Still Struggling with BiPap and Anxiety

Hi - I took a few days off from the Aircurve VAuto and used the S9 Autoset just to see if it helped the anxiety when I wake up. It really didn't change anything. Started back on the VAuto last night and adjusted pressures somewhat. Last night the AHI was higher than before and the problem seemed to be mostly in the 5-6:30 a.m. range where it looks like the machine was trying to go higher than the IPAP of 18.

My original prescription was IPAP of 20, EPAP of 9, and Pressure Support of 5. With those settings, the AHI's were around 5-6. I had slowly raised the EPAP to 12 and reduced the PS to about 2, and the AHIs were around 3, but I would wake up with extreme anxiety and pounding heart, and the anxiety would last all day. So last night I returned the EPAP to 9, and the PS to 5, and lowered the IPAP to 18 to see if I could feel better. I woke up a little tired but not quite as anxious, but the AHI was higher.

Below are last night's results where it looks like the machine was trying to go higher than the IPAP of 18 about the same time as the AHI got as high as 20 during the 5-6:30 a.m. timeframe. I woke up and fell back asleep and everything settled down. I'm using a ResMed nasal mask and the humidity is set to Auto (even though Sleepyhead says a 4). The humidity worked ok last night.

I also have the sleep study reports if that would help any - just trying to figure out what my best pressures and support should be.





Thanks for any advice you might have.

Even though your EPAP min shows set to 9cm H2O, there are times on the chart that it goes below that? Ramp shows as being off as well. Also, it seems the machine wants to spend a lot of time with EPAP at or above 10cm H2O. Most of your AHI consists of obstructive apneas.

EPAP/CPAP can cause cardiovascular symptoms like hypotension if it's raised too high. But you could also be over ventilating yourself with a PS of 5. I think your IPAP is fine...you barely have any hypopneas/flow limitations/snoring.

I would personally try EPAP min of 10 with a PS of 4 and see what happens. I would also wait for others to chime in before going ahead and doing that.

Mine was so high i would wake up choking trying to breath. I put my machine on cpap and tested until i could breath back comfortably. My settings are11 and 6. No more waking up with my heart pounding and anxiety. One of the brothers was having the same issue. The VA set his cpap at 15. He now sleeps comfortably at 11.5 where i put it after testing my way. Try the 10 as mentioned or test as i described.

Softail99fb - I'm a little confused. Do you use an Aircurve VAuto? Do you mean your IPAP is 11 and EPAP is 6.

Do you mean I should try an EPAP of 10, leave the IPAP at 18, and lower the PS Pressure Support to 4 as suggested my Matt00926?

I wore my watch last night and my average pulse was 56-64 - I guess that's ok for nighttime.

I just wish I could shake the awful anxiety and shaking that lasts from when I wake up to about 2-3 every afternoon. It's just awful and Xanax does not help, which is weird. That's why I keep suspecting that it's something about the BiPap and how I am breathing at night (in spite of ok numbers for the most part) that is causing this raging anxiety. There is nothing else going on - no medicine changes and no big life events or anything. I'm just really confused and scared. When I had changed the EPAP to 12 and the IPAP to 20 with a PS of 2, the AHI's were really good at 2-3, but I was still waking up in a panic.

Thanks for your input!

Pressure Support is just the difference between IPAP and EPAP. So if your IPAP is 20 and your EPAP is 12, the PS would be 8 - which is a lot unless you have a respiratory illness.

You may wish to try just switching the therapy mode over to spontaneous bi-level - so one fixed IPAP and EPAP pressure.

Usually for bi-level in the sleep lab they start at IPAP 8 / EPAP 4. Generally IPAP is raised for hypopnea/flow limitation and snoring events. EPAP is raised for obstructive apneas. This is what both ResMed and Respironics suggests to do.

By starting conservatively and raising the values only as needed, using sleepyhead as feedback, you may end up with more precise pressures needed, instead of having wider min and max ranges that may have something to do with your symptoms.

Matt00926 wrote:Even though your EPAP min shows set to 9cm H2O, there are times on the chart that it goes below that? Ramp shows as being off as well. Also, it seems the machine wants to spend a lot of time with EPAP at or above 10cm H2O. Most of your AHI consists of obstructive apneas.

Sometimes SleepyHead doesn't always report the Settings correctly. Despite it showing ramp as being off that sure looks like a ramp pressure graph at the beginning of the night. I wouldn't spend a lot of time worrying about this minor discrepancy.

Dallaslady51 wrote:Softail99fb - I'm a little confused. Do you use an Aircurve VAuto? Do you mean your IPAP is 11 and EPAP is 6.

No....he/she doesn't use the same machine you are using and from past posts this person has made what is used is all over the place but I think maybe the ASV type of machine and what he/she might be using is totally irrelevant to what you are using.

I do think your minimum EPAP of 9 is likely a bit too low....
I still have my doubts as to whether your anxiety symptoms are related to your sleep apnea or its therapy.
Do you happen to have a report handy from when you tried PS of 2 or 3?

Pugsy - here are 3 graphs from Sleepyhead - 2 for the Aircurve VAuto and 1 from the S9 Autoset when I was afraid to use the BiPap (still am afraid but trying it again. I had the best results (but still felt crazy when I woke up) with I followed your advice to raise the EPR a little and either from you or someone to lower the PS.

