Do I need BIPAP?

[jbn3boys]

I've been using my machine for about 2 1/2 months now. My average AHI is nearly 7, with nightly averages as high as 12 just in the last few weeks. Pressures are running around 10-11, with peaks greater than 15. Most nights I am experiencing central apneas, based on the Encore Viewer reports. Some nights the centrals are quite high. Leaks are well controlled, and I don't have any problems using the machine. However, I feel absolutely no better now than I did before starting on cpap therapy.

I just received my full polysonogram report in the mail this last week. I was shocked to find out that they actually had me on bipap for the final few hours of my sleep study/titration. They noted that at a pressure setting of 11 that I was still having hypopneas, so they switched me to bipap. (I can't remember the settings, and I don't have the report in front of me at the moment.) It was during the bipap time that I actually experienced my only extended periods of REM sleep. I had zero rem during the first part of the sleep study (before pap), and only one very short REM period on pap. But once they switched me to bipap, I had a significant amount of rem. However, the recommendation was still for cpap therapy, and not bipap.

Should I be asking to be switched to bipap, based on the sleep study report (specifically in regard to the rem stage) and the fact that I am still not feeling rested? If so, who should I be contacting first? My RT at my DME (who is very good), my PCP, who Rx'd the cpap machine, but really doesn't know much about them, or the sleep doc, who only read the results, but has never seen me? If I need to make this change, I'd like to do it as soon as possible, so all the kinks can get ironed out before the end of the year. (DH's company is switching our insuance coverage startin Jan 1st.)

Thanks for any help you can offer. I still feel like such a newbie!

[Hawthorne]

What do you mean by "too high" when referring to you centrals? Can you give us an average number? You tell us you don't have them every night either. How many nights do your Encore Viewer reports show centrals and over what recording time frame?

My current titrated pressure is 11cm (that is not really a very high pressure) and I do fine on my PR System One auto. I have it in auto mode and have a narrow pressure range set (10.5 to 13 cm). I spent most of the night at 11 and 12 cm , sometimes going up to 13 cm.

My AHI with that, is almost always below 2. Your AHI is a little high an average of 7. What is your highest and lowest AHI so far?

I use the A-Flex (setting of 1) so that I exhale against less pressure than on inhale. With one of the Flex setting set, it is similar to a Bipap then especially for someone who is titrated at only 11 cm.

I don't know why they would have used a Bipap on you at the study. It seems strange to me, given your numbers. They may have wanted to see how much, if any improvement you had on a Bipap.

If you need a Bipap, sometimes you have to fail cpap (not do well) to get switched to Bipap. They may have tried a Bipap, anticipating that you may need it and it may save another sleep study.

You need to talk to your doctor about your data, probably your GP and maybe your sleep doctor. If you talk to your GP, he/she may be in touch with the sleep doctor for you. That happened in my case and things were taken care of a lot faster.

It does take time to adjust to cpap and begin to get any benefit, for some longer than others.

[Mary Z]

It sounds from your post that you are using an AUTO machine, rather than a straight CPAP. An auto can run at a range of pressures, which you described, rather than on straight pressure (which is CPAP). It sounds as though you may need your pressure adjusted.
Good luck, keep us posted. I also would start with the Primary Care Doc, unless the sleep study doc is willing to do a download of your machine and make changes as necessary. Ususally you can talk to the techs at the office and explain the problem and they will do a download and consult with the Doc.

[Julie]

I wonder if you're not mouth breathing while asleep, and losing all the Cpap air that way, like a lot of us. We've switched to full face masks and the problems are gone, or at least we're now getting treated, so AHI's are lower.

[jnk]

The fact that bilevel (also called Bi-PAP) was tried on you during the study does not, in itself, make for an argument for getting one. The fact that you had REM while on bilevel is likewise not an argument for you to get one if the REM happened toward the end of the sleep period; the largest segment of REM usually occurs at the end of the night either way, and you may have gotten a similar amount of REM if you had been using straight CPAP at that time.

HOWEVER, the fact that bilevel was tried means that I would comb through the sleep-study report (the full report, not just the summary) to see if any mention was made of WHY the tech tried bilevel. Indications of hypoventilation, perhaps due to habitus? Signs of struggling against the pressure? Other? THAT might make for an argument for bilevel.

As has been stated, though, "failing" CPAP is often required in order for insurance to pay for bilevel, so painting an accurate picture for your doctors about the problems you are having is the right thing to do. That may allow them to document the results and to do what they may have wanted to do in the first place if insurance had allowed them--get you on bilevel.

