How to overcome Central Apnea using Bilevel?

“Don’t be discouraged. It’s often the last key in the bunch that opens the lock.”

- Author Unknown 

All patients being treated with CPAP therapy by a sleep medical specialist would have gone for a Sleep Study. Should few or no Central Sleep Apnea (CSA) have come up in the Study, it is likely the CPAP machine and the settings being used that are causing CSA to appear after starting sleep apnea therapy. This post will show how I overcome central sleep apnea caused by CPAP by using a Bilevel or BiPAP auto adjusting pressure machine. 

CSA is where you have no obstruction in your upper airway, however you stop breathing. CSA occurs because your brain doesn't send proper signals to the muscles that control your breathing. 

Medical Research has shown that CPAP may actually cause CSA in certain patients including male sex and history of cardiac disease. The presence of CSA may limit the effectiveness of CPAP therapy. Known as Treatment-Emergent Central Sleep Apnea. 

Lehman S; Antic NA; Thompson C; Catcheside PG; Mercer J; McEvoy RD. Central sleep apnea on commencement of continuous positive airway pressure in patients with a primary diagnosis of obstructive sleep apnea-hypopnea. J Clin Sleep Med 2007; 3(5):462-466. 

Read more at the following link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1978327/. 

A major weakness of the CPAP and auto-adjusting CPAP Machines is that the machines are limited to Pressure Support of 3 cmH2O. In addition, these machines do not have settings for Trigger and Cycle and TI Max and TI Min like the machine that I use, which is ResMed S9 VPAP Auto. This is a bilevel auto adjusting pressure machine (bilevel). This machine is now known as ResMed AirCurve 10 VAuto bilevel machine.  

Note that you will also see the bilevel machines known as BiPAP machines. BiPAP stands for Bilevel Positive Airway Pressure. BiPAP is a Registered Trademark owned by Philips Respironics. This company’s machine is known as Philips Respironics DreamStation Auto BiPAP. 

Previously when using the CPAP machine, my breathing would stop or pause when transitioning between Inhales to Exhale and Exhale to Inhale leading to CSA occurring each night. The Trigger and Cycle settings on the bilevel machine overcame these pauses in my breathing reducing CSA to nil or minimal each night. The TI Max setting assists in ensuring that your breathing on inhale goes no longer than is optimal for you. For example, I use 1.2 seconds. 

From the sleep apnea forums (listed right hand side), I note that a number of patients when they use Pressure Support or increase Pressure Support especially above 3 cmH2O, have CSA appearing. The Trigger and Cycle setting is a fantastic feature which has overcome the CSA issue for me. Note that I was only diagnosed with Obstructive Sleep Apnea in my Sleep Study. 

On a CPAP machine, I was seeing usually half or more of my apneas as CSA. This was due to the machine having an estimated “medium” Trigger and Cycle setting. Further, I was being subject to much higher median pressure each night causing many issues when compared to a bilevel machine. You can see the extensive list of issues that arose from using the sleep apnea machine at the blog page Stop CPAP Side Effects and Issues.

Should you have a CPAP machine, I suggest reducing EPR pressure support to 1 cmH2O or completely turning pressure support off to assist in reducing CSA. Clearly, this will require you to not have issues such as a feeling of having too much pressure on the machine. In this situation, whilst not ideal, consider reducing your CPAP pressure. 

By using a bilevel machine and changing the Trigger and Cycle settings to high/ very high from the default setting of Medium and increasing the Pressure Support to at least 5 cmH2O, I have taken over some of the control of the machine. I have made the machine work how I would like it to work. That is, you are setting the machine so that the settings are optimized for you! 

For the Trigger and Cycle settings, I am using: 

Trigger (from exhale to inhale)               High 
Cycle (from inhale to exhale)                 High/ Very High 

You can see the various settings that I am using on the bilevel machine on the blog page Different Bilevel Settings Example.

