Getting stuck with UARS settings!

[Conor2612]

Hi there, big fan of this forum and everybody on it, you're all heros. I've tried to gather as much info over the last two weeks to work on my situation without posting but it seems I'm reaching a confusing, dead end, I hope you can help...

I have UARS (RDI on last test was 15 an hour) and I'm slowly titrating my Bipap to where I believe is the right place. My EPAP is low at 6 as it seems it's covering my OA's, I had successful surgeries to burn away quite a lot of tissue (I was a hot hot mess with cpap 4 years ago, high AHI) but on my last sleep test it was very much 'your AHI is low now but your RDI is high, we can't do anymore surgeries as it's now structural and not loose tissue'. Being left with a highish RDI with countless Reras and feeling like absolute crap I've come back to try Bipap. Learnt a hell of a lot on here and on the lankyleftys channel but I'm not sure where to go next.

EPAP hasn't moved from 6 since I've been back on in the last two weeks but I've titrated my IPAP up slowly and my waveform is looking calm and curved (like I've learnt it should be) in non rem sleep, but it seems in REM it is still struggling to stay open and RERAs occur frequently. I know a lot of you guys seem to prefer vauto mode in bipap but again from lankyleftys knowledge I've been keeping it fixed in S mode and just trying to find that top IPAP that will cover it all. He seems adamant that auto on CPAP or bipap is a no go cos it's too slow to cover the damage that's already occuring and then drops down too quickly when the higher pressure is still needed.

I guess I'm here to ask, what's next? I've visibly seen my higher IPAP smooth out my waveform but for the life of me I'm already up to 14 and it's starting to get funky, aerophagia and obvious CA's from the large pressure support (though I've hesitant to raise EPAP up as it seems to cover all my OA's and I struggle exhaling on higher pressures and the CAs are minimal). Any help would be amazing. Attached a 2 min screenshot of my regular waveform in non REM sleep and attached a 2 min screenshot with reras in REM sleep (and there's several screenshots I could have taken over the night of my choppy REM).

Bare with, there was a lot of general tossing and turning last night, crazy to think it's been hot AF in London!

[Conor2612]

Anybody out there?

[uarstrial]

Could you post zoomed in photos of your breathing during REM? It may be the case that what's actually happening is expiratory pressure intolerance. The airway patency during REM is much lower as all muscles get relaxed. So what's may be happening has nothing do with iPAP and instead ePAP. Also what increments are you using to make pressure changes...UARS is very very sensitive and even 0.4cmh2o is a large pressure swing.

[Conor2612]

Hey, thanks for the reply. The third screenshot is my breathing during REM.

I actually want to try a little higher EPAP tonight. I don't feel a have any intolerance on exhale at 6 EPAP at all but I do wonder in REM if I actually need a little further 'stinting' with a slightly higher EPAP.

In terms of IPAP I've only been going up .4 every couple days. Really gradual over last few weeks.

[Conor2612]

Again, anybody out there? Really tryna find some help

[zonker]

don't have your answer. i'm replying to bump it up. I figure if they see my name, they'll think "what dumb answer has zonker given?" then swoop in to correct me.

[Dog Slobber]

don't have your answer.

What answer, there really aren't any questions.

All the he's asked is: "What's next?" and "Anybody else?".

That subtle waning in REM might be RERAs, but certainly doesn't have to be. The only suggestion made to him was blown-off.

I think he's got a lot of data to look at, buttons to press, and dials to turn. He's now looking for a problem to solve.

[Conor2612]

Cheers for your helpful input dog slobber.

I didn't blow off the suggestion of EPAP intolerance. I feel judging on my tolerance to the settings during non REM sleep I am completely fine with the EPAP. My whole 'whats next' is based around what I do to deal with my REM sleep. How one would keep my airways from collapsing during REM. That's what I'm asking for advice on here! Is it a higher EPAP to help the stint? Is it a higher IPAP. These are all questions I'm trying to figure out.

[Pugsy]

How one would keep my airways from collapsing during REM. That's what I'm asking for advice on here! Is it a higher EPAP to help the stint? Is it a higher IPAP. These are all questions I'm trying to figure out.

Generally it is EPAP that is considered to be the primary force that stints the airway open.

[Conor2612]

Thank you Pugsy,

It's been confusing as everyone on every forum says EPAP for OA's and IPAP for reras. My OAs are covered by my EPAP very effectively. So I've been looking to find out what will help the collapsed airways in REM and by the sounds of what you're saying it's not just IPAP, it's EPAP too.

Also, how long between pressure changes would someone normally wait and sit on a pressure to get used to it before adding more pressure?

[Conor2612]

Hello, just wanted to check to be safe. How long do you sit on a pressure, days, weeks, before making a change?

[musculus]

The RERAs around 3am is not looking too bad - no awakenkings. Just curious how do you rate your sleep quality? 14cm IPAP is already high pressure. Maybe higher EPAP might help such as 8 or 10cm.