Is this bad? Is it UARS? Flow rate questions

[Geer1]

3. The numbers I've been playing with are the minimum pressure and the exhalation relief, with the goals of both treating the hypopneas as well as getting a nice rounded inhalation curve, which I generally get with lower pressures (7-9), but most reliably get at pressures of 10 cm on the inhalation. In an open range of 4-20, my 90% pressure was 7cm, with an epr relief of 3. Which is quite low! So I figured a 10 inhale, 7 exhale would be good....

4. Yes, I have an auto-ramp on so that's why it's lower in the beginning.

Here is an image of me with totally different settings,

Same as me. I can get by with acceptable ahi using min pressure settings but it’s just subpar treatment and after jumping up to 8 cm min I noticed a physical difference and differences in flow graph even though ahi was unaffected. 12 cm felt a little uncomfortable(I think it was the extra noise and venting) so I’ll probably drop back down to 8-10 range after collecting a couple more nights data.

I think you are likely getting as good of relief as you can on this machine. The only difference I personally would make is turning ramp off but that is just a trial and error comfort setting so do what feels best.

I can’t comment on bilevel but have seen a couple comments like slowriter saying it can help. I’ve been wondering about buying a VAUTO instead of Autoset just to have the extra functionality even if I don’t end up needing it.

As a side I was just diagnosed with non allergenic rhinitis. It is causing nasal congestion and is likely a significant part of my sleep disordered breathing. Theoretically I fall under OAS (ahi over 5 due to hypopneas, almost no apnea’s) but I have felt like UARS concepts (arousals) are somewhat applicable as well. I didn’t have in clinic psg so don’t have any of that data to reference though. Did you do an in clinic test?

[Apneak]

So I've done in lab and at home studies....most recently my rdi on my back is really high, like 30, ahi somewhere around 11. I also just had a pap titration the other day, and I requested they test bipap, but who knows if they actually did. Apparently they're really resistant to bipap because it's more expensive and insurance is stingy with it. Anyway you convinced them on Bipap? Or just buying it with cash?

Slowriter, i've seen your post on uars! some great info there. Why do you say I wouldn't get any benefit from "for her"? isn't that meant to treat light flow limitation events like i have? What settings did you try on the apap, and what did you end up with on the BiPap?

[palerider]

2. The range is narrow because over many weeks of data, I have never seen a pressure above 11.5 being delivered even though it was possible. I have no issue with raising the max, but also so no reason to do so.

The reason to not have a lowered max is the unexpected... All you do by lowering the max is to prevent the machine from responding to your needs, if you need something different, over time, or for some unexpected reason one night.

[Geer1]

So I've done in lab and at home studies....most recently my rdi on my back is really high, like 30, ahi somewhere around 11. I also just had a pap titration the other day, and I requested they test bipap, but who knows if they actually did. Apparently they're really resistant to bipap because it's more expensive and insurance is stingy with it.

Slowriter, i've seen your post on uars! some great info there. Why do you say I wouldn't get any benefit from "for her"? isn't that meant to treat light flow limitation events like i have?

You can try for her but it reacts slower and for me resulted in higher flow limitation. I posted my comparison here.

viewtopic.php?f=1&t=177402&p=1331969#p1331969

Here is an interesting article I just found searching for UARS on uptodate (one of the most used medical databases for doctors). I couldn't find any information about bilevel but it kind of makes some sense when you read this article as it appears the build up of CO2 plays a role and the higher pressure support available on a bilevel would help get rid of that CO2. Have you noticed any difference when using the different EPR settings? I only tried changing mine briefly and have stuck with 3.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5015642/

[Miss Emerita]

(For some reason, I have had repeated trouble posting this. I think by now a fair amount is moot, but I'm trying again just in case something is useful.)

Thanks for the chart, Apniak. First off, I hope you are usually getting more than 5-6 hours of sleep per night. That is too little for almost everyone.

