Newbie, waking up frequently with BIPAP

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lenarose
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Newbie, waking up frequently with BIPAP

Post by lenarose » Tue Mar 14, 2023 6:02 pm

Hi CPAP Talk, thank you in advance for your help!

Here is the link to my graph: [https://imgur.com/a/mXJJNPC]

I've finally been able to use my BIPAP for about 5 weeks every night for the whole night after fighting it for a few years upon being diagnosed with moderate sleep apnea. I noticeably felt a little better the first two weeks after using it, then afterwards I feel like the improvements stopped and I still feel pretty tired during the day with severe sleep inertia the first few hours after waking up. I've been looking at my OSCAR data and noticed that, while my AHI is below 2 most nights, I am still waking up at least 5 times per night and sometimes once per hour. I can tell I'm waking up because I will reset the ramp on my BIPAP, as shown in the pressure graph. I have tried to eliminate external sources that may be waking me up––like wearing ear plugs––and it doesn't seem like my mask is leaking when I wake up. I use mouth tape at night with the Dreamwisp nasal mask.

I have one suspicion that I should stop restarting the ramp when I wake up during the night because I'm worried that I'm having events while the ramp is ramping up after I fall back asleep (the ramp is set to 45 minutes). I wonder if this is one reason why I feel like my symptoms are not yet improving.

My questions are: Is waking up this many times normal with the BIPAP or is it affecting the quality of my treatment? Why am I still waking up so much with the BIPAP? Should I try to stop resetting the ramp when I wake up in the middle of the night? Any insight on my pressure settings or interpretations of my graph would be appreciated. Thank you!

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Re: Newbie, waking up frequently with BIPAP

Post by Julie » Tue Mar 14, 2023 6:39 pm

Have you tried shortening the ramp time at all - 45 mins is a long time to go without full therapy and I personally would go for a lot less, if any time. Your situation is different, but most of us don't use the ramp at all unless we have trouble 'getting going'.

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Re: Newbie, waking up frequently with BIPAP

Post by lenarose » Tue Mar 14, 2023 6:44 pm

I haven't tried shortening the ramp time yet but I considered doing that today after I realized the ramping might be an issue. Thanks for the good idea! Do you think that resetting the ramp in the middle of the night could be affecting my treatment quality?

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Re: Newbie, waking up frequently with BIPAP

Post by Pugsy » Tue Mar 14, 2023 6:53 pm

Respironics machines, when in auto adjusting pressure mode, will suspend/end ramp if any signs of impending or happening obstructive apnea events are sensed by the machine. If the machine is going the full 45 minutes during ramp...there aren't enough signs of airway collapsing issues to cause it to suspend/end ramp early.

Now ResMed machines...different story...not only will it not prematurely end ramp if apnea events happen, they don't even record them.

Some questions to start with.

1. Any idea why you might be waking up?
2. Age and gender??
3. Take any medications of any kind? If so, what?
4. Any other physical or mental health issues going on?

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Re: Newbie, waking up frequently with BIPAP

Post by lenarose » Tue Mar 14, 2023 8:37 pm

Thanks for the information, I didn't know that about Respironics machines. Does that mean that resetting the ramp when I wake up isn't a problem? I'm not really sure why I'm waking up, I'm not waking up to go to the bathroom like I did prior to using the BIPAP. I have noticed that sometimes I will wake up and the Dreamwisp mask is leaking air into my eyes a little bit, but the majority of the time I wake up it does not appear to be leaking and I'm able to fall back asleep immediately. I'm female and 23 years old; I was diagnosed with sleep apnea when I was 19. I don't take any medications other than melatonin and Flonase before bed. I don't have any physical health issues but I do have anxiety.

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Re: Newbie, waking up frequently with BIPAP

Post by SleepGeek » Tue Mar 14, 2023 8:54 pm

lenarose wrote:
Tue Mar 14, 2023 6:02 pm
I have one suspicion that I should stop restarting the ramp when I wake up during the night because I'm worried that I'm having events while the ramp is ramping up after I fall back asleep (the ramp is set to 45 minutes). I wonder if this is one reason why I feel like my symptoms are not yet improving.
By all means do NOT Start ramp should you wake during the nite.
Your machine does not detect or treat any events when in ramp mode.

