Poster child for Auto Audjusting pressures

[Pugsy]

Last night was may second night on my new Bippap Pro. Slept great. I had to chuckle when I saw the report. The cluster gremlins played at my house last night.
A little bit of hisotry for those that don't know me. My OSA is worse in REM sleep...like sleep study shows 53 per hour in REM sleep and 12 in non REM. Also I have been using a bilevel machine that auto adjust the pressures. Works extremely well for me. I bought a PR S1 660 model machine from ST Mark. I have a 750 which is the auto model and I also have a S9 VPAP Auto.
I have played around with straight bilevel some but not much on my auto machines. Normally my settings have been 9 EPAP with Pressure support of 4 or 5. I kind of like 4 the best. So that makes me start out with IPAP of 13 but I set the max IPAP to be able to go to 20 as needed. A few times I have kissed the 20 line briefly...most of the time any increases were in the 15 to 18 range for where IPAP went to.

So the first night with the BiPap Pro I used my normal 9/13 only with this machine I can't auto adjust up to anywhere as I am stuck at 13.

This was my first night on the new machine.


And now SH report for last night. Obvious clusters in a pattern and the time frames for the clusters pretty much match up to normal REM stage sleep time. I was not on my back during the night. I have been trying to stay on my side because of worse pain for me with back sleeping so had a wall built to keep me on my side.



And this is the same last night's report from Encore.



Sometimes my pressures don't move much...not much changes and I have a night like the first post.
And then I have night's like last night...obviously the pressure was not sufficient..

I am extremely tired and can't think real sharp so I will do some more comments as need tomorrow because I am heading for bed real shortly here. I can't seem to find a good example fo the BiPap working really hard and I am too tired to go looking at the moment.

So what do I do? I will be adjusting the fixed biblevel settings to hope do a better job at preventing the events.
My pressure choices were great for the first night....obvious inadequate for last night.

So this is a test.....what do you all think I should do? What adjustments should I make from what you see here? I am going to use the machine a few more nights. What ideas do you all have that I might try. Biflex is set at...2...very comfortable to breathe with.
Remember this is a PR S1 Bipap Pro .

[Sir NoddinOff]

Man,it's tough when our high expectations about new equipment get dashed, altho you're only on the second night. I wish I was a technical guru and could say do this, then do that. BTW, I'm in the same boat right now with my equipment: what was going great for two thirds of a year now has some jagged edges. Oh well. Hang in there and people will put their heads together for you.

[kaiasgram]

Hmm, well, you said that your bipap auto works extremely well for you. So my answer: Go back to your auto bipap. I know, I know, that's a smarty pants answer, you were asking about what adjustments to make with the pro.

But what are we supposed to do here? Usually you're the one to answer these questions for us!

[Greg6657]

My suggestion is dial 1-800-cal-pugsy

[-SWS]

So what do I do? I will be adjusting the fixed biblevel settings to hope do a better job at preventing the events.
My pressure choices were great for the first night....obvious inadequate for last night.

Well, if you were in PSG titration for a fixed BiLevel machine, they would address OA clusters by increasing EPAP. That's standard titration protocol since OA is either incipient or frank before inhalation gets started. Therefore IPAP is not used to address OA.

Rather EPAP must be used for OA based on the sheer timing of event onset... Good luck, Pugsy!

[Pugsy]

This is a test for you all. I already know what I will do and will explain shortly. I want you all to think about what you see and what you would offer as ideas to someone who maybe didn't have an auto adjusting machine.. Not every one can get an auto adjusting machine....not everyone can sleep well with auto adjusting pressures even if they had one.
Think outside the box..what do we do when we don't have the "perfect" way to do things with a machine that could do auto adjusting for us.

What I saw the second night....I full expected to see at some point using the BiPap in fixed pressure mode. I just didn't know it would happen so soon. This wasn't a big surprise to me for me.