Second, on the zoomed-in views, especially the first one, there are signs of flow limitation. Ideally the curve above the zero line will rise and fall in a smooth curve. With FL, we will see plateaus, peaks with flat shoulders, or dents. I find that even when I don't have a FL flag on my chart, my breath shapes can show some FL. I suspect we all have some FL at least some of the time, so the question is whether reducing FLs would make a difference to how well you sleep and how rested you feel.

Third, just an aside: the little ups/downs around the zero line are probably cardioballistic, meaning that they are changes in the flow rate caused by your heartbeat. It's not that uncommon (I have it too) and it's nothing to worry about. One thing it can do, however, is louse up the way your inhale/exhale times are represented. (For some reason, the VAuto corrects for this.)

Fourth, I'd be interested in seeing your respiration rate rather than your inspiration time. I'm wondering whether we are looking at a something REM-related, and that might be clearer from the RR.

Fifth, if you think you might be sensitive to pressure changes, then given how well your events are controlled with your present settings, you might consider setting your max = min.

And finally, if you haven't been using CPAP for very long, it's probably a good idea just to continue getting acclimated to it before worrying about getting a different kind of machine. It's really hard to be patient when you keep feeling lousy, as I know full well, but often that is actually the best thing to do. That, plus work on "sleep hygiene":

• Keep a consistent sleep schedule. Get up at the same time every day, even on weekends or during vacations.
• Set a bedtime that is early enough for you to get at least 7 hours of sleep.
• Don’t go to bed unless you are sleepy.
• If you don’t fall asleep after 20 minutes, get out of bed.
• Establish a relaxing bedtime routine.
• Use your bed only for sleep and sex.
• Make your bedroom quiet and relaxing. Keep the room at a comfortable, cool temperature.
• Limit exposure to bright light in the evenings.
• Turn off electronic devices at least 30 minutes before bedtime.
• Don’t eat a large meal before bedtime. If you are hungry at night, eat a light, healthy snack.
• Exercise regularly and maintain a healthy diet.
• Avoid consuming caffeine in the late afternoon or evening.
• Avoid consuming alcohol before bedtime.
• Reduce your fluid intake before bedtime.

[slowriter]

So I've done in lab and at home studies....most recently my rdi on my back is really high, like 30, ahi somewhere around 11. I also just had a pap titration the other day, and I requested they test bipap, but who knows if they actually did. Apparently they're really resistant to bipap because it's more expensive and insurance is stingy with it. Anyway you convinced them on Bipap? Or just buying it with cash?

I insisted the doctor specify to test bilevel, and then I talked to the tech that did the study so she understood my concerns, and what I wanted. I even gave her a short memo with bullet points, one of which was to eliminate RERAs.

I got lucky with the tech. She knew what she was doing, and happy to discuss with me.

As for the machine, I bought a barely used Resmed VAuto bilevel while waiting for the titration study because I wasn't sure how big a hassle it would be to get insurance approval, and I figured even if I did, it could be my backup.

But it turned out they did approve. So I have the prescription; I just haven't used it yet, since I figured I'd wait to see if Resmed releases new machines (based on past history, they're overdue).

Slowriter, i've seen your post on uars! some great info there. Why do you say I wouldn't get any benefit from "for her"? isn't that meant to treat light flow limitation events like i have? What settings did you try on the apap, and what did you end up with on the BiPap?

My APAP machine was the for her model, for one

But also, logically, they're the same machine, with same pressure capabilities; just slightly different algorithms.

You can see my current settings in my signature. I am on a PS of 6 (based on the titration study, actually), which is double the EPR that the Resmed APAP can provide. The EPAP isn't really that different from what my min pressure was on the APAP.

[Geer1]

You can see my current settings in my signature. I am on a PS of 6 (based on the titration study, actually), which is double the EPR that the Resmed APAP can provide. The EPAP isn't really that different from what my min pressure was on the APAP.

Out of curiosity were you able to notice any obvious differences in OSCAR data from APAP to bilevel? If so in what way?