In fact, try this. Make note of every setting before you make any changes at all.

Think of ramp as training wheels for getting your pressure balanced. And soon you won't need it.

Shorten your ramp time to 7 min and raise your starting pressure to 7cm. If this works for you reduce the ramp time by 1min and increase the starting pressure by 1cm. If this is too much too fast then find what works for you.

Give yourself a couple days to adapt to any changes and keep notes in a notebook next to your cpap.
Make notes soon after waking about what worked and what you need to improve on next while its fresh in your mind.

When you find your AHI under 1 then set your starting pressure about 2cm under your avg pressure than you are using today.

In time you should be able to adapt to No Ramp and a higher starting pressure.

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Re: Newbie, waking up frequently with BIPAP

Post by Pugsy » Tue Mar 14, 2023 9:01 pm

SleepGeek wrote:
Tue Mar 14, 2023 8:54 pm

By all means do NOT Start ramp should you wake during the nite.
Your machine does not detect or treat any events when in ramp mode.
You are incorrect. Please read what I wrote above.

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Re: Newbie, waking up frequently with BIPAP

Post by Pugsy » Tue Mar 14, 2023 9:04 pm

From a Respironics provider manual and talking about ramp.

If someone has something different...please provide documentation.

Image

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Re: Newbie, waking up frequently with BIPAP

Post by ozij » Tue Mar 14, 2023 9:54 pm

I have no experience with bi-level's or Respironics machines., so I'm writing the following in the hope that answers from those who do know will help me (and others) learn more:
This is what stands out to me in the charts - except for the ramp issue.
1) Most of the time, there's hardly any difference between the IPAP (Inhale Pressure) and the EPAP (exhale pressure).
You can see that in the numbers on the left, and on the pressure chart as well.
2) Pressure support is set to vary between 0 and 4.
3) The machine does not hit maximum IPAP, but does hit maximum EPAP - and yet rarely does it push the IPAP up to the maximum pressure support.
4) That is despite the fact that there are events happening that under other conditions would drive the pressure up.
5) You're snoring at your maximum pressure
6) It looks like the awakenings are accompanied by higher leaks - I wonder if it is they waking you up.

My understanding of what I see:
Variable pressure support isn't working for you -- see especially the events at about 04:45, and the fact the snores appear even when the machine is at maximum.

As far as I know, PS is the pressure added to the EPAP.

Therefore, my thinking is: Don't uses Auto PS. Set it at a constant 4 and see what happens.

Are you waking up with a dry mouth? Could you be mouth leaking?

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Re: Newbie, waking up frequently with BIPAP

Post by Pugsy » Tue Mar 14, 2023 10:15 pm

ozij wrote:
Tue Mar 14, 2023 9:54 pm
Therefore, my thinking is: Don't uses Auto PS. Set it at a constant 4 and see what happens.
I have used both bilevel brands.

Respironics bilevel, when in auto mode, has both a PS minimum and a PS maximum that must be set.
There is no way to turn off the auto adjusting part of PS when in auto bilevel mode. What has to be done is the minimum and maximum has to be the same number. This essentially fixes the PS so it won't/can't auto adjust.

Side note...one can make the Respironics bilevel in auto mode function like a regular apap by just setting both minimum and maximum PS to zero.

I don't know why the machine didn't/wouldn't increase the PS when we would think it should have. I would have thought it would have done something...either increase base EPAP or use some PS to increase IPAP more than it did. The bulk of any changes were just the normal pressure probes. I am scratching my head over this one.

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Re: Newbie, waking up frequently with BIPAP

Post by robysue1 » Wed Mar 15, 2023 8:35 am

lenarose,

Here's a marked up version of the data you posted:
Image

Like Pugsy, I've used both Resprionics BiPAP Autos and Resmed VAutos in auto mode.

