High pressure, do I need CPAP or BiPAP?

[tschultz]

In my quest to get through my CPAP trial and trying to optimize my treatment I have reached very high pressures to control things and my DME is wondering if BiPAP may not be a better idea although it will take some added justification.

I am currently running in auto mode with pressure set to 15-18, and EPR set to ON, with a pressure of 2 decrease for exhale. I have now ran for the past 3 nights at these settings with no other changes and my numbers look quite good
AHI: 2.1, 4.2, 4.0
HI: 1.1, 1.3, 0.8
Obstructive: 0.9, 2.0, 2.6
Central: 0.1, 0.8, 0.5
My oxygen levels now run 94-98% for almost all night, with the lowest drop I have seen being only to 91% once, my pulse rate is now lower at 64-75 and much more steady when sleeping.

My 95 percentile leak is 0 each night so is not impacting my treatment, and the 95 percentile pressure is 17.9, 17.9, 18.0 for the three nights showing that I need that much pressure and maybe a bit higher even, or at least when using EPR at 2.

This pressure puts me very near the upper end of CPAP machine capabilities and my DME is worried that if things get worse there will be no room for adjustment. I know I am around 65 pounds overweight with the goal to lose that, or what I can, and do hope that this lowers the needed pressure but this is not guaranteed and will take some time to accomplish. I certainly know that with my severity I will never eliminate the need for CPAP.

My sleep doctor wants me to run in CPAP mode with a pressure of 15, but at this pressure if I do not use EPR I do not feel as rested the next day and at the lower pressure my snoring is increased and there are more hypopnea events. I know my sleep doctor is basing his number on my titration study where no exhalation relief was used. For some reason which I do not know he has been unwilling to approve auto-mode, this is something I have done myself to try and determine optimal settings needed by me.

I have definitely noticed that when using EPR the pressure setting needs to increase to compensate or the AHI goes up as well, this I think accounts for the auto algorithm running at 18 for most of the time with EPR on. Centrals are very low and if anything are a bit better also when using EPR.

I do seem to do fine with EPR at 2 or 3 even at these high pressures as I am averaging 7-8 hours sleep and treatment, and am not having difficulties breathing.

Should I be looking at BiPAP then, or does it make sense to stick with CPAP/APAP considering I am not having issues coping with things and would not say I am failing CPAP?
I do know BiPAP is not necessarily my choice but is this somehting I should be pushing for or should I push to stay with CPAP/APAP?

Does it make sense to expect that my pressure should decrease when I manage to lose the weight I need to and my health returns to more normal after all the sleep deprivation?

No matter what I am insisting on a fully data capable machine, and for this I really do like the S9 autoset data collection. By analyzing my data, especially my breathing and airflow, I have learned quite a bit about what happens during my apnea events even if sometimes I oddly seem to be holding my breath. I do want to monitor my treatment on an ongoing basis.

[avi123]

Your data looks so good I don't understand it why you're using such hi pressures. My CPAP was originally set at 6 mm H2O with EPR set at 2. After a month I raised the pressure to 7 b/c those two masks that I been using seemed leaky. A few days ago I raised the pressure to 8 to see what happens. That night my sleep became fragmented. So I lowered it back to 7. I'll see my pulmonologist in a few days to discuss the situation.

My DME is ready to swap my current "Entry Level" CPAP with either S8 AutoSet II, or S9 Alite, under Medicare rental with no additional payment. I could convince them to give me an S9 AutoSet instead, but I rather stay away from it. I don't trust the new technology in it.

As you mentioned, I also lost weight during the last 6 months (about 15 lbs). My BMI is 28, i.e. overweight but not obese. I stopped smoking 30 years ago but still have a slight COPD. My sleep indices improved a lot after the sleep study. But are a bit higher than yours. So why can't I give up CPAPing?

[rested gal]

Your data looks so good I don't understand it why you're using such hi pressures.

tschultz's data looks good because tschultz is using the amount of pressure it takes to keep tschultz's airway open. It apparently takes more pressure to keep tschultz's airway open than it does to keep avi123's airway open.

I do seem to do fine with EPR at 2 or 3 even at these high pressures as I am averaging 7-8 hours sleep and treatment, and am not having difficulties breathing.

That's great!

Should I be looking at BiPAP then, or does it make sense to stick with CPAP/APAP considering I am not having issues coping with things and would not say I am failing CPAP?

