Sierra

On falling asleep one of the very minor things I do is set my machine to warm up. I then starts heating up the humidifier reservoir. It is a menu item on the User menu. I also try to avoid napping during the day to build up sleep demand, and also try to avoid averaging more than 7-8 hours a night sleep, with 7.5 being about ideal for me.

On the event that woke you up, it looks like a standard obstructive apnea and was preceded by a hypopnea event. Your Flow Limitation was not all that high at the time. Your machine responded with an increase in pressure, but of course by the time the event happens it is too late to prevent it. That is a good illustration of why a higher minimum pressure is helpful. Perhaps if you minimum was set at 16 cm, the event would have been avoided. But it is a little early for that conclusion yet.

Not sure what is happening with the respiratory rate being clipped. Perhaps the A10 does not report anything higher than 50, or OSCAR has a bug in reporting it. The real concern is that you are having the Tachypnea type breathing which is rapid and shallow. Notice that your tidal volume goes down when the breathing rate goes up. Definitely something to discuss with your doctor. The good news is that it is about the only abnormality left on your sleep report. It may be possible that use of EPR full time could reduce this type of breathing, but it is a bit early to try that. If things settle out with these low AHI numbers, you may want to try EPR at 1 cm to see if that helps, and then 2 cm. I only use 2 cm, but it seems to help me a lot in reducing hypopnea.

If these low AHI numbers hold up with more nights like this, it would appear there is no justification for a BiPAP machine. If you add back the EPR, pressure may need to be increased some, but probably not as high as 20.

The time thing I believe is a design problem with the ResMed AirSense machines. I have found you can advance the time, but you can't set it back. Right now I am running 1 hour ahead, because I can't set it back. I have researched it a few times, and if you find a solution let me know. But, I think the only way may be to do a full factory reset, which means you lose all your data stored in the machine, and you have to do a full set up of all your pressure settings etc... While you will not lose your data that is stored in OSCAR you will lose whatever is in the machine memory. I have never thought it was worth it, so I live with the time error. ResMed have released an AirSense 11 machine, and I would hope they would have fixed this time issue. There should be an easy way to switch between daylight savings and standard time, or even do it automatically. They are way behind the time on this issue!

The leak rate chart looks good now. On the start pressure, it may be possible that the 5 cm setting was linked to the Auto PAP mode, and it went back to 5cm when you switched to Auto.

I don't think the 15 cm minimum is too high at least for now. In fixed pressure mode you were using 15, and not getting great outcomes. However, if you can get good AHI numbers with it set at 15 and it never goes up much in Auto, then you could consider lowering it. The advantage of a higher minimum pressure is that it stops events from happening, instead of having events trigger an increase in pressure. When you were running Auto earlier the minimum was 10 cm, and that may have been a reason for Auto not working so well.

One good thing about your readings is that central events don't seem to be an issue. They can make things difficult as more pressure can cause CA events to increase. So you can get into a situation called Complex Apnea where more pressure is needed to stop obstructive events, but at the same time more pressure increases the CA events. In that situation one has to thread the needle and try to find a pressure high enough to stop OAs but not cause excessive CA events. With that issue using fixed pressure CPAP mode can be the best way out. But, you are lucky to not have that issue. The pressure is more of a comfort/leaks thing for you. But, I would leave that for fine tuning a bit later.

Well, that is looking more encouraging! I see your pressure increased slightly and seems to be mainly driven by Flow Limitations. The rapid frequency of OA events is gone, and that is good news, but one night does not prove much yet. The collar may be helping. More nights and time will tell. Yes, most people are more prone to obstructive events when sleeping on their back. I do not try to avoid sleeping on my back, but I have back issues and my back certainly encourages me to sleep on my side more. Some people go to the extreme of sewing a tennis ball into the middle of the back of their PJ's. It sounds cruel to me, but that probably would encourage sleeping on a side rather than their back! I recall from my sleep study that the apnea frequency was slightly higher when sleeping in the back position.