The first thing I notice is this: In the red boxes, it appears that leaks may have waken you up. Yes, there are clusters of events as well, but the whole breathing before the wake looks like sleep-wake-junk (SWJ) breathing and I'm wondering if you were drifting between sleep and wake before you turned the machine off and on to restart the ramp. The leaks are not bad enough to be considered "large leaks", but if they're waking you up, something needs to be done. But I think working on the leaks may help your sleep continuity.

The second thing I notice is this: In the blue boxes, you restart the ramp before the ramp period is over. That could mean you never really got back into a sound sleep. Back when I was new I did have trouble with getting to sleep even with the ramp on---the subtle, but steady increase in pressure was there and sometimes that was just enough, combined with a fear of aerophagia to keep me up and prevent me getting all the way to a sound sleep.

I would suggest setting a min PS of at least 2. If you set min PS = 4 and max PS = 4, the PS won't ever vary. Either way, I think getting some actual pressure relief during the exhalations may help you. Also, setting Min PS equal to something greater than 0, you might be able to reduce Min EPAP a bit and increase the beginning ramp pressure a bit. All of that would mean a couple of things:

1) It would be easier to exhale while you are trying to get to sleep
2) The total increase in pressure would be smaller, and that would mean you might notice it less.
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Re: Newbie, waking up frequently with BIPAP

Post by robysue1 » Wed Mar 15, 2023 10:43 am

Pugsy wrote:
Tue Mar 14, 2023 10:15 pm
I don't know why the machine didn't/wouldn't increase the PS when we would think it should have. I would have thought it would have done something...either increase base EPAP or use some PS to increase IPAP more than it did. The bulk of any changes were just the normal pressure probes. I am scratching my head over this one.
Actually, lenarose's machine responded pretty much the way I would have expected it to perform given her settings of:
  • Min EPAP = 11
  • Max IPAP = 20
  • Min PS = 0
  • Max PS = 4
  • and a 45 minute ramp that starts at EPAP = 4
Since Min PS = 0, EPAP and IPAP are both going to start out at 4 cm and ramp up (together) until both reach 11 cm.

And PR's BiPAP Auto algorithm is set up to allow it to increase/decrease EPAP and IPAP independent of each other as long as certain conditions are met:
  • When IPAP - EPAP < max PS, the machine will increase only IPAP in response to RERAs, Hypopneas, Flow Limitations, and as a result of the PR Search algorithm. But PR machines only increase IPAP pressure when there are 2 or more RERAs or Hypopneas or Flow Limitations scored in less than about 3 minutes of each other. And PR machines only increase IPAP pressure by 1cm at a time in response to RERAs and Hypopneas. They wait a bit before increasing the pressure again.
  • When IPAP - EPAP > min PS, the PR machines will increase only EPAP in response to OAs and VS snores. Again, they will only increase EPAP if there are 2 or more OAs scored in less than about a 3 minute period and it will only increase IPAP by 1cm at a time. They will wait a bit before increasing the pressure again.
  • If IPAP - EPAP = max PS and a PR machine wants to increase IPAP because of RERAs, Hypopneas, or Flow Limitations, then the machine will increase both IPAP and EPAP by the same amount.
  • If IPAP - EPAP = min PS and a PR machine wants to increase EPAP because of OAs or snores, then the machine will increase both IPAP and EPAP by the same amount.
  • VS2 snores do not result in pressure increases on a PR machine. Exactly what the difference between a VS snore and a VS2 snore is remains a bit of a mystery. Back in my early days of PAPing when JediMark was first working on SleepyHead and he discovered that PR machines recorded both VS and VS2 snores, there was some discussion about the significance of each of them. Encore reports showed only the VS2 snore data as I recall.

Here's another look at lenarose's data marked up to show the increases in pressure settings that are not simply the ramp or the PR search algorithm's trials that result in no increase of pressure:

Image

The blue box is the only time there are OAs happening close enough together to trigger an increase in EPAP. Since EPAP = IPAP (i.e. PS=0), both EPAP and IPAP are increased by 1 cm and then by another 1 cm.

