Help with Auto BiPap Settings?

I am doing a self-titration on an auto-bipap machine, and could use a little help.

Background: I had been doing really well on straight BiPap set at 16.0 and 13.0. But then my numbers started to creep upward, sometimes more than doubling. (2-3 AHI to 6+AHI) I bumped up the IPAP to 16.5 and then to 17. I'm still having higher AHIs for no discernible reason. So I decided to do a week or two on auto, to see if I can figure out a better setting.

Last night I set my machine as follows:
Max EPAP: 25.0
Min IPAP: 13.0
PS: 5.0

And this is what my report looks like this morning.


I don't know why the image is so blurry. I'll try to fix it.

Would you suggest any changes tonight? I know that I don't want to do major changes without giving it several nights to adjust, but I'm just wondering if I need to up my settings, based on last night.

Thanks for any help! I really appreciate it!

jbn

My first thought would be EPAP minimum being a bit more than 13 and not IPAP adjustments..
EPAP has to be sufficient to take care of the bulk of the obstructive apneas and IPAP is available for the hyponeas.
When I got this same machine as you are using I did some reading on it that was the consensus of everything I read.

Give me a bit and I will see if I can locate the discussions that I read.
Rested Gal had some of them in her storage of links.

I concur with Pugsy:

On the PR machines, it's the EPAP that deals with both snoring and OAs and your relatively high AHI is composed mainly of OAs and you've got quite a bit of snoring going on.

The 90% EPAP for this night is 17 or 18 cm (depending on where you look in the chart, but min EPAP = 13. Maybe bumping the min EPAP up from 13 to 14 or 15cm would help.

Anything else going on health wise----like a bad head cold or the flu? When I'm fighting a head cold, there is a noticeable jump in my AHI's from the 1--2 range to the 2.5--3.5 range.

If you haven't given SleepyHead a try, you might want to. That would allow you to actually look at just how long those OAs are and just how closely packed they are. Because at certain times of the night, it looks as though the OAs are not coming quite close enough together to trigger the auto algorithm into increasing the EPAP.

I can't find the discussions that I read in Rested Gal's links. Perhaps she gave them to me. I forget.

The Auto BiPap has to be treated like the APAP when setting the minimum EPAP. Same rules apply...it takes a while for the machine to increase to where it needs to be so we have to give it a head start by having the minimum close enough to needed pressure that the machine can get there quickly enough to prevent the events.

If it were me I would go up in 0.5 increments on the EPAP minimum end of things (allowing a bit of time at each) and see what happens. I would leave IPAP alone for now. I think your EPAP is very close to what it probably wants to be.
Sometimes we get lucky and 0.5 cm change makes a huge difference.

Thanks so much for the excellent information, ladies! I truly appreciate it.

Unfortunately, I can't use how I feel today as a gauge, since hubby had to wake me up nearly 2 hours earlier than normal. I'm feeling pretty groggy today, but the early awakening (and from the middle of a dream, non-the-less) can be the cause of today's feelings.

Nothing else is going on that would account for any of my numbers. The original change in AHI numbers goes back to mid-November. I have wracked my brain trying to come up with anything that could have caused it. But I've come up with nothing. Since that time, we have gotten a new bed, but that was about two weeks after the change in AHI. And another week after that, I started a new asthma medication, but again, did not see any change in relation to that additional medication. I had been putting on some excess weight, and hit my top weight just after the spike in AHI. However, I've since gradually lost 17 pounds, so if the weight was the issue, then the numbers should have come down as the weight came off.

I really did not have the time to do a lot of research on how to do an auto titration trial on a bipap. I did a little searching, but there is just so much information on the forums, it was difficult to pinpoint the information that I really needed. I ended up just picking the settings I thought would be closest to what I had been using on straight bipap. I think for tonight I will definitely increase the Min EPAP. I may even jump to 16.0, since last night almost seemed "too easy" while I was awake. I'm used to really "feeling" the bipap, and last night it seemed like there was almost none of that. I'm sure I'll check back in again in a day or two, and let you know how it's going. I'm sure I will probably have more questions. I'm so thankful for this forum, and the members who continue to be active. (Thanks Pugsy and RobySue!) I always have great plans to stay active, but it seems once things start going better, I forget to check in very often. I appreciate your willingness to continue to help out day after day, month after month!

jbn

Good luck with your experiment. I recently got myself the same machine as you have and love it. For well over 2 years no one ever heard me say "I love anything" about this cpap stuff. I am finally feeling those good numbers I have had all this time. I have documented part of it here if you are bored. viewtopic/t71442/viewtopic.php?f=1&t=71 ... te#p656179

Keep us posted please.

