New Bipap user - UARS - seeking advice

[tiredintenn]

Long time UARS sufferer (tried almost everything). Was recently titrated using a PES and was titrated on a bipap. My pressure was 14 ipap and 7 epap. I have been on it a few weeks and I wasnt feeling any better. Frankly felt worse. So I downloaded oscar and looked at my numbers. Last night was a 51 ahi with almost all of it (50) clear airway. I attempted to upload the screenshot. Basically every night looks similar to this. Any idea what would cause these clear airways and what i can do to get rid of them. thanks

[Pugsy]

Any idea what would cause these clear airways and what i can do to get rid of them.

Your settings are 14 IPAP and 7 EPAP which makes a difference of 7 cm for pressure support/PS.

Some people find that pressure support can trigger a large number of unwanted central apneas (CAs on Oscar are central apneas).
Now for some people they find that even 1 cm PS can trigger centrals and others they can use a much higher PS before they start getting centrals in unwanted numbers.

The centrals happen because of an imbalance in the blood gases and cause unstable breathing resulting in carbon dioxide levels never getting high enough for the brain to send the "breathe human" signals. PS sometimes causes this unstable breathing in some people. Not everyone but some and it sounds like you are one of those people.

The fix is to reduce PS (assuming you are one of those people who have a problem with a rather high PS).
PS of over 5 we usually advise close monitoring for central flagging. There could be a fine line for you where you don't have too many centrals at so and so PS and a truckload with just 1 cm more PS. I have a friend who gets around 18 centrals per hour with a PS of 4 but less than 1 per hour with PS of 3. Go figure that one. It's normal to have an occasional central apnea and they aren't normally a problem unless present in large numbers and yours qualifies for being a major problem.

Are you comfortable changing you settings yourself?

I have no idea where your line in the sand might be for triggering the unstable breathing and the high number of centrals.
It's going to be trial and error experiment to see where that line might be.

I would start with a nice normal common 4 or 5 PS first and see if that reduction makes any difference.

So....EPAP 7 and IPAP of maybe 11 or 12.
Or conversely if you need to keep IPAP high...14 IPAP and 9 or 10 EPAP.

If it were me and I had the UARS thing mixed in....I would start with 7 EPAP and 11 or 12 IPAP and try to keep IPAP a little lower because higher IPAP is also a trigger for centrals even if PS isn't involved.

[Pugsy]

When posting images please don't try to cram in all the graphs. You end up with unneeded graphs so tiny none of them can be evaluated.

No need to redo this one though....but for future image sharing check out this thread.
We don't need or want all those graphs that you included.

viewtopic/t158560/How-to-post-images-for-review.html

I would also either turn off ramp or shorten it dramatically. When in ramp mode the machine doesn't flag anything so we don't know if nothing happened or the machine just didn't flag it. I am betting with these settings the machine just didn't flag anything during ramp.

Using bilevel pressures at your settings....with a bit lower PS...you shouldn't even need ramp.

[Pugsy]

I would be really interested in seeing the actual sleep study report from the titration study where they came up with PS of 7.
I would want to know if they saw any centrals or not.

While UARS is a problem....not nearly as much of a problem as complex sleep apnea which you now have with this number of centrals.
No wonder you still feel like crap or worse.

[tiredintenn]

thank you, Pugsy. I appreciate the advice. I have a call into my sleep doc now. I dont have the titration study but will try and get.

[tiredintenn]

hello pugsy,

my sleep doc says those are not centrals and that i am mouth breathing. says there were no centrals when they titrated me. does that seem plausible?

[Pugsy]

hello pugsy,

my sleep doc says those are not centrals and that i am mouth breathing. says there were no centrals when they titrated me. does that seem plausible?

Well.....I guess it might depend on just how long they actually used PS of 7 during the titration study.

If you are in the USA....you have the HIPPA rights to your documents pertaining to your medical records. I would be wanting written proof of exactly what they actually did and how they came up with these settings.
You make a request in writing and by law they have to give it to you.

Now as to the mouth breathing excuse....sigh...that's a big load of BS IMHO.
The machine thinks they are central apneas and I bet if we zoom in on a 3 minute segment it will show lack of air flow.
Mouth breathing doesn't show up as central apneas...it would show up as leak maybe depending on which mask you are using.
I have never ever seen mouth breathing show up with a truckload of central apneas....but I have seen PS cause a truckload of centrals.

Which BTW....what mask are you using?

My personal opinion though....the doc is full of crap.

Zoom in on a 3 or 4 minute segment of your flow rate and lets see if you are breathing or not.
Don't know how...the videos here show how.
http://freecpapadvice.com/sleepyhead-free-software

[Miss Emerita]

Mouth-breathing? Give me strength. TiredinTenn, do everything Pugsy is telling you; she's the best:

* turn off the ramp
* reduce your PS
* ask for a copy of your sleep study in writing
* post a 3-minute zoom of one or more centrals.

[Pugsy]

http://cpaptalk.com/viewtopic.php?f=1&t ... x#p1366490

Read the above thread. Similar situation as yours.

Reduce your PS and at least try my suggestion.....one night. You have nothing to lose and everything to gain.

[tiredintenn]

I will lower the PS - would you go with ipap 11 epap 7? see attached for last night. I taped my mouth with somnifix tape so i dont think the centrals are mouth breathing. They are in fact centrals. thanks for all the help.

[Pugsy]

I would try 7 EPAP and 11 IPAP which would make PS 4. Your machine probably just gives you EPAP and IPAP settings I think in S mode which is all your machine will do. If you had the auto model it offers a PS setting in auto mode.

I have no idea how much of a difference reducing PS by 3 will make but we have to start somewhere and 4 PS is the most commonly prescribed PS when people have an in lab titration done on bilevel machines.

PS/Pressure Support is nothing more than the difference between inhale and exhale so it's easy to figure even if you don't have a separate setting for PS.