The three red boxes are the only places where lenarose's PR BiPAP chose to increase just the IPAP pressure. In the first and third boxes, the pressure increase was in response to the PR Search Algorithm deciding the breathing was more stable at the higher pressure. In the second (middle) box, the machine detected at least 2 RERAs close together and during the ramp. So her PR machine increased just the IPAP and continued to ramp the pressures up.

All of the other events recorded during this night's data "isolated" events in the sense that they did not occur close enough together for lenarose's PR machine's BiPAP Auto algorithm to increase either the IPAP or the EPAP.
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Re: Newbie, waking up frequently with BIPAP

Post by lenarose » Wed Mar 15, 2023 1:43 pm

ozij wrote:
Tue Mar 14, 2023 9:54 pm
Are you waking up with a dry mouth? Could you be mouth leaking?
Thank you ozij and robysue1, it would make sense that my awakenings are being accompanied by higher leaks as the other posters have also noted. Last night I took note of if my mask was leaking when I woke up during the night, and it did seem like it was leaking near my eyes. I don't seem to be waking up with a dry mouth so I'm not sure if I am also mouth leaking with the mouth tape on.

This is my data from last night after heeding the advice to increase my starting ramp pressure to 7 and decreasing the ramp time to 30 minutes: https://imgur.com/a/PKGB62V
I seemed to have less events last night but I woke up even more frequently and didn't feel rested at all today. As robysue1 noted, it does look like the leaks may have been causing me to wake up and there was a point in the night where I kept resetting the ramp before it got to full pressure.
robysue1 wrote:
Wed Mar 15, 2023 8:35 am

I would suggest setting a min PS of at least 2. If you set min PS = 4 and max PS = 4, the PS won't ever vary. Either way, I think getting some actual pressure relief during the exhalations may help you. Also, setting Min PS equal to something greater than 0, you might be able to reduce Min EPAP a bit and increase the beginning ramp pressure a bit. All of that would mean a couple of things:

1) It would be easier to exhale while you are trying to get to sleep
2) The total increase in pressure would be smaller, and that would mean you might notice it less.
Tonight, I think I will try setting the min PS to 2 as robysue1 suggested and then see if I should also reduce the minimum EPAP. I'm a bit disheartened that the Dreamwisp mask has been bothering me so much with leaks because this is the first mask I have tried that I've been comfortable enough with to keep on the entire night. Do you think that these leaks are mainly an issue with the pressure settings or is there a possibility that I should look into try a different type of mask? I tried the Dreamwear full face mask but it would leak near my eyes even at the lower pressure setting.

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Re: Newbie, waking up frequently with BIPAP

Post by robysue1 » Wed Mar 15, 2023 3:33 pm

lenarose wrote:
Wed Mar 15, 2023 1:43 pm
Thank you ozij and robysue1, it would make sense that my awakenings are being accompanied by higher leaks as the other posters have also noted. Last night I took note of if my mask was leaking when I woke up during the night, and it did seem like it was leaking near my eyes. I don't seem to be waking up with a dry mouth so I'm not sure if I am also mouth leaking with the mouth tape on.
Since you say you don't seem to have a dry mouth when you wake, in this post I'm not going to worry about mouth leaks at all: If you are taping your mouth and the tape is in place when you wake up in the morning, there's a reasonable chance that the tape is serving its purpose and minimizing mouth leaks.

But since you are saying that you remember waking up with air leaking near your eyes, I am going to focus on mask leaks and what you might be able to do to address them.

You also write:
I'm a bit disheartened that the Dreamwisp mask has been bothering me so much with leaks because this is the first mask I have tried that I've been comfortable enough with to keep on the entire night. Do you think that these leaks are mainly an issue with the pressure settings or is there a possibility that I should look into try a different type of mask? I tried the Dreamwear full face mask but it would leak near my eyes even at the lower pressure setting.
I would not recommend giving up on the Dreamwisp just yet. I just think you need to spend some time figuring out the best way to fit the mask at the beginning of the night. And you also need to figure out a better way to deal with the leaks than restarting the ramp.

