
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