Here's last night's information. I think, in my totally uneducated estimation, that it looks better than the previous night.





My main question today, aside from how do you think these look, is this:
Am I in the right ballpark to have the PS set at 5.0? If I understand correctly, that is the distance between IPAP and EPAP. But is that the minimum, the maximum, or is that always what it is? (I have previously had straight bipap settings at 16.0/13.0 and 17.0/13.0)

Thanks again!
jbn

**Edited to correct pictures

PR S1 BiPap Auto with PS of 5 allows for PS to range up to 5 cm difference. It is not a fixed range.
In straight bilevel mode it would be a fixed range.

Jnk did the "dance floor" analogy a while back. Have you read his explanation? It helped me a lot.

PR S1 PS in auto mode is a "range" that the machine can dance around in. Difference between EPAP and IPAP will never exceed 5 but it could be less.

Since your EPAP & IPAP minimums and maximums are relatively close together now we don't see a wide range here. If your EPAP minimum was say 10 cm..we would see a more dramatic change as IPAP drags EPAP up.

I think your last night's report shows improvement. I have never fully understood just how much the PS support needs to be changed (like if or when or how much) so I don't know if changing PS would impact things.

I will say that when I first started on the BiPap my numbers were a bit higher than I had been getting on my APAP but with time and no changes they seemed to trend downward till now I often have AHI less than one. You made a significant change last night and it shows. I would give this change a few nights to see how it trends before thinking of another change. Just my thoughts....

Pugsy wrote:PR S1 BiPap Auto with PS of 5 allows for PS to range up to 5 cm difference. It is not a fixed range.
In straight bilevel mode it would be a fixed range.

That makes perfect sense. If I would have thought it through, I may have come up with that.

Pugsy wrote: You made a significant change last night and it shows. I would give this change a few nights to see how it trends before thinking of another change. Just my thoughts....

Thanks kind of what I was thinking, too, unless I also needed to change the PS (which it sounds like I do not need to do).

If I get time today, I'm going to try to get sleepyhead running, and see what information is there.

jbn3boys wrote:Thanks kind of what I was thinking, too, unless I also needed to change the PS (which it sounds like I do not need to do).

In my reading I never could find examples of how the PS actually impacted therapy data. Like what happens when we reduce PS or increase it and don't change EPAP or IPAP. Logic tells me that with lower PS then IPAP could/would bring EPAP up closer to it and this might help with keeping the EPAP a bit higher IF IPAP seemed to need to be higher. EPAP being needed for obstructives. How critical is PS setting for effective therapy? I don't know.

Of course comfort comes into play here. At IPAP pressures of 20 something we are going to need more "difference" in IPAP and EPAP to exhale easily at these pressures.

So how much of PS is comfort and how much affects therapy? I don't know. I do figure that comfort is an important feature because if we aren't comfortable and don't sleep well.... then all the other stuff is rather moot point.

jbn3boys wrote: My main question today, aside from how do you think these look, is this:
Am I in the right ballpark to have the PS set at 5.0? If I understand correctly, that is the distance between IPAP and EPAP. But is that the minimum, the maximum, or is that always what it is? (I have previously had straight bipap settings at 16.0/13.0 and 17.0/13.0)

Thanks again!

Just adding numbers to that excellent response by pugsy. And you are right: PS = IPAP - EPAP and on the PR System One BiPAP Auto, PS is NOT constant when using Auto mode. (Note that on the Resmed VPAP Auto, the PS is a constant when running in auto mode.)

On the PR System One BiPAP Auto with your current settings are:

• Min EPAP = 15
  Max IPAP = 25
  PS = 5

the pressure levels and PS will stay in the following ranges:

• 2 <= PS <= 5
  15 <= EPAP <= 23
  17 <= IPAP <= 25

At the beginning of the night, EPAP = 15, IPAP = 17, and PS = 2. EPAP will increase for snoring and OAs; IPAP will increase for flow limitations, hypopneas, and RERAs. The PR "hunt and peck" algorithm is used on IPAP. In other words, the machine will regularly increase the IPAP by a bit to see if the shape of the inspiratory part of the wave flow improves; if it does, the machine leaves the IPAP at the new level, and if it doesn't, the machine reduces the IPAP back down to the previous level. That's why the IPAP graph has saw tooths in it.