From my personal experience, it is much easier to breathe using a bilevel machine than using a CPAP or an Auto Adjusting CPAP machine. The bilevel auto adjusting pressure machine is very smooth and it is a natural feeling when breathing. Your breathing can be in sync with the machine. From my experience, the bilevel machine offers better comfort, compliance, therapy and sleep quality. 

By using the Trigger and Cycle settings and TI Max of 1.2 seconds, I have minimized or completely removed CSA occurring each night. These settings are critical to me when using pressure support of between 5.0 to 5.6 cmH2O every night and to having successful sleep apnea therapy. 

From a practical point of view, the various sleep apnea machines can be likened to televisions. 

The CPAP fixed pressure machine is like the old black and white television.  

The auto adjusting CPAP machine is like the old colour television.

The Bilevel or BiPAP auto adjusting machine is like a high definition colour television. 

Which machine would you prefer to sleep with each night especially since you may be sleeping with this machine for the next 40 to 50 years? 

There is a comparison of the CPAP and Bilevel Machines using my SleepyHead data on the blog page CPAP Vs Bilevel Settings Example.

 

An update to this blog post using BiPAP and Bilevel ST machines to overcome Central Apnea is at:

 

Are BiPAP and Bilevel and Ventilators reducing Deaths during Coronavirus? 

Since originally writing this blog post, in early 2021 I began using a very high starting IPAP of 18.2 cmH2O and EPAP of 13.0 cmH2O (inhale and exhale pressure) which may cause central sleep apnea. This was essential to stop hypoxia (oxygen desaturation) and sleep disordered breathing causing the symptoms of Dementia. More details are on the blog post:

 

What BiPAP Settings prevent Alzheimer's due to REM sleep breathing issues? 

 

Should you be having side effects and issues with your sleep apnea therapy; CHANGE what you are doing so that you can wake up feeling refreshed and energized each day. 

“Have courage. Be adventurous and Go for it! Overcome your fear.”

- Mrhelpful

 

Stop CPAP causing Weight Gain: Use Bilevel

“When you get into a tight place and everything goes against you, till it seems as though you could not hang on a minute longer, never give up then, for that is just the place and time that the tide will turn.”    

- Harriet Beecher Stowe (American Author – 1811 – 1896) 

Many people including myself when using CPAP have had Weight Gain. A number of people have detailed their experience on the various sleep apnea forums (listed right hand side). In addition, some sleep medical specialists are unsure of how to stop CPAP causing weight gain and why more patients do not have weight loss. Should CPAP be causing weight gain, seriously consider using a Bilevel or BiPAP Auto adjusting pressure machine. From my personal experience, when you use a bilevel machine, you will be able to get rid of any weight gain and achieve weight loss!

You can read articles on CPAP and weight at:    

https://doctorstevenpark.com/cpap-use-found-to-cause-weight-gain

https://www.cpap.com/cpap-weight-loss/

As mentioned on the blog page Why is CPAP Compliance Rate Low? it is likely that up to an estimated 80% or more than 15 million users of the sleep apnea machines are non-successful, non-compliant and failing. I have detailed on various posts and pages what I did to finally overcome all the side effects and issues that I was having using the sleep apnea machines especially CPAP therapy. 

The question is: Should you be experiencing weight gain after starting CPAP therapy; what, if anything can be done about your sleep apnea therapy? 

After starting CPAP therapy, I gained weight of up to 2 kgs. The sleep medical specialists may consider that it is not much of a weight gain. However, I did not lose weight as I was lead to believe when I began using a CPAP machine. The weight gain happened despite exercising up to 5 times per week for greater than 30 minutes at a time including walking up and down hills. Also my diet was being watched every day and my body mass index (BMI) was 26. In addition, I was having yearly medical checkups including blood tests. I thought I was doing everything possible to lose the weight that I had put on even outlaying money to buy a CPAP auto adjusting machine. 

Though I did all these things, I still could not lose the weight that I had put on since starting CPAP therapy. This is the reason for the quote at the top of the post by Harriet Beecher Stowe. Just when you think you have run out of options, hang in there a bit longer, you have some luck and the tide turns! 