Sounds like you're getting effective, comfortable therapy with the machine you already have.

I do know BiPAP is not necessarily my choice but is this somehting I should be pushing for or should I push to stay with CPAP/APAP?

If you're doing fine with the machine you already have, there's no real need to push for a bilevel machine. True, you're up near the top limit of the pressure an autotitrating cpap can deliver, but you're getting good results there.
The pressure needed for you now is likely as much pressure as you'll need for many years, unless you gain a lot of weight over the next year or so.

On the other hand, a bilevel (and especially, a bilevel auto) machine would be nice to have -- just in case. Just in case you do need more pressure later on. But, you may never need that, and you do know already that you like the machine you're using and are doing well on it.

I guess what I'm saying in a wishy-washy way is.... if I were you, I might try to get a bilevel auto, but I wouldn't be particularly disappointed if I didn't get it. I wouldn't be disappointed much, because I'd still be getting good, comfortable treatment with what I already was using and knew worked fine for me.

Does it make sense to expect that my pressure should decrease when I manage to lose the weight I need to and my health returns to more normal after all the sleep deprivation?

That's always possible. Many people on this forum have reported significant weight loss resulted in their needing less pressure to keep their airway open.

[STL Mark]

I also use an S9 and keep it set at 16/20. My original titration was 18. I've had great results and no problem with compliance. If it ain't broke, don't fix it.

I find most insurance companies rent BiPAP/VPAP and buy CPAP/APAP.

[scrapper]

Your numbers look great right now............but when something changes, I agree that a bipap might be more beneficial.

It appears that you are comfortable at high pressure--I am finding more leaks at a similar pressure.

I would love to hear others input in similar situations....

[MoonBear]

Hi, I am at top range of 20 for some period every night on my S9. I range between 4 and 20 with 95% at 13. If I were you, I'd keep going with what you are doing because it is effective. If it ain't broke, why fix it? I would be at peace now, focus on the weight loss (perhaps we can cheer each other on?), and face the bipap bridge when you come to it. You never know; weight loss may change things substantially for you (and me, I hope).

Warm regards,
MoonBear

[HoseCrusher]

Since you are looking for ideas...

If I had those numbers, I would set the machine in CPAP at a pressure of 16 and an EPR of 2. I would run a night or two at that and then compare the oxygen profile to what you have now.

If the oxygen saturation remains the same, then you can "fine tune" the pressure by making very small adjustments to see what effect that has on your machine scored AHI.

Pulse rate by itself is interesting, but more importantly is how it reacts to desaturations of oxygen. I don't know what pulse oximeter you have, but if you can adjust the scoring parameters set them to score an event at a 3% desaturation. This will increase the sensitivity of the desaturation events. Now you can review your data with an eye on your pulse rate. If your pulse rate drops around 20%, then increases to somewhere around 150% of your low number around the same time as the O2 desaturation, that is significant. If the desaturation has no effect on your pulse rate, the significance is greatly reduced.

Since there is basically no correlation between O2 desaturations and machine scored AHI, I think it is better to treat them separately. The major goal is to eliminate desaturations below 90%. A secondary goal is to eliminate the "saw tooth" pattern of desaturations. Once you have your oxygen levels under control, you can then see what you can do about the machine scored AHI.

If you end up running at a pressure of 18, you are at about 90% of the capability of your machine. I don't know enough about how people's pressure changes over extended periods of time to venture a guess on staying with your current machine or trying to trade up to one that is capable of a little higher pressure.

Keep in mind that once you get your oxygen desaturations under control, it is time to focus on how you feel after a nights sleep. While it is nice to be able to report a low machine scored AHI, if you still feel like crap something isn't working. If you end up with a good average O2 saturation and no desaturations below 90% and feel great, it doesn't matter too much if you machine scored AHI is 5 or 1.

My $0.02 worth...

On a side note... Your pulse rate seems normal but I have been concerned with mine. My average pulse rate while sleeping is in the 48 - 52 range. When I mentioned this to my cardiologist, he smiled and put the pulse oximeter on his finger. Sitting there in the office his resting pulse was 45. While he assured me that I was fine, I still think I am running a little low and that he is a bit of an anomaly.