I'm just curious if it is something you can see with OSCAR or if you pretty much need to do PSG with EEG.

[slowriter]

You can see my current settings in my signature. I am on a PS of 6 (based on the titration study, actually), which is double the EPR that the Resmed APAP can provide. The EPAP isn't really that different from what my min pressure was on the APAP.

Out of curiosity were you able to notice any obvious differences in OSCAR data from APAP to bilevel? If so in what way?

I'm just curious if it is something you can see with OSCAR or if you pretty much need to do PSG with EEG.

The most straightforward and obvious difference you can see in the FL graphs and numbers. Compare this early one on APAP, with this more recent one on bilevel.

Screenshot from 2019-12-08 19-17-02.png (116.88 KiB) Viewed 11374 times

Screenshot from 2019-12-08 19-16-23.png (110.67 KiB) Viewed 11374 times

[Apneak]

You can see my current settings in my signature. I am on a PS of 6 (based on the titration study, actually), which is double the EPR that the Resmed APAP can provide. The EPAP isn't really that different from what my min pressure was on the APAP.

Out of curiosity were you able to notice any obvious differences in OSCAR data from APAP to bilevel? If so in what way?

I'm just curious if it is something you can see with OSCAR or if you pretty much need to do PSG with EEG.

The most straightforward and obvious difference you can see in the FL graphs and numbers. Compare this early one on APAP, with this more recent one on bilevel.


Screenshot from 2019-12-08 19-17-02.png

Screenshot from 2019-12-08 19-16-23.png

What do your pressure charts look like?

[Apneak]

(For some reason, I have had repeated trouble posting this. I think by now a fair amount is moot, but I'm trying again just in case something is useful.)

Thanks for the chart, Apniak. First off, I hope you are usually getting more than 5-6 hours of sleep per night. That is too little for almost everyone.

Second, on the zoomed-in views, especially the first one, there are signs of flow limitation. Ideally the curve above the zero line will rise and fall in a smooth curve. With FL, we will see plateaus, peaks with flat shoulders, or dents. I find that even when I don't have a FL flag on my chart, my breath shapes can show some FL. I suspect we all have some FL at least some of the time, so the question is whether reducing FLs would make a difference to how well you sleep and how rested you feel.

Third, just an aside: the little ups/downs around the zero line are probably cardioballistic, meaning that they are changes in the flow rate caused by your heartbeat. It's not that uncommon (I have it too) and it's nothing to worry about. One thing it can do, however, is louse up the way your inhale/exhale times are represented. (For some reason, the VAuto corrects for this.)

Fourth, I'd be interested in seeing your respiration rate rather than your inspiration time. I'm wondering whether we are looking at a something REM-related, and that might be clearer from the RR.

Fifth, if you think you might be sensitive to pressure changes, then given how well your events are controlled with your present settings, you might consider setting your max = min.

And finally, if you haven't been using CPAP for very long, it's probably a good idea just to continue getting acclimated to it before worrying about getting a different kind of machine. It's really hard to be patient when you keep feeling lousy, as I know full well, but often that is actually the best thing to do. That, plus work on "sleep hygiene":

• Keep a consistent sleep schedule. Get up at the same time every day, even on weekends or during vacations.
• Set a bedtime that is early enough for you to get at least 7 hours of sleep.
• Don’t go to bed unless you are sleepy.
• If you don’t fall asleep after 20 minutes, get out of bed.
• Establish a relaxing bedtime routine.
• Use your bed only for sleep and sex.
• Make your bedroom quiet and relaxing. Keep the room at a comfortable, cool temperature.
• Limit exposure to bright light in the evenings.
• Turn off electronic devices at least 30 minutes before bedtime.
• Don’t eat a large meal before bedtime. If you are hungry at night, eat a light, healthy snack.
• Exercise regularly and maintain a healthy diet.
• Avoid consuming caffeine in the late afternoon or evening.
• Avoid consuming alcohol before bedtime.
• Reduce your fluid intake before bedtime.