In 2014, after being unsuccessful for nearly 4 years with trying to resolve the various side effects and issues caused by using the CPAP fixed pressure and auto adjusting machines, I decided to purchase a ResMed VPAP S9 Bilevel Auto adjusting pressure machine. Now known as ResMed AirCurve 10 VAuto. More details at The Secrets to Success using CPAP and Bilevel.

It was after using the Bilevel machine and optimizing the settings on the machine that I was able to take off all the weight gain that I had put on after starting CPAP therapy. Further, my weight has now dropped more than 1 kg below my pre CPAP weight of nearly 9 years ago and I currently have a BMI of 25! 

Buying the Bilevel machine was a huge leap of faith and I did have some luck in buying the machine. I thought the machine would work great; however, at the time I had little knowledge of how the machine truly worked with all its various options. There was no way of knowing this until I actually used the machine each day. After some time using this particular machine, I was able to resolve all the issues that I was having with my sleep apnea therapy. Have a look at the improvement in a comparison of CPAP Vs Bilevel Settings Example.

On the blog post Use Different CPAP and Bilevel Pressure Settings and the blog page Different Bilevel Settings Example, I advised that using the one setting on your sleep apnea machine was not always appropriate in all situations. For example, when eating and drinking late at night, I use a Bilevel Auto machine with Pressure Support of 5.0 cmH2O. Using Pressure Support greater than 3.0 cmH2O stops me from hyperventilating or over-breathing when asleep and waking up feeling tired in the morning. Importantly, median Minute Ventilation rate at 6 litres/ minute or lower can be maintained.  

 

Based on my personal experience, using Pressure Support greater than 3.0 cmH2O has good implications for those users who have gained weight since starting CPAP therapy and/ or have a high BMI. A discussion with a medical specialist at one of the major equipment suppliers supports this conclusion. 

Unfortunately, a major weakness of both the CPAP fixed pressure and auto adjusting machines is that maximum pressure support is limited to only 3 cmH2O. 

As further discussed on the blog page Guide to Success using CPAP and Bilevel, the steps to take to optimize your sleep apnea machine settings are:  

1. Have a regular Apnea-Hypopnea Index (AHI) of 1.5 or lower. Does not have to be daily, but ideally most of the time;  

2. Minimize Leaks from the Mask and Mouth Breathing. Ideally reduce Leaks to Nil so that a Zero appears on your sleep machine every morning; 

3. Reduce median/ average pressure of IPAP (inhale pressure) and EPAP (exhale pressure) as much as possible. The maximum or top pressure is only required as necessary to cover obstructive sleep apneas. 

4. Reduce median/ average Minute Ventilation (MV) to 6 litres/ minute or lower and keep the 95% to 100% rate “under control”. Apply the principles of the Buteyko Breathing Method to your sleep apnea machine by slowing your respiratory rate down and reducing the volume of air that you are breathing in. 

For tidal volume settings, I use Ideal Body Weight (IBW) on CPAP and Bilevel or Predicted Body Weight (PBW) not my actual body weight. Normal MV rate is considered to be 6 litres/ minute per Medical Textbooks. Further information on Minute Ventilation and the Buteyko Breathing Method is at: https://www.normalbreathing.com/.

By optimizing the settings on a Bilevel Auto adjusting pressure machine, the tide turned and I was able to stop CPAP causing weight gain. In addition, I was able to get rid of any weight gain and achieve weight loss of more than 1 kg from my sleep apnea therapy! A comparison of the two machines is at CPAP Vs Bilevel Settings Example. 

Dr Steven Park, Medical Surgeon wrote on a blog post 7 October 2020:

It turns out that overall, CPAP use has been found to increase weight significantly, in proportion to how long you use CPAP. The more hours you use CPAP every night and the more number of years, the higher the amount of cumulative weight gain.

