[therapy] Help with UARS and AirCurve 10 VAuto

[n15305]

Hi, I hope everyone is doing well.


Recently I was diagnosed with UARS and mild sleep apnea from a WatchPAT sleep study. Across two nights, on average, the results were: RDI: 23, and AHI: 6.9 (~90% accuracy compared to PSG). Both RDI and AHI were significantly worse in REM, which seems to fit the UARS diagnosis.

I'll be receiving a ResMed AirCurve 10 VAuto very soon, and I was wondering whether these settings be a good place to start?
o Mode: VAuto
o Min EPAP: 6
o Max IPAP: 20
o PS: 6
o EasyBreathe: On
o Ti Max, Ti Min: default
o Trigger, cycle: medium
o Mask: nasal (using a Bleep Dreamport)
o Ramp time: Off
o Climate ctrl, tube temp: auto
o All other settings: default
It'll come with a humidifer and climate line tubing.

If these settings are ok, should I try them for a week before asking for any further advice (assuming no other problems)?

Other potentially relevant info: 22 years old, male



Thank you so much!
n15305

[Pugsy]

o Mode: VAuto
o Min EPAP: 6
o Max IPAP: 20
o PS: 6

I wouldn't be doing PS of 6 right now. I wouldn't go over PS of 4 right now. Sometimes PS over 5 can trigger central apneas in some people.
PS of 6 would give you inhale of 12 and exhale of 6 and it likely won't be all that comfortable anyway for someone just starting therapy. I don't recommend it.

The rest of your setting choices appear to be default settings and a good place to start.
I don't recommend changing these unless there is a real need. There is a reason they are the default settings and it's because the majority of users do well with them.
o Ti Max, Ti Min: default
o Trigger, cycle: medium

You shouldn't need ramp at these settings and hose temp and humidity settings...default is as good of a place as any to start and you have to start somewhere. Adjust as needed later once it is determined there is a need or not.

UARS...a tough nut to crack because you have to remember that the auto adjusting algorithm was never designed for the minute changes in the airway that make up UARS. It was designed for OSA and you don't have a very remarkable OSA.
I wouldn't be surprised if you needed more minimum to resolve any UARS (assuming you have UARS) symptoms than the machine will want to give you because of the algorithm. Gotta start somewhere though.

Be prepared to keep detailed logs as to how you slept in general, sleep quality, hours of sleep, number of wake ups and how you feel each day because subjective feelings are critical for UARS patients.
We see if often...AHI numbers nice and low with UARS patients when on cpap but they still feel like crap....they usually need pressure adjustments beyond what the machine wants to give them.
I know of one person who got a near perfect AHI of 0.0 at 8 cm pressure but when actually titrated in a lab setting with the Pes device (only real way for UARS diagnosis and monitoring) they needed 13 cm to resolve the UARS issue.

It's complicated and not a quick easy fix. I have always said I would much rather have the worst OSA than UARS because OSA is much easier to monitor and figure out how to deal with it.

[Miss Emerita]

Welcome! It sounds as though you're getting the machine on your own and not receiving additional help from the people who prepared your sleep report. (Or maybe you did the sleep report on your own too?)

This is fine, and plenty of people follow this path. I would suggest you start with much less pressure support and a lower minimum EPAP. Just to get going: min EPAP of 4 and PS of 3. It's fine to leave the max IPAP high, just so you can see where the pressure wants to go.

Please download the Oscar software so you can post charts. This will enable people to offer you much better advice. I would suggest posting a chart after one night, since you're right at the beginning of figuring out your best settings. Please post in this same thread.

When your machine arrives, try setting it up during the day or evening outside your bedroom and using it while your read or watch TV. This will help you get used to the new experience.

I hope very much you'll have a smooth start to treatment, but don't worry if there are some bumps in the road. You'll get there!

[Miss Emerita]

Just read Pugsy's advice, which is in a similar in its general direction to mine. Please follow her advice, which is grounded in much much more experience!