Yes, I still can't figure out what is causing the anxiety - last night used the BiPap

This was Aircurve VAuto Bipap with EPAP of 12, IPAP of 20, and PS of 1.6.



This was S9 Autoset 10-17, EPR of 1



This was Aircurve VAuto Bipap last night with EPAP of 9, IPAP of 19, and PS of 5

Which settings are the most comfortable to you initially at the beginning of the night?
Which settings would you use if you were just going to maybe read a book or watch TV and not worry about going to sleep but instead would pick to use just from a comfort level while awake?

The minimum of 9 EPAP last night...just a tad bit too low but not a deal breaker.
Overall in terms of report results there's not any huge difference in any machine or setting choice except maybe with the S9 and the flow limitation graph.

It feels Much more Comfortable around 2-3 for PS - 5 feels too strong when falling asleep and especially in the early morning. It feels too strong to breathe against.

That's where I started initially when I got the BiPap and just kept lowering it a little at a time. The more I lowered the PS and raised the EPAP (about 2 for the PS and 12 for the EPAP), the more the "numbers" improved.

I guess I got a little worried because on another forum everyone was jumping on me for lowering the PS and raising the EPAP. So last night went back to the 5 PS and 9 EPAP and it didn't feel good.

But I don't want to be causing any "issues" with my respiration or whatever that maybe I'm not seeing in the "pretty" numbers.

I think tonight I will go with EPAP of 11 , IPAP of 20, and PS of 3. Just see what it looks like. Let me know if doing that is dangerous or something - I don't really know what to do.

I just don't see much difference between the Auto and the Bipap - what did you mean "except the flow limitation graph"? I don't know how to read that one and a couple of the others.

FYI - I actually set a camera up last night and there was little movement and I did not see any mouth breathing with the ResMed Nasal Mask I have settled on. Also, it is the only one where the humidity is not working properly - no water spraying or too much dryness. Finally......

Thanks for your reply!

Dallaslady51 wrote:I think tonight I will go with EPAP of 11 , IPAP of 20, and PS of 3. Just see what it looks like. Let me know if doing that is dangerous or something - I don't really know what to do.

Worth trying and not dangerous. Go for it.
We need to be comfortable first because if we aren't comfortable we fight the settings and the breathing and start to get all worked up because we are "having issues". For some people PS is more comfortable...more PS means more comfort but it's not necessarily that for all people especially someone who never used much exhale relief and you didn't.

Don't worry about my Flow limitation graph comment. I am not so sure that the difference in graphs couldn't simply be related to difference in model machines. Either way it's not a big deal.

With EPAP of 11, IPAP 20, PS 3, on the VAuto, does that mean the machine would start at 14 IPAP / 11 EPAP, and then increase when needed, where the IPAP max is 20? So if EPAP increased to 12, IPAP would increase to 15, and so on?

Matt00926 wrote:With EPAP of 11, IPAP 20, PS 3, on the VAuto, does that mean the machine would start at 14 IPAP / 11 EPAP, and then increase when needed, where the IPAP max is 20? So if EPAP increased to 12, IPAP would increase to 15, and so on?

Yep, that's how the VAuto bilevel machine works.
With ResMed bilevel the PS is fixed and won't vary unless a person gets one of the ASV machines that has a variable PS.

So with fixed PS the EPAP and IPAP will always be 3 cm apart (when using PS of 3) and the machine will auto adjust up to whatever the max IPAP is.
If IPAP of 20 gets hit with a max of 20 then EPAP will be at 17 when max is reached.

Just trying things. Last night I felt more restless, but the numbers are ok I guess. Increased the EPAP to 11 and reduced the PS to 3.6. I actually woke up about 7:30 and just stayed in bed. I feel really tired this morning.

Your numbers are fine. Not quite half that AHI is central/CA and some of those probably can be blamed on being restless.
We know of at least one wake up from the machine being turned off and back on again.
When you say "restless" does that mean you slept fitfully and remember several wake ups even if brief?
How's the anxiety level today?

Yes I could remember some tossing and turning. Anxiety level is awful as usual - no real change regardless of settings. I am trying to become friends with the Bipap and not be scared of it. Since I don't understand it, I have this underlying fear that it is doing more harm than good (not saying it's rational - I just think that's part of my anxiety). The other part is a bunch of moderate health issues that could become worse, but I should try to find ways to quit worrying about that so much. Found a good therapist and start with her on Thursday.

I think historically with the Auto, my pressure resuts stayed between 12 and 16. On the Bipap Titration if I remember, they reduced AHIs to zero between about 14 and 17. Based on the Titration study, what you typically see my settings on an Aircurve be based on:

PS of 3
PS of 4
PS of 5

Since I still can't understand how the PS works, I don't quite know what would be reasonable settings for the IPAP and EPAP to get to around maybe 13-18 pressure range? Is it better to have a higher PS to give the machine more range?

I did find one of the best Sleep Doctors in my area to work with long-term. The bad news is my appt is mid-September.... Obviously, she is really good and all the doctors refer their patients to her. She knows the machines and looks at all areas not just what a sleep study says - she reviews medications, what's going on in your life, etc.

I can't remember if I ever posted my sleep studies from October on here, but I could do that if it would help. The first one was a no machine/Auto study, and the second one was a Bipap titration.

Thanks again for your help.