It's really no different that what I saw when I used APAP machine with minimum pressure of 9 cm and those are the clusters that I saw with APAP minimum at 9 but the clusters were broken up with minimum of 10.

So don't think that I am unhappy with my new machine because I am extremely happy with it. I knew full well that this would happen and it is fixable and not really all that difficult. This is not the end of the world for someone without an auto adjusting machine. Trust me.

[Pugsy]

But what are we supposed to do here? Usually you're the one to answer these questions for us!

I want you (collective you and not you singled out) to be able to think for yourself. We never know how long any one of us is going to be in a position to take up the slack if something was to happen to me or anyone else here on the forum.

It has always been my number one goal to educate so that a person can think for themselves and not for me to spoon feed what to do. I want people to understand the whys and whats of what we do and not "heck, I will do this because so and so said to"
No one learns when we spoon feed stuff.
This is why I often write long explanations as to why I would suggest so and so or do so and so if it were me.

[RandyJ]

Ultimately I would consider increasing epap but perhaps after a few more nights' data to see if last night was a fluke or trend...

[chunkyfrog]

I would hope that engineers in this field are lurking about; (they should be--just for the free info)
In a perfect world, one would register, and at least start a PM dialogue with Pugsy. (Fingers crossed)

[Pugsy]

Next lesson. Last night I increased EPAP to 9.5 from 9.0.
SWS is right...we don't really need to worry about IPAP because what I have an abundance of is OAs...it's always been that way for me..this is nothing knew. If I had an abundance of hyponeas then IPAP for sure needs to go up a little.
EPAP for OAs and IPAP for hyponeas. I know it seems backward but that's what we do.

I choose to increase IPAP by the same 0.5 cm because I like Pressure Support (difference between EPAP and IPAP) set at 4. It's simply more comfortable. That's the only reason. PS of 4 or 5 is easier to breathe with than PS of 3 or even 3.5 for me.
So my choice of PS is comfort only choice.

Below is last night's report with 0.5 increase...still had one remaining cluster...around 2 AM. Now granted you all may think...I am making changes really rather quickly and not waiting for the pattern. I have already done this experiment once before. Back when I got my BiPap Auto and actually wanted to do an extensive experiment in fixed bilevel mode because I had never really done a cpap mode experiment for any great length of time. I jumped right into APAP mode and did well so never really tried cpap mode.

So I already know where I am going with this fixed bilevel mode machine and why I knew full well what I was getting with Mark's BiPap Pro. I already have over 3 months of using my Auto BiPap in fixed bilevel mode.

My point to this exercise is to show that if someone doesn't have an auto adjusting machine (be it cpap or bilevel) we can get optimal therapy with fixed pressures. It may take a bit of tweaking but it can be don't and really isn't all difficult.
Auto adjusting machines aren't for everyone for any number of reasons that I won't go into right now.
Yes, I am someone who can do very well with auto adjusting pressures but I can also do just as well with fixed pressures with just a little education and tweaking for optimal results and maybe a little compromise here and there.

Clusters of events...I have found that once I break up the clusters...I feel fairly decent...random events spread out through the night I don't really see any big difference in how I feel. So my main goal is simple ....find an EPAP number that will prevent the clusters from occurring on a consistent basis. A random cluster every now and then of maybe 3 or 4 events back to back...not a big deal as long as it is random and rare.

Oh, BTW I have done some cpap mode experiments. To prevent the clusters of events in cpap mode..I seem to need between 13 and 14 in cpap mode. It's doable if I had to but everyone knows that I would rather use lower pressures for the bulk of the night and let the machine auto adjust for those maybe 15 minute clusters in REM where I sometimes need higher pressures.
I have nights where I have zero need for much of an increase in pressures...even on the APAP mode machine with 10 cm minimum...some nights I never went above 11 cm...but some nights I might need 18...

Remember my OSA is much worse in REM sleep where my AHI was 53...and not very exciting in non REM sleep..only 12 per hour. Supine sleeping has never been a factor in pressure needs or severity of OSA. I have tried multiple experiments with supine vs non supine to make sure.