Go onto the Comments section and see many people who have put on more than 10 pounds or 5 kgs since starting CPAP! 

https://doctorstevenpark.com/can-cpap-make-you-gain-weight

An additional reason to seriously consider using BiPAP and Bilevel auto adjusting machines rather than CPAP is that they may improve any back and neck issues that you may have. From personal experience, on changing to a bilevel machine, my back and neck issues improved by 5% to 10%!

Since originally writing this blog post, in early 2021 I began using a very high starting IPAP of 18.2 cmH2O and EPAP of 13.0 cmH2O (inhale and exhale pressure). Ideal Body Weight was used in setting the median Tidal Volume and Minute Ventilation. This was essential to stop hypoxia (oxygen desaturation) and sleep disordered breathing causing the symptoms of Dementia. More details are on the blog post:

 

What BiPAP Settings prevent Alzheimer's due to REM sleep breathing issues?

 

Should you be having side effects and issues with your sleep apnea therapy; CHANGE what you are doing so that you can wake up feeling refreshed and energized each day. 

“Have courage. Be adventurous and Go for it! Overcome your fear.”

- Mrhelpful

Use Different CPAP and Bilevel Pressure Settings

“The definition of insanity is doing the same thing over and over and expecting different results.”

- Albert Einstein/ Others (German born Theoretical Physicist - 1879 - 1955)

By using different CPAP and Bilevel or BiPAP pressure settings for different situations, I now wake up feeling refreshed and energized each day. Should you be having some “bad” days or are having the feeling of “is this as good as it gets” using your CPAP and Bilevel machine, CHANGE what you are doing! 

Many users of sleep apnea machines will have experienced for themselves that at least 1 to 2 days per week up to every day of the week; they are waking up tired, lacking energy and are unrefreshed. I was once in the same situation that many people now find or have found themselves.

On the blog page Different Bilevel Settings Example, I show the results using my actual sleep data and SleepyHead reports of using the Bilevel auto adjusting pressure machine for three different situations. For a CPAP machine, apply the principles of what I have done. The different situations are: 

1. Normal day;

2. Eating and drinking late at night; and

3. Hard day at work and/ or many hours of driving. 

Your pressure needs may change on a daily basis and will depend on many factors. Such factors may include sleep hygiene and lifestyle factors such as exercising daily and eating food late at night and medication and other health conditions that you may have. Should you be doing similar activities each day, having the one set of pressure settings on your sleep apnea machine may be all that you require for optimal treatment. The machine that you are using may only require a little adjustment to optimize your sleep. 

When you consider the many benefits from waking up refreshed and energized each day, the cost of the bilevel machine has been recovered many times over as I have been able to resume full time work. Further, I wanted to be 100% refreshed each day as in the past, tiredness nearly caused me to have a major car accident on the highway when my life flashed before my eyes. Putting someone else’s life at risk is not something I want to do when I can take steps to prevent it.

I did not sleep properly every night for the first 4 years of using the sleep apnea machine, was fatigued and tired most days and struggled constantly to do any paid work. Some days I would get up out of bed, read emails and go back to bed 15 minutes later. I was “totally stuffed” to put it nicely! It was not until 2017, some 7 years after I was first diagnosed for obstructive sleep apnea that I woke up feeling great and energized each day. 
    
One of the key Secrets to Success using a sleep apnea machine was to change from using a CPAP machine to using a Bilevel auto adjusting pressure machine. Another key Secret to Success was to use different pressure settings for different situations on the bilevel machine. More details are at Different Bilevel Settings Example.

I began using different settings on the machine when I realized that using the settings for a “Normal day” were not appropriate in all situations such as eating and drinking late at night. At the time, I was having issues such as hyperventilating or over breathing and feeling tired in the mornings. To overcome these issues, I tried using different settings on the machine depending on what was happening on a particular day. By trial and error, I succeeded in overcoming these issues and now wake up feeling refreshed and energized each day.  