Hi Miss Emerita,

I generally do get more, yes! Sometimes though I'll take off the mask in the morning and get some side-sleep in, since my disorder is positional largely. ALso thanks for the note on cardioballistic, I was wondering about why it would go positive/negative/positive like that. I've attached an image below of the same night, with flow limitation and respiratory rate. Also, The closeups i posted were a couple of aberrations. Generally, I do get round tops and a smooth exhale, but sometimes the exhale takes an overly long time, or the inhale takes a long time to start. (assuming the machine starts measuring "inhale" as soon as flow goes positive). Although my ahi was controlled at lower pressures, I would often get flat tops or squiggley tops. What does an ideal exhale look like on the flow chart?

[slowriter]

What do your pressure charts look like?

Very stable, with slight bumps at a few points.

[Apneak]

So I've done in lab and at home studies....most recently my rdi on my back is really high, like 30, ahi somewhere around 11. I also just had a pap titration the other day, and I requested they test bipap, but who knows if they actually did. Apparently they're really resistant to bipap because it's more expensive and insurance is stingy with it.

Slowriter, i've seen your post on uars! some great info there. Why do you say I wouldn't get any benefit from "for her"? isn't that meant to treat light flow limitation events like i have?

You can try for her but it reacts slower and for me resulted in higher flow limitation. I posted my comparison here.

viewtopic.php?f=1&t=177402&p=1331969#p1331969

Here is an interesting article I just found searching for UARS on uptodate (one of the most used medical databases for doctors). I couldn't find any information about bilevel but it kind of makes some sense when you read this article as it appears the build up of CO2 plays a role and the higher pressure support available on a bilevel would help get rid of that CO2. Have you noticed any difference when using the different EPR settings? I only tried changing mine briefly and have stuck with 3.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5015642/

Interesting, I know they were different nights, but it almost seems like the overall effect on flow limitation wasn't notably better with the "for her", it just responds more gently with smaller pressure increments. That's kind of disappointing! I thought it would totally knock out flow limitations. Perhaps playing around with the minimum pressure there would be interesting though.

As for the C02, I know that that's a theory for why UARS causes the symptoms that it does, but APAP should take care of that, at the right pressures. It's true that a very high exhale pressure would cause some co2 build up, but it would have to be so high that it impedes your exhale, probably over 15-20? Right?

[Apneak]

You can see my current settings in my signature. I am on a PS of 6 (based on the titration study, actually), which is double the EPR that the Resmed APAP can provide. The EPAP isn't really that different from what my min pressure was on the APAP.

Out of curiosity were you able to notice any obvious differences in OSCAR data from APAP to bilevel? If so in what way?

I'm just curious if it is something you can see with OSCAR or if you pretty much need to do PSG with EEG.

The most straightforward and obvious difference you can see in the FL graphs and numbers. Compare this early one on APAP, with this more recent one on bilevel.


Screenshot from 2019-12-08 19-17-02.png

Screenshot from 2019-12-08 19-16-23.png

But at what median pressures? For example, it seems like your bpap probably delivers an inhale at around 15cm, and exhale around 9? In that case Bpap makes a lot of sense because exhaling at 12cm would be super uncomfortable, right?

[slowriter]

But at what median pressures? For example, it seems like your bpap probably delivers an inhale at around 15cm, and exhale around 9? In that case Bpap makes a lot of sense because exhaling at 12cm would be super uncomfortable, right?

It's a tad less than 9 and 15, but yes, that's the basic idea.

[Geer1]

The most straightforward and obvious difference you can see in the FL graphs and numbers. Compare this early one on APAP, with this more recent one on bilevel.

Did you ever try APAP with minimum pressures of 14+? If so did it reduce flow limitation but was just not bearable?

I see your exhalation pressure would have stayed the same(assuming EPR of 3) but inhalation pressure would have been 3 cm higher. I assume the higher inhalation pressure is what reduced the flow limitations and not the increase PS/EPR per say.