Complicated case -- help with CPAP pressure and other

dcg494 wrote: ↑

Mon Jul 23, 2018 12:25 pm

How have you found the autoset algorithm on the ;airsense for her' ? Seems you've tried a respironics system before, are you able to compare ? And generally, do you know if the Aircurve VAuto can respond to FLs the same way as the airsense ?

I like the For Her algorithm...but I also did well with the regular apap algorithm.
Yes I have used several different Respironics machines in the past.
I have lost count the number and models that I have tried just for grins. I have even used ASV for a while.

I have no idea if there is any difference in the response to FLs between the AirSense and the AirCurve auto models. Sorry.
I am not a good one to compare to when it comes to FLs because I have never really had very many. I have the most boring FL graph in the world.
I have plain old OSA with no complicating factors and I try different stuff because I am bored...not because I am unhappy with my therapy.

Pugsy wrote: ↑

Mon Jul 23, 2018 10:14 pm

dcg494 wrote: ↑

Mon Jul 23, 2018 12:25 pm

How have you found the autoset algorithm on the ;airsense for her' ? Seems you've tried a respironics system before, are you able to compare ? And generally, do you know if the Aircurve VAuto can respond to FLs the same way as the airsense ?

I like the For Her algorithm...but I also did well with the regular apap algorithm.
Yes I have used several different Respironics machines in the past.
I have lost count the number and models that I have tried just for grins. I have even used ASV for a while.

I have no idea if there is any difference in the response to FLs between the AirSense and the AirCurve auto models. Sorry.

As far as I've been able to determine, Resmed uses the same 'autoset' algorithm in the autoset and Vauto machines. the Vauto just has a wider range than EPR between the inhale and exhale pressures, as well as some other tweaking that makes it customizeable for people with a variety of lung disorders. (restrictive/obstructive, etc).

https://www.youtube.com/watch?v=4GW97Xk06N8

Thanks again for the help! This sounds crazy, but I got my hands on a dreamstation bipap yesterday. Was extremely lucky, as a guy right around the corner was selling his for an amazing deal. Hardly used.

Well, I tried it last night, and the PS felt great. I'm started low at 4 EPAP and 7 IPAP. The auto- kicked in once to 5 EPAP and 8 IPAP. There was a cluster of Hypopneas that triggered it apparently. Was thinking I'd go up by 0.5 slowly, keeping the auto on with a small range of +1 on E- and IPAP and a PS range of 3-4 (just to see what the machine wants to do).

I think a pretty low pressure is enough to get rid of any OA for me (5-6cm). It's mostly hypopneas/FLs after that. So I'm thinking I'll try inching up with the IPAP (I.e. up with the PS) ?

I really hope I don't have the same problem as with CPAP -- that I'll hit 9cm pressure and then get aerophagia and more RERAs.

Play with the BiPap...don't go over PS max of 5 though.

Minimum EPAP is going to be your most critical setting...so inch it up slowly.
You might be able to tolerate a little more than 9 IPAP before the aerophagia monster comes back because you can use the lower EPAP to offset the time at IPAP somewhat.

Pugsy wrote: ↑

Wed Jul 25, 2018 6:17 am

Play with the BiPap...don't go over PS max of 5 though. Minimum EPAP is going to be your most critical setting...so inch it up slowly. You might be able to tolerate a little more than 9 IPAP before the aerophagia monster comes back because you can use the lower EPAP to offset the time at IPAP somewhat.

Great, thanks Pugsy! I hope you're right!

And if we go above PS 5, does that increase the chances of CAs / Centrals ?

Last night wasn't too great.. I assume it's because of the low EPAP setting currently. I was hoping I could get away with a very low EPAP, but I guess 4.5 is really still too low. One can restrict on exhalation too, after all ?

dcg494 wrote: ↑

Thu Jul 26, 2018 1:11 am

And if we go above PS 5, does that increase the chances of CAs / Centrals ?

Yes...for some people..not all people but enough that we watch closely.
The higher the PS...the greater the chance of centrals popping up. I had a friend who sent me a note in panic mode....she never had more than a rare normal central and all of the sudden she was having 10 per hour average.
So she sent me her report from her bilevel machine. She had decided to try PS of 10...wow I can't believe she even slept with that much PS but I guess she did. So we quickly dropped PS and she played with it and found out she was okay with PS up to 6 and above that the centrals would become too numerous. Too much PS can cause a person to sort of hyperventilate and blow off too much carbon dioxide too soon and the blood levels for the carbon dioxide never gets high enough to trigger the brain's response to breathe. So the brain doesn't tell the body to breathe and a central apnea happens.

