Sierra

I have no experience with this N30i mask. The only popping sounds I have experienced from the mask/hose is when I moved my machine while full of water and the water somehow overflowed into the hose. That definitely causes a gurgling/popping sound. Another possibility if you are not using a heated hose is that condensation is collecting in the hose. Using a heated hose generally prevents that. If by any chance the popping sound is coming from the machine, and if the reservoir on the A11 is similar to the A10, I have found it can make popping sounds if the water reservoir is not firmly pushed into the slot. These sound occur with each breath. I suspect the silicone seals inside are flopping around and making the sound.

Yes, I think you are making progress. I would suggest some simple cosmetic things that will help make the OSCAR Daily report a little more useful.

• The little arrow to the left of the data can be clicked to hide the full month calendar which takes up valuable space. It is just a toggle so you can click it again to bring the full month back.
• The pie chart takes up useful space and is kind of redundant as the colored bars right above it have the same data along with the actual number. To hide this pie chart go to File, Preferences, Appearance tab. There uncheck the box that says "Show Event Breakdown Pie Chart".
• I find it helpful to turn on the leak rate redline on the Leak Rate chart. Left click on the vertical scale, Dotted Lines, and then select "Leak Rate Upper Threshold". This gives you a better idea when leak rates are too high. I also click on the y-Axis and set the graph maximum to 50. I this keeps it from auto scaling and making lower leak rates worse than they really are.
• It would also help to move up the Minute Ventilation graph so you can see it when you expand the scale to explore what is happening when CA and H events are occurring.
  

You asked about the seriousness of hypopnea and RERA. I do consider them less harmful than full CA or OA apnea events. The issue with hypopnea events is that they can trigger pressure increases, which in turn can trigger CA events. My thoughts at this point would be to switch to a fixed pressure CPAP mode to see if you can get better results. I think I would start with a lower fixed pressure setting of 9 cm. Keep the EPR in ramp only and set at 3 cm. This would be a trial to see if that reduces CA events without increasing OA events by much. Then if that works, the next step would be to try EPR at full time, and then with increasing amounts of level. Start at 1 cm, 2 cm,... But, first I would try the fixed pressure of 9 cm. It may have to be adjusted a bit before bringing the EPR back into it. My experience is that EPR full time can reduce hypopnea, but I would leave that for now to see what fixed pressure only can achieve.

It is difficult to determine whether or not hypopnea events are central initiated or obstructive initiated. If they are central in nature then increasing pressure in response to them is not helpful. That is the reason for going to fixed pressure CPAP mode. But, if you want to explore, expand the scale before H events occur and see if you can see in cycling in the breathing flow rate pattern. It will also show on the Minute Ventilation graph with it cycling too.

Hope that helps some. Be patient, as I think this will take some time to sort out.

First, it is good that the A11 is now working better. I am not certain the setup for the AutoRamp is quite right yet. You have the display zoomed in somewhat so I can't see the pressures at the start of the night. In any case this is how I would set up the AutoRamp. Here is a rundown on what I would suggest for settings:

Mode - AutoSet Minimum Pressure - 6 cm (but I would suggest trying 7 cm) Maximum Pressure - 10 cm (but you may be able to reduce that after some experience) Ramp Time - Auto Start Pressure - 6 cm (but I would suggest trying 7 cm, Start Pressure cannot be above Minimum Pressure) EPR - On EPR Type - Ramp Only EPR Level - 3 cm

When you have the Ramp Time set to Auto, it will hold the pressure at the Start Pressure level of 6 cm. But as I suggested setting minimum pressure and the Ramp Start at 7 cm may be more comfortable and more effective. With the EPRR on, set to Ramp Only, and the EPR Level at 3 cm, it will reduce the exhale pressure by 3 cm until the auto ramp decides you are asleep (up to a maximum of 30 minutes). However when the Ramp Start and Minimum pressure is at 6 cm, it cannot reduce the pressure any lower than 4 cm as that is the lower limit on the machine. So you will only get an EPR of 2 cm. However if you start at 7 cm, then you will get the full 3 cm EPR. If you move the Mask Pressure graph up you can see the pressure being reduced on each exhale, and then flattening out once you go to sleep. When set up like this it should be easy to breath without restriction while you are going to sleep. I find a higher pressure makes it easier. My Ramp Start pressure is 9 cm. Looking at your results it seems you pressure never goes below 8 cm, so you minimum and Ramp Start could be set as high as 8 cm. That would make breathing easier when going to sleep.