When I eat and drink late at night, my breathing becomes faster than normal when asleep. My Minute Ventilation (MV) increases as I was not taking my normal full breath on inhale. Median/ average MV may rise up to 7 litres/ min or more from my normal 6.0 litres/ min or lower. In addition, the median respiratory rate may increase up to 16 breaths/ minute from 14 breaths/ minute. Minute Ventilation is the total volume of air entering the lungs in a minute. 

My solution was to reduce pressure support to 5.0 cmH2O from 5.4 and 5.6 cmH2O and reduce the minimum pressure. In addition, by using the same time for inhale, I was able to control and slow my respiratory rate down back to my normal median of 14 breaths per minute. Importantly, no matter what the situation, median MV stayed at 6 litres/ minute or lower. Examples of what I have done in three different situations are on the blog page Different Bilevel Settings Example.

Today, I have a separate bilevel machine for each of the three situations outlined above. Changing settings on the one machine late at night was getting annoying and I was prone to making errors when changing settings on the one machine due to tiredness. An example is provided of how I use these machines in a typical week at the blog post Athletes need Maximum Performance: Use Bilevel. Observe what I have done and apply the principles to your own situation.

On the blog post Change or Reset your Circadian Rhythm, when I use a Bilevel auto adjusting machine with different settings, I have a different circadian rhythm or sleep cycle for each different setting. By using the Bilevel machine I have optimized my sleep every day.

Circadian rhythms are your body's internal clock or sleep/wake cycle which repeats roughly every 24 hours. Ideally, wake up at the end of a sleep cycle not in the middle of one otherwise you may feel tired and sleepy all day.

In addition to sleep apnea, I also have a genetic disorder, Hemochromatosis. This disorder is characterized by having too much iron absorption from the foods that you eat. Where your iron levels are too high, you may feel incredibly tired and lethargic and may lead to health issues such as cirrhosis of the liver, heart disease and diabetes.

Body iron level helps regulate our circadian rhythms and their link to metabolism. You can read more at this article.
https://theconversation.com/bleed-me-why-excess-iron-can-be-dangerous-41339    

Importantly, Research is supporting that a brain's ability to clear a protein closely linked to Alzheimer's disease is tied to our circadian cycle.

Rensselaer Polytechnic Institute. "Clearance of protein linked to Alzheimer's controlled by circadian cycle: Ability of immune system to destroy Alzheimer's-related protein oscillates with daily circadian rhythm." ScienceDaily. 10 February 2022.

https://www.sciencedaily.com/releases/2022/02/220210154215.htm

Some people may feel the cost of buying three machines is a lot of money and not necessary. As these were second hand machines, the total cost was far cheaper than buying one new bilevel machine. More importantly, my sleep medical specialist would only prescribe a CPAP fixed pressure machine and refused to prescribe an auto adjusting CPAP machine as “I did not need it”! For these reasons, I felt I had little chance of obtaining a bilevel auto adjusting pressure machine.

Based on discussions with a senior executive of a major equipment supplier, depending on country, only 2% to 4% of total patients get issued with a bilevel machine. This further supports the reason to buy the machines out of my own funds. I have purchased a few second hand bilevel machines with low machine use hours, saving plenty of money, from a company, Secondwind CPAP in the USA. Details are at: https://www.secondwindcpap.com.

Other benefits of having more than one machine include:

1. Having two backup machines should one machine fail to operate; 
2. Not having to worry about obtaining a new Bilevel machine for many years; and 
3. Having all three machines the same allows for continuity of using the same accessories such as the tubing and power adapter. 

Above all, by optimizing the settings on the bilevel machine and using different pressure settings for different situations, I have successfully overcome and stopped all the  CPAP side effects and issues caused by the machine. Side effects and issues include aerophagia, central sleep apnea, insomnia, mask leaks, tiredness and lacking energy issues even though AHI<1.0 and weight gain.

Should you be having issues with your sleep apnea therapy; CHANGE what you are doing so that you can wake up feeling refreshed and energized each day. 

“Have courage. Be adventurous and Go for it! Overcome your fear.” 
- Mrhelpful