To help you get started on this process: What's your favorite sleeping position? How do you fit the mask at the beginning of the night? And have you spent time far away from bedtime trying to troubleshoot how you are fitting the mask?

Here's what I would suggest that you try several hours before bedtime: Lie down in your favorite sleep position with the mask on. Turn the machine on, but do not turn the ramp on---you need to fit the mask at your full therapeutic pressure. Pay careful attention to where you are feeling air coming out of the mask. Be sure you understand where the mask's vents are located so that you don't mistake the intentional leaks (venting) from any unintentional mask leaks. If you find mask leaks, start playing with the headgear. Consider loosening the straps as well as tightening them. The Dreamwisp uses an air cushion to seal the nasal cushion against your nose. If the mask straps are too tight, the cushion might not be able to fully inflate, and that can cause mask leaks. After every mask adjustment, gently pull the nasal cushion away from your nose just a tiny bit. Be prepared for a strong stream of air. Then let go of the cushion and allow it to settle back against your nose and check carefully for leaks. Keep readjusting the straps while lying in your favored sleep position as much as possible. Be open to the idea of using a asymmetric adjustment for the straps: You may find that you need the straps on one side of your head looser than the straps on the other side. Or you may find that you need to tighten (or loosen) the top straps more than the bottom straps. But if you keep working at the problem while you are fully awake and far away from bedtime, you should be able to find a way to adjust the straps so that there is no perceptible leaking when the machine is delivering your full therapeutic pressure.

After you've got a good adjustment for the straps, try moving around in bed to figure out what kinds of movements seem to trigger leaks. This will also allow you to figure out whether the hose is somehow pulling on the mask when you move around. (With the hose attached at the top of the mask, that should be much less of a problem, however.) Anytime you do manage to trigger a leak, see if you can fix the leak by pulling the cushion away from the nose just a bit and then letting the cushion go so it can resettle all by itself. If it does, then you know you've got a pretty good strap set up and leaks caused by mask movement can be fixed with a simple "pull the cushion away and let it go" movement.

You may want to use a permanent marker of some kind to mark where you want to adjust the straps. That way when you wash the headgear, you don't have to guess where the velcro ends of the strap should go to get a good overall seal.

Now the next part of the puzzle for teaching your body how to sleep well with this contraption on your nose is figuring out how to deal with mask leaks when they wake you up in the middle of the night. And this is easier than you might think---if you have a reasonably good strap adjustment in the first place. When you wake up in the middle of the night and you're aware of a leak near your eyes (or anywhere else that is not a mouth leak), then just pull the cushion away from your nose just a bit and when the big rush of air starts, let go of the cushion and allow it to resettle against your nose. Many times that's all that's needed to fix a mask leak---provided the headgear is properly adjusted in the first place.

The advantage of this strategy is that it involves a whole lot less work than reaching for the ramp button. And so with some practice and a bit of time, you can start doing the "pull the cushion away and let go of it" way of dealing with leaks without having to come to a full wake. And that should allow you to more quickly get back to sleep since you don't have to move around in bed at all to do this.



You also write:
This is my data from last night after heeding the advice to increase my starting ramp pressure to 7 and decreasing the ramp time to 30 minutes: https://imgur.com/a/PKGB62V
I seemed to have less events last night but I woke up even more frequently and didn't feel rested at all today. As robysue1 noted, it does look like the leaks may have been causing me to wake up and there was a point in the night where I kept resetting the ramp before it got to full pressure.
Given that data, I can see why you don't feel rested: To my eyes it looks like you got no more than about 3-4 hours of actual sleep during the 8.67 hours you were in bed with the machine running. And the longest bits of what might be decent quality sleep all look to be less than an hour in length.