[n0hardmask]

But what are we supposed to do here? Usually you're the one to answer these questions for us!

I want you (collective you and not you singled out) to be able to think for yourself. We never know how long any one of us is going to be in a position to take up the slack if something was to happen to me or anyone else here on the forum.

It has always been my number one goal to educate so that a person can think for themselves and not for me to spoon feed what to do. I want people to understand the whys and whats of what we do and not "heck, I will do this because so and so said to"
No one learns when we spoon feed stuff.
This is why I often write long explanations as to why I would suggest so and so or do so and so if it were me.

Pugsy,
This is a WAG, but disregarding the CA's a minute, you need to up the higher number closer to the 18 you said solves the majority of your OA's.
The large number of CA's bother me, so I wonder- does the BiPAP treat CA's or not? If not, then also adjust the lower number up as well. Don't think you can stick with your 4 differential, though.
If the BiPAP is capable of treating CA's then you probably need to drop the lower number a tad.
And I'm still unsure if the leaks are causal or a result of the events.
DISCLAIMER these ramblings are almost "unencumbered by the thought process". earl
I'm guessing earl will get a grade of 'E'.

[Pugsy]

you need to up the higher number closer to the 18 you said solves the majority of your OA's.

Actually that's the backwards thinking that I have had trouble getting wrapped around my brain myself but
EPAP for OAs
IPAP for hyponeas
this is the general consensus. If I were in a sleep lab...they would increase EPAP and not IPAP.
Think of EPAP being like a minimum APAP setting in this situation or even fixed cpap pressure.

The large number of CA's bother me,

You think this is a large number of CAs? It's not. 1 or less than 1 per hour is not a large number. It's a long way from a number that warrants treatment.
BiPaps do NOT treat CAs....at least the bipap model I have. This is NOT the ASV type of BiPap.

Let me add this disclaimer about my CAs .....these are NOT related to pressures any any way. I have seen pressures of 18 to 20 on my APAP and my auto BiPap...with zero CAs get flagged.
My CAs or centrals are either awake/semi awake breathing irregularities or most often....tossing and turning over in bed hold my breath central which I do a lot of because of pain when I stay in one position too long.
I have had many, many nights with zero CAs or maybe one.

You all can safely ignore any CAs we see on my reports. They are not the scary kind at all. I have more nights with 1 or 2 all night or none than I have with more of them.
Less than one per hour on last night's report....not a large number at all.

[-SWS]

This is a test for you all. I already know what I will do and will explain shortly.

I didn't realize you were testing the message board at-large. Rather I thought you were testing the treatment modality. Sorry.

[khauser]

LOL. You passed. Surprised?

I had the same idea, but didn't want to post it. I think we've talked about that in the past so I didn't feel the need to show her I understood it again.

[Pugsy]

Side note for newbies not aware of why I am on bilevel.
Strictly personal choice. I got a chance to try one about 18 months ago and was blown away by how much better I felt after the very first night and it was a BiPap Pro that I tested (it was going to a friend and I was to set it up for her...so I just had to at least try it)....Took me all 2 minutes, before even sleeping, to tell myself..."I gotta have one of these"
And the AHI was over 9 that very first night because I had pressures way too low. I still felt remarkable. My main symptom to go away on bilevel...need to nap. If I get around 7 hours of good sleep...I have zero need to nap in the afternoon.

So the AHI didn't really matter and the very first ugly report didn't really matter. I still don't know why I feel better on bilevel but I do. It wasn't that I felt bad on APAP either. It was just a fluke that I even tried bilevel.
I had no problems with APAP at all...no exhale issues...no aerophagia issues...no nothing of great excitement.
I don't care...I feel better and sleep a little longer which I am sure is a factor. Why? I don't know and probably will never know.
My main goal all along has been sleep better and feel better and damned what the reports say...good or bad.