Help titrating BIPAP for sensitive sleeper

[semblables]

Hi! I'm about 3-4 months into using BIPAP. I've seen a big improvement over CPAP, but am still needing to sleep 9-10 hours a night and to practice strict sleep hygiene in order to be functional. The machine doesn't pick up many apneas or hypopneas, but I see a lot of unregistered ones and also just funky stuff in the breath graph. I'd love to know how to titrate IPAP and EPAP in order to get BIPAP as good as it can be.

On CPAP in an in-lab sleep test I was having 11-12 non-movement arousals per sleep cycle, so apparently that's enough for my sleep quality to tank. So I'm guessing that's going to need to get down to near zero for me to really sleep well. I'm going to have another in-lab test in January, so I'll get some more hard data about what's happening in my brain then.

My doctor started me out on IPAP 10 EPAP 6. I felt like I wasn't getting enough air on that, so I bumped EPAP up to 6.6. Once I adjusted to that, I slept way better than I did on CPAP.

Then I bumped IPAP up to 11.2 keeping EPAP at 6.6. Again, I saw a massive improvement, roughly equivalent to the change from CPAP to BIPAP. The headline numbers didn't really change and I didn't personally see a big change in the breath-by-breath graph, but the difference in symptoms was obvious.

I met with my pulmonologist yesterday and he suggested bumping the IPAP up to 12.2 and the EPAP up to 7.6, but he couldn't really articulate why I should increase base pressure compared to pressure support and didn't look at the breath-by-breath data, so while I'm more than willing to give his suggestion a try, I'd like a more informed opinion.

One last note — on CPAP I had gotten my leaks down to near-zero, and on the same mask / mouth tape set up I'm getting a number of leaks per night on BIPAP now. Any ideas what's going on with that? Do I need a new mask?

SleepHQ link: sleephq.com/public/teams/share_links/30afd911-9006-4693-a2f4-9df813ef9686/dashboard

Thank you!!

[Miss Emerita]

Welcome! A couple of observations.

For some reason, your events are showing up as unidentified. When I zoom in on them, they look like breath-holding. You inhale, then comes little or no exhalation, and a pause. You may be holding your breath while you turn over, though I'm not sure that explains the UA tags.

You are also for some reason not showing any flow limitations.

When I zoom in on your flow rate, I see several anomalies. One is that many of your inhalation curves have a more pointed shape than we usually see. This may indicate that you could use some more pressure support.

Another is that many of your exhalation curves include a sharp downward point. This may indicate that you are exhaling through your mouth while inhaling through your nose. That's puzzling, though, if you're using tape. Is the tape secure when you're done with your sleep? It's also possible that you're experiencing some kind of partial airway collapse during exhalation.

I'm going to ask some experts here to swing by and take a look at your chart.

[semblables]

Hi, thanks so much for this! Really interesting.

On the tape, it does appear to be fully secure every time I wake up, even if I let the IPAP pressure go against it. Taking the nasal pillow off, it takes a good bit of pressure blowing out to get air to pass under the tape. I use kinesiology tape which is pretty hefty. But the machine is showing leaks, so if they're happening, they must be happening somewhere.

[Miss Emerita]

I'm still hoping an expert will be able to help you.

About the leaks -- you might check to make sure that you don't have any little holes in your hoses and that the hose attachment to your machine is secure.

Do you take any medications? Any special stress and strain going on in your life? Is your sleep environment good? (Cool, quiet, good mattress, etc.) Do you drink in the evening or use caffeine in the afternoon or evening? Do you eat close to bedtime?

[semblables]

Thanks for the reply! For the hose, would the check there be a visual check? I'm not noticing a change in leaks when I switch to a new hose, though I guess that could have to do with the attachment? It feels secure but I'm not sure how to test it to know for sure.

On sleep hygiene, I don't take any medications, sleep in a cool (65F) and quiet room, and don't drink any caffeine at all or alcohol within about 5 hours of going to bed. I don't eat close to bedtime. There's definitely stressors in my life, but the ones in my control I deal with, and the ones out of my control I can't. Mattresses have been a struggle — I've gone through four and can't find one that I find comfortable. I hurt a bit every time I wake up at night and have to turn over, but new mattresses don't seem to help. I've read apnea can perhaps cause this, but I'm just not sure what to do because I don't have the money to try mattress after mattress, and it seems like you need a different kind of mattress depending on how you sleep anyway — I usually sleep on my stomach, but am trying to learn to sleep on my side, and I need a softer mattress for the latter than the former. (Any thoughts/suggestions on these things are welcome!)

[ChicagoGranny]

I usually sleep on my stomach, but am trying to learn to sleep on my side

Before you give up entirely on stomach-sleeping, check out Dr. Falcon's blog on the ideal stomach-sleeping position for CPAPers - https://www.uarsrelief.com/sleeppositions.html

[semblables]

I switched to VAuto to get flow limitation data; here's a screenshot from OSCAR:

Image 12-13-25 at 12.53 PM.png (578.24 KiB) Viewed 2758 times

[ChicagoGranny]

From that screenshot, it appears you are getting excellent CPAP therapy. If you want us to look at breath forms, please use SleepHQ, which allows us to zoom in.

[semblables]

Hi! Here's an updated SleepHQ link (most recent data is on Dec 12, so you'll need to click back a couple days):

https://sleephq.com/public/teams/share_ ... bddeba0dee

Also I tried the falcon pose and it seemed to relieve pressure on my back! Amazing! Thanks so much!!

[semblables]

Here's an image of the flow rate shape I'm seeing now, with this kind of two-phase inhalation.

Image 12-15-25 at 8.26 PM.png (46.59 KiB) Viewed 2436 times

Seems weird. It's like I start breathing in, then I get stuck, then it clears and I breathe in the rest of the way. Over and over and over. And it looks liek the "stuck" period varies a little bit breath to breath -- sometimes it's less than half a second, sometimes almost two seconds. Are these RERAs?

Could this be caused by having too long of a rise time, and so the pressure is ramping up over my inhale, so it's closer to the EPAP pressure in the beginning, my throat collapses, then it rises up closer to the IPAP pressure and it clears so I can breathe in the rest of the way? Or is it something else?

I took a nap today that I think overwrote my data from last night when I slept with an IPAP of 11.2 and EPAP of 7.6 (+1 EPAP from where I was at with IPAP 11.2 / EPAP 6.6), so I'll have to update with that data soon.

[Nocibur]

Or is it something else?

It's something else.

Inspiration is only that part of the waveform above the -0- line.

[semblables]

Ah I see; thanks! Makes sense.

Here's my sleep HQ for the higher EPAP of 7.6. Since there's still events, should I just keep cranking it up?

https://sleephq.com/public/teams/share_ ... b95199888e

[Nocibur]

...should I just keep cranking it up?

Based on the data presented, you don't even need BiPAP, much less more pressure.

[Miss Emerita]

Nocibur, thanks for swinging by. I'd love to get your thoughts about the bumps or lumps in the inhalation trace. (See screenshot.) These seem pretty frequent in semblables's graphs.

Screenshot 2025-12-17 at 10-36-07 SleepHQ.png (119.09 KiB) Viewed 2167 times

[semblables]

Based on the data presented, you don't even need BiPAP, much less more pressure.

Hi! I don't know anything about the data but I can say based on symptoms I do need BIPAP. When I switched from CPAP to BIPAP I felt 10x better and had deeper more restful sleep.