I would make sure I got an autobilevel (also called VPAP Auto or Auto Bi-PAP) if I was going on bilevel, since that gives you full options for future treatment. That's what I did, anyway.

[jbn3boys]

Okay, I'm home now, with access to all of my information, so I will try to answer the questions that have been asked so far.

Regarding my centrals--I have never had a night with zero centrals. My lowest nightly index is 0.7, which has only happened twice. My highest nightly index was 13.3 per hour. The average (over 2 1/2 months) is 3.4 per hour.

Regarding AHI-- the lowest I've ever gotten was 2.6 (only once). The vast majority of my nights the AHI is well over 5, with the highest recorded at 17.7 (higher than I had during my sleep study before they hooked me up to cpap).

Yes, I am using my machine in Auto. I think my range is 9-20. The average 90% pressure is 13. From the charts I get, I have seen the pressure go as high as 17, and never below 10. I have the A-Flex set at 2. I have no problems with this, but like I said, I do not feel any improvement, and I'm concerned that the only REM sleep I got during my sleep study was during the bipap segment of the titration.

Regarding mouth breathing-- I have asked my husband if I breathe through my mouth, and he has never seen it happen. (He has nights that he is awake a lot, and he has often checked for me.)

As far as why they put me on bipap during titration, this is what my sleep study summary finding says:
"The pressure settings on the CPAP were escalated from 5cm of water all the way up to 11 cm of water. At the highest pressures, a few hypopneas were noted. Nasal BiPAP at a pressure of 14/11 cm of water was used in the end with no significant obstructive sleep apnea or snoring being seen."
The end of the summary states: "Initially, the patient can be started on a nasal CPAP at a pressure of 11 cm of water along with heated humidity and a nasal mask. A clinical correlation is advised."

[jbn3boys]

One more question. Have I "failed" cpap (auto pap) if I'm still just as tired after 2 1/2 months as I was before? (no symptom improvement other than no more snoring?)

[jnk]

One more question. Have I "failed" cpap (auto pap) if I'm still just as tired after 2 1/2 months as I was before? (no symptom improvement other than no more snoring?)

The answer depends partly on your doctor, partly (perhaps) on the amount of documentation obtained during your titration, and partly on your specific coverage. A case might have to be made in a very specific way, depending. It might require some paperwork. But if you are not benefiting fully now, despite all your efforts in cooperation with your team to make your present form of therapy therapy successful, it would be a case worth making.

[Bons]

One more question. Have I "failed" cpap (auto pap) if I'm still just as tired after 2 1/2 months as I was before? (no symptom improvement other than no more snoring?)

An AHI of 8 after three weeks got me a Bipap. Talk with your doctor.

[allen476]

Regarding my centrals--I have never had a night with zero centrals. My lowest nightly index is 0.7, which has only happened twice. My highest nightly index was 13.3 per hour. The average (over 2 1/2 months) is 3.4 per hour.

That seems rather high, possibly pressured induced. The night that it was 13.3/hour, what was your pressure at?

Regarding AHI-- the lowest I've ever gotten was 2.6 (only once). The vast majority of my nights the AHI is well over 5, with the highest recorded at 17.7 (higher than I had during my sleep study before they hooked me up to cpap).

What is your average AHI after 2-1/2 months?

Yes, I am using my machine in Auto. I think my range is 9-20. The average 90% pressure is 13. From the charts I get, I have seen the pressure go as high as 17, and never below 10. I have the A-Flex set at 2. I have no problems with this, but like I said, I do not feel any improvement, and I'm concerned that the only REM sleep I got during my sleep study was during the bipap segment of the titration.

That is a very big range for your pressure. You might want to try a range of 9-14. Then tune it from there.

As far as why they put me on bipap during titration, this is what my sleep study summary finding says:
"The pressure settings on the CPAP were escalated from 5cm of water all the way up to 11 cm of water. At the highest pressures, a few hypopneas were noted. Nasal BiPAP at a pressure of 14/11 cm of water was used in the end with no significant obstructive sleep apnea or snoring being seen."
The end of the summary states: "Initially, the patient can be started on a nasal CPAP at a pressure of 11 cm of water along with heated humidity and a nasal mask. A clinical correlation is advised."

The clinical correlation part means basically that whoever interpreted the study left the results up to what the symptoms are. Or in other words, start you on cpap and see how you do. If you are not doing any better, then maybe try bi-pap.

