bonjour

Very typical, I call that behavior Consistently Inconsistent. A CPAP is not designed to and cannot treat Central Apnea. "Treatment" of Central Apnea using CPAP and BiLevel without Backup is by avoiding Central Apnea.

https://www.apneaboard.com/sleepyhead/

Sierra has this nailed. The typical path to an ASV is to fail CPAP, Fail BiLevel without backup, Fail BiLevel with Backup, and finally succeed with an ASV. Fail means to fail to adequately treat your apnea.

Based on your in lab sleep test the best machine, IMHO the only CPAP variant that would be able to treat you is the ASV. But, you are currently mild enough that with good position management, sleeping on your side, and I do not understand why that would work for central apnea, should be able to manage your apnea. I ask how you could best monitor your apnea going forward to determine if it is getting worse.

On why the difference between the in lab test and the at home test. Were you in a strange bed, in a strange room, with a strange pillow? Were you fully wired up and had freedom of movement, were various contraptions connected to various parts of your body? The answer is obvious. While there is currently no better standard for determining SleepApnea than an in lab sleep test, it is just not normal, and those differences can account for the differences. The in Lab test had the electrodes attached professionally, these are a major indicator in determining Central Apnea so if your in home test was performed by a lesser qualified individual, with a different quality setup, the results, while similar, could easily be different.

CPAP and Auto CPAP are considered to be single constant pressure machines, though auto will algorithmically alter that pressure. Point here is you are only dealing with one pressure. EPR is intended to be a comfort setting by ResMed and the Medical community. It subtracts 1, 2, or 3cmw from your pressure "for comfort". I'll get back to this later. Titration on CPAP is based on having only one pressure and as such inhale = exhale or IPAP = EPAP

BiLevel machines operate totally without EPR but with a different pressure for inhale and exhale called IPAP and EPAP. The difference between these pressures is called Pressure Support or PS. Titration protocols call for increasing the EPAP pressure to resolve obstructive events. This is identical to raising the pressure on a CPAP. IPAP pressure is also increased to match the increase in EPAP pressure generally keeping the PS the same.

Now the question is why have 2 different pressures?

1. Comfort, it is generally more comfortable when exhale pressure is lower than inhale pressure.
   
2. Pressure Support, the increase over EPAP is used to treat Flow Limits, RERAs, Hypopneas, and snoring by increasing the difference between EPAP and IPAP

Officially CPAPs do not number 2 above. Unofficially by manipulating EPR and Pressure settings they can, up to the limit of 3cmw available with EPR. This is also why if someone just throws EPR on they can get a significant increase in obstructive events (because they just effectively lowered their pressure settings.) So, in general, you add 1 cmw to your pressure for every 1 cmw of EPR that you add to maintain the same level of effective therapy.

Realize that Increasing EPR and Increasing Pressure can make (not in everyone) Central Apneas considerably worse. Sierra is one of those very "lucky" individuals. (Note the sarcasm)

The trouble therapeutically with ramps is that your machine is not treating you with fully therapeutic pressures until the ramp completes. Most of the long term users do not use ramps. Using EPR during the Ramp is a comfort thing, as is the ramp itself, making it easier for you to fall asleep. Because there is pressure during the ramp you are getting some therapeutic effect.

Too tight is the single largest cause of mask leaks, yes, it is counter-intuitive.

The issue is your tongue is coming off the roof of your mouth opening your airway to both your mouth and nose. I do understand that some are more sensitive than others to the "pressure". The objection is usually more to the flow than the pressure. How much pressure are we talking about? An easy experiment is to get a tall glass of water, 8 inches is ideal, and a straw. Put the straw in the glass to the bottom and blow bubbles. THAT is the MAX pressure your machine is capable of, 20 cmw. It really is not much. To recommend a setting to start at we would need to find the pressure taht triggers this and then slowly raise pressures back to your optimum therapeutic pressure.

As much as I can, which means not as much as I like. I smoked 3.5 pounds of Salmon Wednesday. A Maple Orange brine and a Maple Orange Glaze. Awesome

It is easy enough, the question is would you like too? The changes Sierra suggested are totally safe and are considered "Comfort" settings by both ResMed and the Medical community.

[http://www.apneaboard.com/wiki/index.php?title=Enhanced_Expiratory_Rebreathing_Space_(EERS)] Enhanced Expiratory Rebreathing Space (EERS) This is an option for the treatment of therapy onset Central Apnea with CPAP This is a much less expensive option than getting an ASV machine. EERS is discussed in this wiki with contact information to the doctor and DME researching this option. EERS works by maintaining enough carbon dioxide in the breathing circuit to prevent central apnea. Please feel free to show your doctor this information and request that he consult with Dr. RJThomas, or prescribe an EERS mask from the DME.

The trouble with this therapy is finding a doctor or medical facility which utilizes this treatment.

That is a common adjustment in a sleep lab. The difference is that someone is monitoring you and your instrumentation and there is more instrumentation.