Sierra

Welcome to the forum. Your clear airway apnea is over 4, and your obstructive apnea is zero. Also for the most part your pressures are quite low. That is a bit unusual. How long have you been on a CPAP? Do you know what your AHI was at diagnosis, and the breakdown of central and obstructive events?

I am assuming from what I see that you have EPR turned off? Are you using the ramp function? In Auto?

If you are comfortable with adjusting your own pressures my suggestion would be to significantly reduce the maximum pressure. It is currently at 14 cm. As a test I would set it at 6 cm, so you have a minimum of 5 cm and a maximum of 6 cm. The objective would be to see if that reduces the central events, and if it results in an acceptable amount of obstructive events. If you are not comfortable with adjusting your own machine, then I would ask your provider to do that after a discussion with them as to what they think the problem is. If you are comfortable adjusting your own machine, but need help, just ask.

Some suggestions to improve the SleepyHead layout:

• I would get rid of that menu bar on the right. It just takes up valuable screen space. Just press F10 on a PC.

• Hide the month calendar. Just click on the little triangle to the left of the day specific bar. That will allow more detail to show on the left

• Last, get rid of the pie chart. Without it more detail will show on the left sidebar. Use File, Preferences, Appearance, and just uncheck the box that says display pie chart.

• Also it would be nice to see your flow limitation and snore graphs on the screen too. Just click and drag on the gray bars between the graphs to scrunch the size of them down a bit. What is currently puzzling is that something is driving up your pressure but it does not appear to be OA events. Snore and flow limitations can drive up pressure though.

With those changes more of your machine setup and results will show, and there will be more room for the graph detail. The rest of your screen shot is great though. Very clear.

What I like to do, when using SleepyHead is just mouse over the OA events in the flagging bar while watching the pressure chart and in particular the numbers just above the left end of the Pressure chart that give the EPAP and IPAP where the cursor line is located. This will let you either mentally or by taking notes on a piece of paper identify what the pressure was just BEFORE the event occurred. It is not a perfect process but when I have a new pressure in mind, I keep track of how many of those events potentially may have been avoided with the higher pressure.

I tried to do that by eye with your charts, and as close as I can see, I would agree with you about changing the set pressures to 9.5 min and 11 max to try it. I think you may prevent a few OA events.

It is really encouraging to see that you got zero CA events. It would seem that preventing pressure from going above 11 cm may be preventing their occurrence.

The leak rate at times is a bit high, but overall this is so much better than where you started. For now I think the only change needed would be a 9.5 cm for a minimum.

First welcome to the forum!

The need for it kind of depends on your climate and home heating system, and also your desire for something simple to set up and get working. The normal humidifier is controlled by supplying more or less heat to the bottom of the water reservoir. You can manually set the humidity. If you set the humidity level high, and your room is cool, then the humidity can condense in the tube and collect water which can in turn collect in your mask and be pretty annoying. It is sometimes called rainout. If you can locate your machine at or a bit below head level and have the hose go up, then this water will tend to run back into the machine instead of into your mask. Another solution is to buy or make an insulating cover (cosy) for your hose which helps to keep it warmer and avoid condensation. This all assumes the standard non heated hose. However if you buy the heated hose and your machine has the features like the ResMed does, then it will detect the hose and automatically control the humidity to make it comfortable and avoid rainout. You also then get the ability to set your air temperature which is controlled by the hose heating. It has a temperature detector at the mask end of the hose to determine what actual temperature is. Normal set point is about 27 deg. C.

One advantage of a CPAP is that it reports back to you daily what your residual apnea is. And, you can look at your detailed results in a free software program called SleepyHead. I am not any kind of medical professional so can't give you any advice on that subject as to which would be better.

I see in the UK that the normal practice seems to be that you buy the CPAP through your National Health Services with the machine coming direct from the manufacturer? Not sure if that is the cheapest option but I see on the UK Amazon site that a good machine sells for £700.00. That is certainly cheaper than the surgery cost. But, yes you may have to use a CPAP for life. Another option to investigate is the dental appliance route for sleep apnea. Some dentists specialize in it, and would be able to give you a price. In Canada that is not a cheap option though, and you are always left wondering how effective it is, as you do not get any reporting from it other than your subjective feeling.

In any case if you decide to go the CPAP route, I would suggest the Auto machine and in particular this one:

ResMed AirSense 10 Autoset

If you have any questions about the CPAP route just ask.