Here's a marked up version of your data:

Image

As you've already noted, leaks seem to be waking you up: All four of the red boxes show evidence that leaks are what woke you up and caused you to hit the ramp button.

The blue box is when you kept hitting the ramp button before (or right after) the machine reached your minimum therapeutic pressure. And, until the end of this box, leaks are not an issue. So that begs the question: What was causing your restlessness throughout this time frame? It looks like you got almost no actual sleep between 7:30 and 9:20, but leaks only get bad after the breathing starts to settle down around 9:20. Notably, you don't turn the machine off after that final ramp period ends, but by around 9:50 (the purple box), your breathing looks like it could be sleep-wake-junk breathing. Real sleep breathing finally starts around 10:40 at the end of the purple box.

And that observation raises these questions:

1) What's going through your head when you are lying in bed with ramp on, but you're having some trouble getting back to sleep?

2) Does the lower pressure at the beginning of the ramp period actually help you to get to sleep or not?

3) When you hit the ramp button before the ramp period is finished, do you hit it because you feel like the pressure is too high for you to be comfortable? Or are you hitting the ramp button because you haven't yet fallen back to sleep and you're more worried about being awake rather than being uncomfortable because the pressure is too high for you to breath comfortably while awake?

4) Or do you hit the ramp button before the ramp period is finished because you keep noticing pesky little leaks that are bugging you and you hope that going back to the ramp's beginning pressure will magically fix those leaks?
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Re: Newbie, waking up frequently with BIPAP

Post by lenarose » Wed Mar 15, 2023 7:05 pm

Thank you for your in depth response robysue1!
robysue1 wrote:
Wed Mar 15, 2023 3:33 pm

To help you get started on this process: What's your favorite sleeping position? How do you fit the mask at the beginning of the night? And have you spent time far away from bedtime trying to troubleshoot how you are fitting the mask?
To answer these questions, I typically am only able to fall asleep on my stomach. To fit the mask, I've been putting it on my face, turning the BIPAP on to ensure that there are not leaks when it comes to full pressure, then resetting the ramp to fall asleep. Based on your response, it seems like my mistake has been setting the mask into place before the pressure comes on. I haven't spend much time far away from bedtime trying to troubleshoot how I'm fitting the mask, so I will definitely try your suggestions now and see if they help tonight. I think that maybe I have been over-tightening the mask and unintentionally causing leaks because I'm fitting the mask before the pressure comes up and have been afraid that the mask will move out of position in my sleep. I normally readjust the mask when I wake up in the middle of the night by turning the machine off, setting it on my face, then turning the ramp on but I will now try pulling it away from my face at full pressure.
robysue1 wrote:
Wed Mar 15, 2023 3:33 pm

And that observation raises these questions:

1) What's going through your head when you are lying in bed with ramp on, but you're having some trouble getting back to sleep?

2) Does the lower pressure at the beginning of the ramp period actually help you to get to sleep or not?

3) When you hit the ramp button before the ramp period is finished, do you hit it because you feel like the pressure is too high for you to be comfortable? Or are you hitting the ramp button because you haven't yet fallen back to sleep and you're more worried about being awake rather than being uncomfortable because the pressure is too high for you to breath comfortably while awake?

4) Or do you hit the ramp button before the ramp period is finished because you keep noticing pesky little leaks that are bugging you and you hope that going back to the ramp's beginning pressure will magically fix those leaks?
You noted that it seemed like my restlessness occurred starting at 7:30; that is when my partner gets up and we share a bed so it makes sense that I woke up during that time (I wear earplugs but I think I am still disturbed by them getting up). I get frustrated when I'm lying in bed with the ramp on and have trouble getting back to sleep. I think the high pressure makes it harder to fall asleep. However, I think I will have to test whether or not the lower pressure at the beginning of the ramp period is still helping me fall asleep. I believe I've mainly been hitting the ramp button before the ramp period is finished partially because the mask starts to leak and partially because I'm worried about still being awake. I'll have to do some more examination of why exactly I've been hitting the ramp button before the ramp is finished.