Once you fall asleep the machine will stop reducing the pressure on exhale. The hope is that the pressure will not be as high however, and the pressure does not go so high in auto. The overall object with doing this is to control the OA events without having the pressure go as high. And if the pressure does not go as high, then hopefully the CA events will be reduced too.

If a sweet spot is not achieved, then there is one more adjustment that could be tried. That would be to switch the machine into fixed pressure CPAP mode. Then you adjust the pressure up and down to try and find a sweet spot where both OA and CA frequency is low. But, I would exhaust the settings in Auto first before trying that.

You are obviously taking this very seriously and tracking your results. It reminds me of my early days trying to sort out my issues where I was also using a spreadsheet to track things. If you think things are getting better with respect to central apneas then that is a good sign. They may be treatment induced and are going away. Lets hope! One of the things I have found with my apnea which is about 2/3rds central on most nights, is how erratic it is. In the space of a week I can have a night over 2.0 AHI and another night at 0 AHI. I just take comfort that I am now averaging less than 1.0 for AHI.

I have never tried to correct my AHI for apnea when I am awake instead of sleeping. I think it does happen. Some call it "sleep wake junk". Fortunately I sleep well enough that I have never thought it was significant for me.

On the Cheyne Stokes Respiration I did some checking. It is reported and highlighted in green on the A10 machine and I assume the A11. It appears that feature was not in the S9. However it is easy to recognize by just looking at the flow chart zoomed in right before central events occur. It also helps to put the Minute Ventilation beside the Flow graph. Here is an example of what it looks like. Towards the left there are two events which did not last long enough to be flagged. I suspect they were obstructive events. This disturbs the breathing and you can see the Minute Ventilation gets upset. It settles out and then gets disturbed again. This results in three CA events in a row. When you see that wave in the breathing I am breathing deeper and deeper and then more and more shallow. It can start another cycle or cause a central. In any case that to me is what happens when the breathing control system is unstable. If it repeats enough times it gets flagged as CSR. When the breathing goes in regular cycles like this I believe I am asleep. My thoughts would be to look for times when you are seeing a number of CA events to see if there is any pattern like this. Or, look at the time after an obstructive event to see if breathing starts to cycle.

The AutoRamp on the A10 and A11 is really a hold, rather than a ramp. You select a ramp start pressure and the AutoRamp holds the pressure at that level until you fall asleep, then it ramps up to the minimum pressure. If you don't fall asleep in 30 minutes it ramps the pressure up anyway. I find it a comfortable way to go to sleep as I can set the pressure at what I find comfortable. and not have the pressure ramping while I am still awake.

A quick response to try to catch you tonight. I am pretty sure the issue with the A11 is that it is in the "For Her Auto" mode. If you switch it back to the regular Auto mode it should behave like the S9 if all the settings are the same. That chart you posted showed it controlling pressure early in the night and then going to the max pressure and staying there. However, if you don't want to take a chance on it overnight, then perhaps try it for an afternoon nap.

Your more recent Daily graphs are showing a much higher incidence of CA or central apnea events. Sometimes these events occur when CPAP treatment has been started, and are primarily due to the increased pressure of the CPAP upsetting the breathing control system. In these cases the CSA is called treatment emergent central apnea. In most cases this effect goes away in 6-8 weeks after treatment is started.

In an earlier post you said that your sleep study indicated a very high proportion of CSA events. That is a bit unusual in that no pressure is used during the sleep study test. And the first OSCAR report you posted showed very little CSA which was unusual considering the sleep study outcome. However now you are showing more CSA. This makes me a little less optimistic that minimizing pressure for your treatment may bring your AHI down, or at least the central part of it. You should have a look at the article at the link below to see if any of the causes of central apnea may apply to you. I have seen outcomes from people that live at high altitudes have issues with central apnea for example. There are heart conditions that may lead to central apnea. And there are medications which can cause it as well. The main ones are opiates. I have never taken them, but I do take a beta blocker (bisoprolol) for my blood pressure. It slows the heart rate and at least in my opinion must reduce blood flow rate. Reduced blood flow from heart conditions can cause central apnea. I discussed it with my doctor and convinced him to cut the amount of bisoprolol in half. I think he was skeptical but it did seem to help me. In any case have a read of the article to see if any of the causes may apply.