[Pugsy]

Not all that much difference between my thoughts and Miss E's thoughts.
Hers would be a good place to start as well.
I tend to push 4 PS because that is what I use.... though I can use PS of 3 just as easily. I just happen to like the way PS of 4 feels to me. It is also the most commonly used starting PS when there is a bilevel in lab titration and the most commonly prescribed PS setting. The majority of PS prescriptions are 4 or 5 for people. When a higher PS is advised it is usually because of special circumstances though I do know one person using 6 just because it feels best for him.

When just starting out though and we don't know what someone needs or likes I always go with the most commonly used settings. It's a numbers game of sorts. Play the odds because sometimes the odds work out just fine.

You can play with both settings and see what simply feels best to you...my ideas or Miss E's ideas and either is a good starting point. Right now the main objective is getting you comfortable with this therapy because we need to comfortable so you can fall asleep and stay asleep. Without sleep none of this matters.

Warning...don't panic if you see AHI numbers that are higher than your sleep study numbers if you have trouble falling asleep....it happens often with newbies because the machine will flag awake irregular breathing as some sort of apnea event and if you aren't asleep anything flagged isn't real and doesn't matter. You must be asleep for it to matter and these machines only measure air flow. They don't have anyway to know if we are asleep or not and awake breathing is very irregular when compared to asleep breathing. It's a limitation of the machine that we just have to accept and deal with.

[n15305]

Wow, thank you both for all the advice!
Will lower the PS and min EPAP in that case.

Yep, no additional help from any professionals; support / recognition for UARS is quite poor in the UK so I didn't choose that path.
Wearing it in the evening sounds like a great idea; hopefully I can get used to it much quicker that way!

Yeh I've heard it's hard to treat UARS with xPAP; I'm planning to get some ortho to treat UARS in a few months, but my symptoms are so bad that I wanted to try a bipap to see if I could get any improvement and cope better in the meantime. Fingers crossed!

Thanks again

[n15305]

I've attached a screenshot for the first night.
I wore it for a bit before bed, to get used to it, and surprisingly managed to fall asleep quickly, at around 00:40-01:00 AM.
The clear rubber part of the Bleep Dreamport came away from the tubing, I think just after 3AM, so will make sure to tape them together tonight.
Due to the broken sleep, I woke up feeling like usual - no noticeable difference. I don't remember waking up, though, apart from having to turn the machine off. If I hadn't been half asleep, I would've tried to refit the mask for a few more hours of data.
Overall, slept from around 1AM to 10AM.

I think I'll just try the same settings for a few more nights and evaluate based on more complete data?

Also, out of curiosity, does anyone know if remote CPAP titration is possible? E.g. from Barry Krakow's lab in the US remotely to my CPAP machine in the UK?


Thanks!

[Pugsy]

Also, out of curiosity, does anyone know if remote CPAP titration is possible? E.g. from Barry Krakow's lab in the US remotely to my CPAP machine in the UK?

No way to do any sort of remote titration except by someone just reviewing the data from the software detailed reports that I know of and I don't know of any sleep labs doing that sort of thing. They want you physically in their facility.
In lab titrations involve making adjustments many times over a single night and they would have no way to do that remotely.

You can learn to do it yourself though. It's not rocket science.
https://document.resmed.com/en-us/docum ... er_eng.pdf

You can't expect to feel any difference with such a short time on the machine and plagued with leaks and mask issues and awakenings.
You had a crappy night's sleep for various reasons and most of the night your sleep apnea went untreated so we really can't expect improvement...first night or 100th night.

[n15305]

Ok, that makes sense - thanks!
Will check out the titration guide.

I was asking about the remote titration because I'd seen this paper https://pubmed.ncbi.nlm.nih.gov/21247800/, as well as https://pubmed.ncbi.nlm.nih.gov/21247800/. I was hoping at least one sleep lab had started doing this by now!

[Pugsy]

I was asking about the remote titration because I'd seen this paper https://pubmed.ncbi.nlm.nih.gov/21247800/, as well as https://pubmed.ncbi.nlm.nih.gov/21247800/. I was hoping at least one sleep lab had started doing this by now!

10 year old studies and small...and done when auto adjusting device home use isn't possible. Don't understand that limitation but I guess there are situations where that happens.

It never took off. No one jumped on that band wagon. To be honest the most likely reason would be cost vs what they could make off doing such a thing and how often would it be needed.