[Jayjonbeach]

My sleep doctor wants me to run in CPAP mode with a pressure of 15, but at this pressure if I do not use EPR I do not feel as rested the next day and at the lower pressure my snoring is increased and there are more hypopnea events. I know my sleep doctor is basing his number on my titration study where no exhalation relief was used. For some reason which I do not know he has been unwilling to approve auto-mode, this is something I have done myself to try and determine optimal settings needed by me.

Good to see you took this into your own hands, doctors in Canada are behind the times I believe. I knew more about APAP than my doctor did sad to say then when she found out about the requirements she changed my prescription from APAP to CPAP just because she didn't even want to write up all the paperwork and try and qualify me.

I seen at least one person who had a cooperative doctor BUT that was one out of 100's.

Your numbers are WAY down, for all you and the doctor know the proactive algorithm is helping you avoid apneas yet the "doc" wants to go back to CPAP....

Good luck. secondwindcpap sells the machine you want (when they have them) for much less than it can be bought up here if you run into resistance. The requirements for ADP for APAP are dumb and no doubt VERY hard to qualify for as I pointed out to you in another thread but if your doctor won't even give you the script I guess that wont matter. I don't think retail here will sell anyone an APAP with a CPAP script, not from what I have seen but I have heard that the USA will.

[tschultz]

...I don't think retail here will sell anyone an APAP with a CPAP script, not from what I have seen but I have heard that the USA will.

I've already commented on my wanting the S9 autoset to the company I am dealing with, but have decided that if it turns out to be too much trouble, I will simply get an S9 Elite with the humidifier and heated hose using ADP so they pay their 75% of the whole set. I will then get an S9 autoset without the humidifer and hose from a US vendor, shipped trhough a relative in the US, and use the elite as a backup unit if anything fails with the autoset. This actually works out to be less money out of pocket than if I were to have to buy the whole thing here in Canada without the ADP help. I'm simply not going to fight a losing battle to only pay even more money in the end.

Having said all that, I have started to draft a series of carefully worded letters to send to the various government and medical agencies voicing my opinions on the whole process and I have experienced it so far. They likely will do no good but at least will make me feel better for trying to change a very broken system. I truly think if used properly the auto-titrating machines such as the S9 autoset could be leveraged by the sleep doctors, with the data collection, in many cases to help reduce the burden on an overburdened system and result in a money savings and more optimal treatment for patients. It seems however things are setup with compliance as a concern and not optimal treatment.

I am however currently waiting to get some confirmation from the sleep doctor regarding if he wants me on CPAP or BiLevel. The concern is that with CPAP there little room to increase things if I get worse over the next couple of years. I am hoping that they improve but that may be over optimistic I just don't know. If he wants me on BiLevel then there is of course a much more complicated process with ADP that then has to start.

[jweeks]

In my quest to get through my CPAP trial and trying to optimize my treatment I have reached very high pressures to control things and my DME is wondering if BiPAP may not be a better idea although it will take some added justification.

Hi,

When using EPR, your machine is acting sort of like a BiPAP. For example, if the pressure is set to 18, and you have ERP at 2, you are getting 18 inhale, 16 exhale (18 - 2 = 16). EPR normally goes up to a difference of 3 cm of pressure. You can think of a BiPAP as doing the same thing, but allowing a wider spread in the EPR. For example, I am running 20/13, 20 cm on inhale, 13 cm on exhale, for a difference of 7. That would sort of like be an EPR of 7.

Since your AHI numbers are down, and you can tolerate the machine, your doctor can argue that you are getting effective treatment with the machine that you have. So it doesn't appear to be a medical necessity to get a BiPAP. If you are having trouble using it this way, then a BiPAP would be your answer. So, it boils down to comfort. If you think having more exhale pressure relief would help, then push for the BiPAP.

If you like the S9 machine, note that there isn't an S9 BiPAP yet. The S8 is a pretty good machine, but uses an older style smart card that isn't as convenient to use. The PR1 BiPAP Auto is also a very nice machine if you don't mind switching brands.

Another question is if it is worth the hassle to get your medical system to part the waters and allow you to get a BiPAP. Is it worth the effort it would take for the $1600 worth of machine? In my case, I had no insurance, so I bought a used machine--that might end up being cheaper in the long run. I also wanted a 2nd machine as a back-up, so I saved up my money and bought a new S8 VPAP. You might want a 2nd machine at some point, too, perhaps that would be an opportunity to get a BiPAP if you want one in the future.

-john-