Central Sleep Apnea and Obstructive Sleep Apnea

The combination of obstructive and central sleep apnea is sometimes called complex apnea. The combination can be tough to deal with. More pressure can reduce the OA events, but cause more CA events. Some sleep clinics push people to move to a BiPAP machine if an APAP (like your S9 or A11) does not work. A BiPAP provides more pressure and more of a differential between inhale and exhale. Neither is really helpful for dealing with central apnea. If you do end up with persistent central apnea that cannot be treated with fine tuning your APAP, you may need to investigate an ASV (Adaptive Servo-Ventilator) with your sleep clinic. I recall you have an upcoming appointment, and that would be a good time to discuss. That said I still hope that there may be opportunity to further reduce your apnea without resorting to that option.

One of the patterns that I see very occasionally (once every month or two) is CSR ( Cheyne-Stokes Respiration). I believe that is associated with poorer blood circulation or perhaps other cardio issues. Here is what it looks like.

If you left click on your graphs repeatedly (or use the arrow keys) you can zoom in on the flow chart to see this level of detail. This may give you some help as to the nature of your central apnea. I click on the left end of the Minute Ventilation chart and move it up near the flow chart to see the relationship. When you see the Minute Ventilation cycling up and down that indicated unstable breathing control.

I hope that helps some. But, I have not given up on you being able to improve things with the machine you have now. The AirSense 11 is not really that much better than the S9 but you could give it a try in standard Auto mode. The biggest advantage of the A10 and A11 is that they have an AutoRamp feature. I see from your OSCAR chart that you must have that turned on. I like it.

Did you get an AHI on the top display when you push the Info button? My wife uses an S9 machine and the one issue I have had occasionally is that the SD card is not fully inserted. The location of the slot and how it works can make it look like it is fully inserted when it is not. When it is fully inserted you should get a "Please Wait- SD card in use...." message that stays up for quite a long time, before it can be used.

If an AHI was recorded you should get some idea how well it worked.

It is really hard to tell exactly when your apnea is happening. You can expand the flow chart until you can see each breath leading up to an obstructive apnea, and see if you can tell when it is happening. On this graph, up is inhale, and down is exhale. An apnea could start at the beginning, end, or during the inhale. I am not sure what that would sound like when you are sleeping. Also keep in mind this only applies to an obstructive apnea event. With a central event, you simply stop breathing with the airway open.

Yes, I would go back to a max pressure of 9 cm in the hope that without EPR your results will improve. Switch the EPR mode to Ramp Only, and leave it set at 3 cm. It will reduce pressure for comfort on exhale during the ramp period, but will stop when the ramp ends. What you are looking (hoping) for is that this will reduce the number of CA events you are having without increasing the number of OA events. If OA frequency is reasonable then you could try stepping it down some. If OA events are still high, you will probably have to increase the pressure some again.

What you are trying to do is reduce the pressure as much as you can without causing excessive obstructive events. Having EPR active on ramp only may help with that.

First on the AirSense 11 machine, I think the issue is that you have the machine set in the "For Her" mode. This algorithm is different than the standard Auto mode. It increases pressure faster and holds it higher longer. I see that it also adjusts the minimum pressure up. I suspect that is the reason you are seeing the pressure going up to maximum and staying there. This machine can be set to the standard Auto mode and then it should behave much more like the S9 in Auto mode. Here is a link to an article about the "For Her" mode. It is kind of long and complex, but if you skip down to the "AutoSet for Her Algorithm" section it explains what is being done differently. The article:

Obstructive Sleep Apnea in Women: Specific Issues and Interventions

On your S9 graphs I see quite a few central apnea events starting to show up. I think you may want to change strategy a bit. I would switch the EPR mode to Ramp Only, and lower your maximum pressure to 9 cm to see how you do there. The issue with using EPR full time is that if you have obstructive apnea events on the exhale part of the breath, the EPR is reducing the effective treatment pressure by the amount of the EPR used. If you get a reduction in the obstructive events with EPR turned off then I would continue to reduce the maximum pressure in small steps to see if you can find a pressure where OA's are not high, and CA's are also not high.

You asked about the purpose of increasing the minimum pressure. It can have benefits if you are having OA events at lower pressures before the machine can automatically increase the pressure to stop them. It also keep the pressure from cycling up and down so much during the night. When I was using the Auto mode I set the minimum pressure as high as only 1 cm less than the maximum. Then I switched to a fixed pressure when I decided what was the optimum, without using Auto mode.

How are you making out? Have you sorted out your issues with the AirSense 11? I have been trying to think of reasons why it would stay at a fixed pressure. If the AutoRamp mode is turned on it will stay at a fixed pressure (Start Ramp Pressure) until it determines you are asleep. If you can post a daily screen from the A11 it may be helpful in determining what may be wrong with it.