I noticed that your start pressure on the ramp has gone back to 5 cm. If you find that more comfortable that is fine, but most, and especially when there is flow limitation issues, find a higher pressure like 7 to 9 cm can make breathing easier. What I do is take really quick deep breaths and see if I can feel any flow restriction. I increase the start pressure until I can't feel any restriction at all to the quick deep breaths. In my case I found 9 cm to be just right. I don't like that feeling that the machine or mask is restricting the flow of air into my lungs. Kind of gives me a suffocating feeling. The other thing you can do for comfort is set the EPR to 3 cm, but also set it to Ramp Only. Then you will get the help exhaling with the EPR exhale pressure reduction up until the time you go to sleep. Then it will turn off.

Your main AHI score for this night is coming from hypopnea. EPR full time may help that, but I would not try that until you have established a baseline with the machine in Auto, and with the cervical collar.

On the Leak Rate graph I find it helpful to set the leak rate red line. To do that you mouse over the Y-Axis scale and right click to bring p the options, and then click on Dotted Lines. Then check off the Leak Rate Upper Threshold box. That will display the red line on the graph. I don't worry much about the leak rate as long as it is under that line. Under these options I also set the Y Axis to Override with a min of 0 and max of 50. This keeps the relative proportions the same from day to day. Auto Scaling can make things look worse than they really are.

I had a closer look at your OSCAR data and have done a little bit more google research. The first thing I need to say is that I am a retired mechanical engineer and not any kind of medical professional. I draw my experience from reviewing my and my wife's data, and many others from this forum and others. With that context these are my thoughts, in no particular order.

That period of time where you had the very high respiratory rate is likely called Tachypnea or Nocturnal Tachypnea if you were asleep when it happened. It seems to be fairly rare but has been seen in people being treated with a CPAP. Possibly it happens in others, but without a CPAP or titration test equipment, it is never recorded. You can google it, but I am not sure in your case that it has an obvious cause. If you were awake, it could be simple anxiety, and I am not sure one can get anxious when asleep. If it is anxiety there are a number of drugs that can be used, but one should question if they should be used. I have taken an Ativan single pill before cataract surgery to deal with anxiety, but I think using it on an ongoing basis can be addictive. You mentioned Ambien, and that would likely be less addictive, but may have other side effects. I take a beta blocker, bisoprolol, for blood pressure control, but I understand it can be used, off label, to control anxiety as well. If you feel it is anxiety these are things to discuss with your doctor.

The areas flagged by your CPAP as CSR or Cheyne-Stokes Respiration, are more of a concern. I suspect those are quite disruptive to your sleep, and they may be resulting in low blood oxygen levels. You could consider getting an oximeter that clamps on your finger and gives a record of O2 levels during the night. SleepyHead and I believe OSCAR can accept the data from some of these meters so you can correlate events like the CSR flagged times to O2 levels. I believe OSCAR should give you some information on which meters it can accept data from.

With respect to it actually being true Cheyne-Stokes Respiration I am not so sure. Have a look at this simplified illustration comparing CSR to another condition called Biot's. True CSR has a smooth waxing and waning pattern, while Biot's does not. I do not see that in your example. It is more of a sudden increase and then some waning back to nothing.

Here is an example of what I think is true CSR from my personal data back in 2018 when I was having issues with it and central apnea.

Notice the smooth waxing and waning which starts even before the CSR green areas. The other big difference is that you are having obstructive apnea events between each while I am having central apnea events, which is no obstruction, just me not wanting to breath. I don't know much about Biot's other than it is rare, and your pattern does not fit it exactly either. Not sure if it is associated with OA or CA events. I think there is a good possibility that what you have is simply obstructive events with gasping periods for air between each one, and not Biot's either. That would be very disturbing to your sleep.

So this all said, I think for the short term, I would focus on more pressure in auto mode to see if the obstructive events can be prevented with more pressure. If my theory about you gasping for air between each obstruction should stop too, if the obstruction is prevented.

The part about doctors is complicated. I am in Canada and I am sure the overall system is different here. I have just gone to a sleep clinic where they give you a home test kit to take home. They send the results out to some cyber doctor somewhere that is supposed to be qualified to read them. Then they want you to buy a machine for $2400. Since I have no insurance for CPAP, I just bought my machine on line for about $800 and have done everything myself since then.