But my take would be that bi-pap might be better suited since you have a higher than normal CA average along with no improvement in symptoms. You stated that your PCP is the one that rx'd the machine and I suspect only read the first part of the summary. If it were me, I would make an appointment with your PCP and talk to them about a switch to bi-pap for a 2 week trial. This usually will satisfy the insurance company if you can prove that you are doing better on bi-pap than cpap. Since you are only 2-1/2 months into your rental/purchase of the APAP, then you shouldn't have a problem in exchanging it if it does work.

But then again I am not a Dr.

Allen

[jbn3boys]

I apologize for not responding to your questions sooner, Allen. Life got a little crazy around here for a few days!

The night my CAs were 13.3 my average pressure was 12.6 with a 90% pressure of 16.5. ON another random night, my CA was 6.9 with average pressure of 12.0 and 90% pressure of 14.9. Overall, for the full time on apap, the average pressure is 10.3 with 90% pressure of 12.9.

Average AHI for 2 1/2 months is 6.7, with highs of 12.2 (and 17 twice in the first week of therapy), and lows occasionally in the 3.x range.

Thank you for your insight, and for clarifying what the "clinical correlation" is. That's what I was thinking it meant, but I really wasn't sure.

Thanks to everyone for your input. I think as soon as this cold subsides, I will see my PCP and ask for a trial on bipap. Maybe that will be the "golden ticket" to my finally feeling better.

[victormiller]

I had a new sleep study two weeks ago. This one -- unlike the previous four -- went quite well. I had a sleep efficiency of 90%. I asked them to use nasal pillows since I've found that the most comfortable, and I exhibited no mouth breathing. The next week when I met with the sleep doc he said that things had gone well -- my AHI during the study was below 2, and my O2 saturation never got below 98%. He said that the regulation done by the sleep tech was all over the place so he prescribed a Respironics System One Bipap auto with cflex (plus humidifier). I've been using it for a little over a week, and really feel awful. I got the Encore 2.2 software and so looked at the data on my smart card and it indicated that I've been having an AHI of over 50! and periodic breathing of 45%. When looking at the detailed reports I see that the vast majority of the apneas are central apneas -- for instance last night out the AHI of 50, about 36 were for central apneas. I'm wondering if these are being induced by the bipap. The settings on the bipap are 15/5. One other thing -- the ramp feature doesn't do anything. The tech who set up the machine said that with the EPAP of 5 that the ramp wouldn't kick in (which seems a little weird). I notice when going to sleep that most of the times that I inhale it's like my nose is being slammed with a really high pressure. I thought that the biflex was supposed to mediate that. Any suggestions?

[jbn3boys]

VIctor,
You might want to start your own thread with this question. I'm sure there are many bipap users who could help you. From the little I've read about it though, it seems like the pressure setting is off. That seems like a huge range to me. I thought the difference between the two numbers on bipap (or bilevel) was usually 2-4, not 10. But, like I said, I have no experience with bipap, I'm just trying to decide if I need to ask for a trial with one.

[timbalionguy]

Victor, please start a new thread for your interesting situation. In the meantime, call your doctor and confirm your machine settings. It is really unusual to see an IPAP/EPAP spread of more than about 5. That could explain a lot of your observations.

[elena88]

HI JBN,

After months of struggling with my apap, and many charts and graphs I showed to my doctor, she suggested a bipap..

I had already purchased my apap for cash, so it was too late to change to bipap, but she had the hospital lend me a malibu vpap, and I took
it home for ten days.. the first night was rough, the second better, and by the third night I had it wired.

I have to tell you it was much more comfy than my apap, and I really wanted to get one.. but then I did some experiments with my apap
and discovered I could get by with a pressure of four cm, so that nullified the need for the bipap..

I think they normally say you need to "fail" at cpap, or apap, but if you happen to be a shallow breather, or have a long exhale, or
a pause after your exhale, its very hard to get any good sleep with a cpap. If you have some lung issues too, that can put you in the bipap column.
My doc would have given me one, but now I dont need it.. I hope you get a machine that lets you get some rest.. it sounds like you
arent going into any restfull sleep, and I wasnt either.

When I decided I wanted to get a bipap, I was looking at the resmed vpap 25 auto.. that looked pretty sweet.. If you do get a bipap, get
an auto, its just sooooooooooooooooooooo much easier.. ... all the way around.. youll be glad, get an auto bipap if you go bipap..

goood luck and best wishes for some restful sleep ahead!

elena