Using the ramp can improve going to sleep comfort if you are finding the minimum treatment pressure uncomfortable. If you need to go higher than 9 cm it may become more valuable to you. If you are going to use it I would suggest a ramp start pressure of about 6-7 cm, whatever feels comfortable to you. I like a pressure that feels like I am wearing no mask at all that is restricting my flow. If you don't set the ramp start pressure the machine will likely default to 4 cm, which I find much too low for comfort. As for time 15-20 minutes works for most. Ideally you want it to be at the minimum pressure by the time you go to sleep. Using the ramp will not affect the treatment effectiveness, and you should see the ramp effect in SleepyHead.

The Bi-Flex is a little more complicated, and I was leaving that aside until you got your basic pressures zoned in. On the ResMed machines it is a little simpler and it does affect your treatment effectiveness and the basic pressures you need. It works essentially like pressure support but in the opposite direction. It reduces pressure on exhale to make it easier to breathe out. A setting of 1, 2, or 3 is simply the number of cm it reduces pressure. ResMed call it EPR or Expiratory Pressure Relief. The problem with EPR is that it can increase apnea events due to the reduced pressure during EPAP. If the machine is in automatic mode, then it in turn causes pressure to go up, so you go full circle. For that reason using EPR on a ResMed is not a great idea unless you only use it during the ramp, which is what I do.

Bi-Flex is as I say more complicated. To my knowledge there is no way to set it so it is used during the ramp only, so you have it full time or not at all. The 1,2,3 setting is not really cm of pressure reduction like the EPR, but more like, a little effect, medium effect, and more effect. That is because Respironics do not reduce the pressure for the full exhale cycle. They mainly smooth the transition from Inhale to Exhale and vice versa. I have not seen it documented, but it is my personal theory that Flex does not impact treatment to the same degree as EPR does. However, some do think it has an impact on effectiveness. Here is a link to what looks like a quite old (2009?) document on their Flex technology.

Respironics Flex Technology

This document shows how it affects the shape of the inhale exhale pressure. To my eye the affect is very minor, but Respironics have done studies which are claimed to show that users like how it feels to them.

So what does that mean for you? Again I think it is worthwhile to stay the course with optimizing the basic min max pressure settings first. When that seems to be working and you have a good baseline on what you can achieve for AHI it would not hurt to try the Bi-Flex at the various settings to see what it does to improve comfort for you. If it does nothing for comfort then just leave it turned off. If you feel it has improved comfort then leave it at the most comfortable setting and try it for a while to see if it has any negative impact on AHI. The objective is not only to get a low AHI but also equally important to get a long uninterrupted sleep. If the Flex can help get your there with no impact or very minimal impact on AHI I see no reason not to use it.

On the issue of comfort, are you using a timed ramp? Do you have a ramp start pressure set? These settings should be in the Comfort section of the setup menu. And also in the Comfort section of setup do you see a setting for Bi-Flex or Bi-Flex Comfort? Is it turned on or off and if on what is it set at?

As I think about it, in the interest of trying to get you to the point of being comfortable through the night you may want to set the maximum pressure at 11 cm now. So that would be a minimum of 9 cm and max of 11 cm. If you can make it through the night with that lower and tighter setting, then we may be able to see if that is close to what will work for you in the longer term. If your AHI suffers then we will be able to see at what pressure and whether OA or CA is the bigger issue.

I think what we know now is that 8 cm is too low, and 11 cm may be too high. No problem trying 9 cm. I had picked 11 cm based on what the machine was doing itself in auto. At some point if you can find a pressure that is effective on the OA events, without causing you discomfort and without causing CA events then you may be pretty much there. Ideally you want to find a pressure you can tolerate all night and get a good sleep with. At that point the next step may be to start bringing the maximum pressure down to be about 1 cm higher than the minimum. That will prevent the machine from getting carried away and bringing pressure up too high.

This may take some time, and if there is no magic in between number then it may be time to try the pressure support (phase 2).

I wish you luck with the F20. I could not use it past about 4 nights or so. It started to irritate the bridge of the my nose and I was still having trouble with leaks. If you still have the mask liner things, that might help you some. I never did try that.

Oh, and on the periodic breathing issue, it does appear to be the control system instability issue. Your event seems to have started with an obstructive apnea which is like the sudden hill for the cruise control analogy. The upset it caused initiated a cycle in the breathing effort. In your case it is not pronounced enough to have caused a central apnea, only a hypopnea. I believe that is a good example of a hypopnea being a central event that did not go to full stoppage of breathing.

I would hope it is not serious as in comparison my periodic breathing is more fully developed, and I would suggest a little more serious looking... Something to watch, but not panic over in my opinion.