10 years ago a lot of doctors were still in the belief that fixed cpap was a better way to treat obstructive apneas and they were reluctant to get on the auto/apap adjusting band wagon and let the machine sort it out.
Heck, we still have doctors who think that way but a lot more are beginning to trust the machine and apap is becoming more common and in lab titrations are much less common and in fact a lot of insurance companies won't pay for an in lab titration and instead just say use a home apap machine to find optimal pressures. It saves them money.

Now one other thought...for someone with maybe UARS...even if a remote titration could be done it wouldn't be a good option for UARS treatment unless someone also slept with the Pes device which is the gold standard for UARS evaluation, diagnosis and treatment. It would be impossible for a patient to use the Pes device in a home setting.
If I thought I had UARS and I wasn't getting the results with cpap that I wanted then I would want the gold standard...titration in lab with Pes device and that's a huge hurdle here in the US and I expect an even bigger hurdle in the UK. Finding a sleep lab that even knows what a Pes device is....extremely difficult here in the US.
This is why I say that I would much rather have OSA than UARS.

You are going to have to take a lot of big patience pills to get adjusted to just the machine and mask and then fix leaks and then be able to sleep soundly before you can really even just evaluate therapy subjectively.
Subjective evaluations are extremely difficult anyway but that's really all UARS people have to go on.
It's not going to be quick and easy.

[Miss Emerita]

That was a pretty good first night! You had a bunch of CAs as you were falling asleep; that's not uncommon and is likely to go away as your body gets used to PAP treatment.

The leaks do need to be addressed. I'm not sure I understand where the Bleep fell apart. Maybe you're describing where the short hose meets the little ring that in turn snaps onto the Dreamport? Sometimes I need to twist and push the short hose to get it solidly attached to the little ring. If that's where you taped, I don't see any problem with your fix.

Do you think you might have been mouth-breathing some? Perhaps your mouth felt quite dry?

[n15305]

Hmmm yeh that's a good point about the Pes-titration - can't beat that!

I think it's just above the little ring you're talking about; the clear rubber piece which says 'bleep' on it came away from its plastic base.

I did tape my mouth, but not 100% so I think some air may have leaked out of the sides; I didn't have a dry mouth, however.

[n15305]

Attached is a screenshot for night #2. I only really fell asleep at 1:40, due to mask comfort issues.
The mask came off at around 4AM, like yesterday, but at a different point this time!
The silicone rubber dual-prong DreamPort piece came away from the two quick release connectors - so will need to tape those bits too for tonight.

Woke up feeling the same as usual - probably due to the very fragmented sleep.
Slept till around 10AM.
No noticeable dry mouth; I do remember getting 'chipmunk' cheeks a few times though, since I properly sealed my mouth up with tape this time. Hopefully that'll go away with time as my tongue muscles adapt.

Are there any tips as to where I should place the machine, and how to orient the tubing to minimise chances of the mask being yanked off?

Thanks!

[Pugsy]

Get some sort of hose management system so the stress on the hose is reduced.
Stuart has a video on his setup here at his website...."cpap tube management for sleep"
https://bleepsleep.com/instructions/

Your last night's report includes a lot of awake time which of course is useless.
Did you know you can turn off sessions from viewing and at least remove the known awake times from messing with your data?
Look over on the left side and scroll down below the statistics for each sleep session segment. If you click on a session it will turn it off (or back on) and when off that data is omitted from everything. You can always turn it back on but if you know you were awake the awake data is useless and confuses evaluations.

Also remember that your machine can't tell if you are asleep or not. Awake breathing irregularities can and will fool the machine into flagging some sort of event and responding to what it thinks is some sort of airway flow reduction.
I suspect that is what happened when the machine went to 14 cm at 12:45 but you weren't asleep.
Usually false positive awake flagging is centrals but we can have false positive in OA and hyponeas as well and when we do the machine doesn't know it is trying to deal with awake breathing irregularities instead of asleep flow rate issues.

Awake breathing...doesn't count for sleep disordered breathing...you must be asleep for it to matter.

[n15305]

Ah perfect, that video is exactly what I was looking for!

I have an EEG sleep tracker, so I'll use that to leave out CPAP data for wake periods, from now on.
Thanks for the tips.