Shin Ryoku CPAP progress thread...

[ShinRyoku]

I think I've finally found settings that work for me. Thanks to Pugsy and everyone else who helped me (I previously posted under the username FrederickRose).

For quite a while I was using an EPAP range of 17-20 with PS 4. Over the past couple weeks, I figured out that I can breathe comfortably without PS and that somehow that lets me keep the event rate down with lower EPAPs. Can't think of why that would be the case, but it seems to be so. Last night, I had my best AHI ever:



(I know that's not the order or sizing of charts that folks here want, but it's how I like it)

I'm a little uncomfortable with the fact that the titration guidelines suggest considering BPAP when over 15 cm H2O and that a minimum recommended PS is 4 cm H2O. It makes me wonder if there is some reason other than comfort that the experts feel that PS ought to be used at high pressures. But I can't find any evidence to support those recommendations, so I'm sticking what works: EPAP 14-20, PS 0.

[Josiah]

Nice numbers. Experimentation is the way to go.

[silversleeper]

why were you prescribed a bi-pap?

[TedVPAP]

Congrats. At some point you may want to try pushing the EPAP minimum from 14 to 15.

[Jay Aitchsee]

I'm a little uncomfortable with the fact that the titration guidelines suggest considering BPAP when over 15 cm H2O and that a minimum recommended PS is 4 cm H2O. It makes me wonder if there is some reason other than comfort that the experts feel that PS ought to be used at high pressures. But I can't find any evidence to support those recommendations, so I'm sticking what works: EPAP 14-20,

I think the deal here is probably justification for a bilevel. If a PS of 4 is not needed with a higher pressure, then neither is a bilevel. A CPAP with an EPR of 3 provides essentially the same therapy as a bilevel with a PS of 3.

[Pugsy]

'm a little uncomfortable with the fact that the titration guidelines suggest considering BPAP when over 15 cm H2O and that a minimum recommended PS is 4 cm H2O. It makes me wonder if there is some reason other than comfort that the experts feel that PS ought to be used at high pressures. But I can't find any evidence to support those recommendations, so I'm sticking what works: EPAP 14-20, PS 0.

I think the bulk off the 4 cm PS recommendation is purely comfort related but there could be some instances where IPAP is wanted to be higher but only briefly so PS is used.
The general consensus is EPAP for OAs and IPAP for hyponeas. There are several ways to accomplish this goal.
I suppose it might be possible that if someone was having a lot of hyponeas and not many OAs then maybe having PS do some of the work instead of having EPAP always higher (which will also kill hyponeas) .
And maybe with EPAP always higher instead of sometimes higher other problems are reduced or avoided. Like maybe aerophagia issues.

You know the old saying "more than one way to skin a cat"....well there's more than one way (or setting(s)) to achieve whatever desired results we are looking for.
I like PS...I like bilevel and I actually noticed a difference in how I felt when using bilevel (PS of 4) both in terms of how I felt during the day and how long I slept from the very first night I tried bilevel. The AHI with or without PS didn't really change but since how I sleep and feel is REALLY important to me (and actually more important to me than minor AHI variations) I opt to use/do whatever it takes to maximize my sleep quality/quantity and since I learned a long time ago that sleep quantity makes a huge difference in how I feel that's what I work hard towards.
I discovered that with all other things being equal I was sleeping approx an hour longer on bilevel than on apap with Flex relief (using Respironics back then). For me that extra hour or so made a significant difference in how I felt. Now I never could figured out why I slept an hour longer and I tried but I never could figure out for sure why. I had a sleep tech tell me once that maybe the body/brain just liked the predictability of the bilevel and the comfort. It just happens that way for some people.

Now not everyone likes or needs bilevel or even exhale relief but I figure that people should use/do whatever makes them feel the happiest and most satisfied with their therapy because it's their therapy. I know that what works for me doesn't/won't necessarily work for the next person.

You have done your experimenting and figured out what gives you the results you desire and you are good with it. That's the important thing...that you are good with your results.

It's not just AHI that I measure...I always look at the big picture with sleep quality being right up there at the top of the list because if I get crappy sleep I feel crappy no matter what that AHI is.
Some people want to target the AHI and that's fine if that is what makes them feel good about their therapy.
I have other health issues that mess with my sleep and my sleep quality is already really fragile so for that reason I have to look at a bigger picture anyway.

If you feel better...sleep better...get better AHI ....without PS or any exhale relief and you are happy doing it then by all means do it.
More than one way to skin a cat.

[ShinRyoku]

why were you prescribed a bi-pap?

I titrated myself up to 17-20 EPR 3 on APAP and had a residual OA index ~5, plus at the time I felt like I could use a little more PS for comfort.

So at that point I bought a BPAP.

[ShinRyoku]

A CPAP with an EPR of 3 provides essentially the same therapy as a bilevel with a PS of 3.

Except that a CPAP doesn't achieve an EPAP greater than 17 while EPR 3 is operating, whereas a bilevel with a PS of 3 can keep EPAP at 20.

Most nights I spend a good portion of the night with EPAP at or near 20. Last night was an exception.

[ShinRyoku]

Congrats. At some point you may want to try pushing the EPAP minimum from 14 to 15.

Thanks, why would you think to increase the EPAP min based on these results? The flow limitation?

[TedVPAP]

Congrats. At some point you may want to try pushing the EPAP minimum from 14 to 15.

Thanks, why would you think to increase the EPAP min based on these results? The flow limitation?

Mostly because you never know unless you try. I wouldn't try it until after I had a good baseline at these settings.
If you look at just past 4:30, you can see the machine tried to prevent those events but failed. Maybe if the min was a little closer to your need those could have been prevented. Maybe. Fine tuning is about understanding your baseline and then trying.

[ajack]

You are getting enough tidal volume without PS, so if you are comfortable, go ahead. Your o2 is a very flat line, everything looks good.
Were you getting CA with desaturations when PS was used? Other than that I would have thought the auto machine would have kept the obstructive stuff sorted. A PS of 3 reduces breathing effort by 50%.

You could titrate the BPAP again if you find the breathing hard. I can't think of a reason for BPAP to increase obstructive events. Roughly when using PS, the epap becomes the ipap. So on this charts, I would have min epap 10 PS 4, if I started using PS.
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https://www.scribd.com/document/3534028 ... -Titration

[ShinRyoku]

You are getting enough tidal volume without PS, so if you are comfortable, go ahead. Your o2 is a very flat line, everything looks good.
Were you getting CA with desaturations when PS was used? Other than that I would have thought the auto machine would have kept the obstructive stuff sorted. A PS of 3 reduces breathing effort by 50%.

You could titrate the BPAP again if you find the breathing hard. I can't think of a reason for BPAP to increase obstructive events. Roughly when using PS, the epap becomes the ipap. So on this charts, I would have min epap 10 PS 4, if I started using PS.
Page 35
https://www.scribd.com/document/3534028 ... -Titration

Somehow min EPAP 10 PS 4 and min EPAP 14 PS 4 both seem to give me more obstructive events per hour on average than min EPAP 14 PS 0 does. I can't think of a reason for it either.

As for which settings help me feel as well as possible with a minimum of spontaneous awakenings, that is harder to say. Pugsy makes a good point that there is more to this than the AHI.

[ajack]

If you are having apnea, it's pretty safe to say you are arousing/waking up, even though you may not be aware of it. The rera are harder to tell and I don't know the accuracy of the machines. But you aren't having significant arousals an hour. It's sensibly to treat the obstructive events first, then have a look at what's left.