As long as 2 < PS < 5, the IPAP and EPAP pressures will vary independently of each other. If PS = 2 and EPAP needs to be increased, then both EPAP and IPAP will be increased. If PS = 5 and IPAP needs to be increased, then both EPAP and IPAP will be increased.

Hope that helps.

Pugsy wrote: In my reading I never could find examples of how the PS actually impacted therapy data. Like what happens when we reduce PS or increase it and don't change EPAP or IPAP. Logic tells me that with lower PS then IPAP could/would bring EPAP up closer to it and this might help with keeping the EPAP a bit higher IF IPAP seemed to need to be higher. EPAP being needed for obstructives. How critical is PS setting for effective therapy? I don't know.

I think you're on the right track here.

I think the one time PS might matter is when it takes a lot more pressure to control of a person's obstructive hypopneas, RERAs, and flow limitations than it does to take care of his/her snoring and OAs. In that case, a relatively high PS setting lets that IPAP increase as needed without dragging up the EPAP unnecessarily.

And if you're prone to aerophagia, then keeping that EPAP as low as possible, while still taking care of the OAs of course, tends to reduce the overall average pressure setting, which in turn should lead to less swallowing of air and less aerophagia. I think this is the main reason behind offering a BiLevel or BiLevel Auto trial to folks who are having trouble with aerophagia while try adjusting to straight CPAP or APAP.

Of course, from a pure "effective therapy" point of view, minimizing discomfort due to aerophagia is largely a "comfort" issue.

And I'll go out on a limb here, but I think the reasoning is also similar for why BiLevel is often first suggested for those who have centrals that emerge after starting CPAP/APAP therapy: If the centrals are indeed caused by "too much pressure", then a bi-level with a relatively large PS setting will be able to control the obstructive stuff but also perhaps allow the overall "average pressure" to be just enough less so that the centrals are less likely to happen.

That makes a lot of sense. I'm guessing that PS=2 is the minimum PS allowed by PR System One.

I also got SleepyHead installed today, and I think I have it all up and running. I'm not sure I really understand what all I'm looking at, but I'm sure I'll figure it out. Here's a snapshot of the first page when I open it:

Here's a close up of the main window:

jbn3boys wrote: I'm guessing that PS=2 is the minimum PS allowed by PR System One.

Yep, this is what you have by default when you first turn the machine on. It is 2 cm above chosen minimum EPAP. I watched it and spent the better part of an afternoon trying to get it to give me a 4 cm PS that I had when I used the PR S1 BiPap Pro that ended up with mmkof5 (she needed it much worse than me since she used 16.5 cm) and it was that machine that got me on the BiPap wagon.. OMG I really liked that 4 cm PS. In auto mode we are stuck with the minimum default of 2 cm until event precursors start triggering pressure increases. I didn't care about what happened when I was asleep... I wanted 4 cm PS while I was awake. Didn't work out that way. Finally figured it out that I only get that 4cm difference with straight bi-level mode. So I decided to try straight bilevel for a while. Then I got to try the ResMed VPAP auto and I was in heaven..it let me set PS to 4 cm immediately so I could have it while awake..down side is that PS is fixed if someone happens to need a varying range in a situation like Robysue mentioned which makes perfect sense in regards to centrals and/or aerophagia.

I am lucky..no problems with aerophagia or centrals so I can play as much as I want to. I have discovered that I do well with either the BiPap or VPAP and I do well in either mode. So I am very lucky.
Main thing after 2 1/2 years on APAP is that I actually am sleeping longer and feeling better and the only change has been sleeping longer for some reason. AHI has always been very decent unless I played with a lower EPAP (which I did) and quickly changed.

Go to the events tab in SleepyHead if you haven't already.. open each event classification...then click on a single event and the graphs will automatically change to a zoomed in up close and personal close up of the event. Way cool. Can't do that in Pro unless you sort through all the wave form stuff.
You can also customize the graphs so you see the most commonly used graphs without having to scroll and you can change the size of the graphs also.