If you are in a situation where your insurance will cover it, I would try to find a pulmonologist that has sleep apnea experience and show them the results you are getting. If increased pressure does not solve things you need to get to the bottom of what is happening. At some point you may need to get a cardiologist involved too.

But for now give the 15/20 auto pressure setting a try. If it helps but still jams out at 20 cm, then you probably will have to pursue the BiPAP alternative with the hope a bit more than 20 will help. They go up to 25 cm. The extra pressure support from the BiPAP is not looking promising as you did not get a significant improvement with the EPR at 3 cm.

Your test in Auto at 15 min and 20 max should be very informative as to what possibilities there are. The cervical collar is still worth trying too. It may provide relief from the rapid sequencing of obstructive events.

To speed things up so you can get as much information before your appointment on Dec 21, I would suggest going back to the APAP Auto mode. With a minimum pressure of 15 cm and maximum of 20. This is a higher minimum than you were using before and may give better results. When you have a low minimum you can get a lot of events happening before the machine decides to raise the pressure. With Oscar you will be able to see the impact of higher pressures, and determine what you may need.

One issue with EPR is that it lowers your pressure on exhale, and if you are susceptible to having obstructive apnea events on the exhale part off the breathing cycle, it can increase them. I went with EPR on the Ramp Only (which is an option) for a long time and was averaging about 2.8 for AHI. When I went to full time it dropped to my current average AHI which is 0.8. The big change was a reduction in apneas. It seems that adding EPR for me did not increase OA events, but everyone is different. I think for now it is probably best to focus on pressure as a solution and then come back to using EPR as a test when pressure is optimized. There is some logic to using the Auto mode to determine the best pressure and then go back to fixed CPAP mode once you settle on a pressure. That is basically what I did.

In your post you make reference to a "PA". Is that a doctor, and if so what specialty?

Yes, I see what you were talking about with getting the best results with a higher pressure of 16. And I see you have tried APAP mode a couple of times with not great results. For now I think I would try the EPR at 3 cm for another night. One of the issues with adjusting a CPAP it takes some time to see what the result really is. Perhaps the first night with EPR was an outlier.

But, if that does not work, then I would suggest increasing the pressure to 16 cm like you had before and give that a try. The other option would be to put it back into auto with a range of say 13 minimum to 18 max. The advantage of doing the Auto range now that you have OSCAR is that you can see the impact of pressure changes each night. That may help identify the best pressure to use, and then you could switch back to that as a fixed pressure.

I will give you some more detailed thoughts tomorrow. I have probably missed your bedtime for tonight anyway.

It may be worthwhile doing a screenshot of the Statistics page. Normally it will show a new line each time the setting is changed on the machine, along with some basic data for the period of time the setting was used. Not sure how much will be saved there when there was no SD card in it.

You may want to try the AirFit F10 For Her X-Small 63139. See this sizing guide, which I think is the right one for this mask.

https://document.resmed.com/documents/products/mask/airfit-f10/fitting-template/1017454_airfit-f10_fitting-template_row_eng.pdf

Product guide for the mask:

https://document.resmed.com/documents/products/mask/airfit-f10/product-guide/1017251r3_airfit-f10_product-guide_usa_eng.pdf

OK! I was not expecting that. Can you squeeze down the Flow Rate graph height and show the Flow Limitation to see if that changed? Have you tried the soft cervical collar yet?

Have you always been on a fixed pressure? If not then did the Auto mode not work for you? And, how about at a higher pressure. Is 15 cm the most you have used?

It is not going to help your event frequency, but one of the easy things to consider doing for comfort is setting your Ramp Time to Auto. And also your Ramp Start pressure to about 9 cm instead of 5 cm. When set this way it will start you out at 9 cm of pressure which should be more comfortable, and it will hold at that pressure until the machine decides you are asleep (up to a maximum hold of 30 minutes). Then it will ramp up to your set pressure of 15.

That respiratory rate seems a bit odd too. Your flow rate seems high, but perhaps you are taking quick short breaths. Expanding the scale out should provide more info. Compare it to when you are breathing at a more normal rate. Minute ventilation is low and fairly constant as well as Tidal Volume. Seems like you are breathing fast but not accomplishing much air transfer. Again you should ask the sleep specialist about this as well.