It's actually the carbon dioxide level in the blood stream that is the trigger for the brain to tell us to breathe. It's not low oxygen like a lot of people think.

You needed more EPAP last night for more than just comfort breathing...you needed it for apnea prevention as well.

With your wanting to restrict max IPAP to 8.5...there's really no room for the machine to auto adjust much. I know why you are doing it but you are essentially making the machine almost a fixed bilevel machine which is okay as long as it treats your apnea effectively and the aerophagia monster stays away.

My suggestion in your situation...
Minimum EPAP 5.5
Minimum PS 3
Max PS 4
Max IPAP at 9
It's a tight range but let's see how your report looks and see if the aerophagia monster stays away.

You are going to be like RobySue...need bilevel at lower pressures with a very tight range.
You may have to compromise and accept a not quite so pretty report but let's at least try to clean it up a little without bringing home the monster.

Pugsy wrote: ↑

Thu Jul 26, 2018 5:40 am

My suggestion in your situation...
Minimum EPAP 5.5
Minimum PS 3
Max PS 4
Max IPAP at 9

Thanks a lot Pugsy! Took me a while to get back, since I first tried to go up with the IPAP -- to see if the lower EPAP would help with aerophagia. Sure enough, didn't have any problems, even when the IPAP hit 10.5 for an hour or so (not in the below graph, but another night).

Now I'm up at EPAP 5.5 with PS 3-4, but think I should increase EPAP another notch. My numbers were better on the Cpap, but think it's because of the higher EPAP I was using (~6 w c-flex on). I'm hoping from there, I'll still be able to tolerate IPAP 9-10.

On another forum someone was saying EPAP is only titrated until obstructive apneas are eliminated. Then IPAP is used for Hypopneas and flow limitations. I'm guessing that's the standard titration protocol, but doesn't suit everyone ?

dcg494 wrote: ↑

Mon Jul 30, 2018 1:39 am

On another forum someone was saying EPAP is only titrated until obstructive apneas are eliminated. Then IPAP is used for Hypopneas and flow limitations. I'm guessing that's the standard titration protocol, but doesn't suit everyone ?

Yeah...pretty much standard protocol but doesn't always suit everyone and sometimes if people add more PS just to get a higher IPAP...it can cause problems. You can have "too much PS" so we are careful with PS changes. 4 to 5 PS on a regualar bilevel machine (not ASV bilevel for centrals) is the most common PS setting for plain jane OSA.
There's more than one way to skin a cat...you can also get higher IPAP by simply raising EPAP a bit. Just because the EPAP has already killed off most of the OAs doesn't mean we can't use a little more to give IPAP a hand in killing hyponeas.

Thanks Pugsy! Tried EPAP min 6, IPAP 9, PS 3-4 but it was a bit uncomfortable with some aerophagia again.. Also, no difference from before in terms of AHI.

Not sure where to go from here. My AHI was lower on CPAP at 7.5 (w c-flex at 2) and I don't know why.

Pugsy wrote: ↑

Mon Jul 30, 2018 7:22 am

Just because the EPAP has already killed off most of the OAs doesn't mean we can't use a little more to give IPAP a hand in killing hyponeas.

Interesting! Can hypopneas be caused by low EPAP too though ? Quite a few of my breaths seem to stop at exhalation, not inhalation.. Can you help me understand why obstructives should be eliminated by epap and hypopneas/Fls by IPAP ?

dcg494 wrote: ↑

Tue Jul 31, 2018 1:30 am

Can hypopneas be caused by low EPAP too though ? Quite a few of my breaths seem to stop at exhalation, not inhalation.. Can you help me understand why obstructives should be eliminated by epap and hypopneas/Fls by IPAP ?

EPAP is what holds your airway open. EPAP too low, airway closes, and you've got an obstructive apnea.

Everything else, hypopneas, flow limitations, snores, are all things that happen when the airway isn't closed, but narrowed...raising pressure during inhale can often overcome those without more base (epap) pressure.

Alternatively, just raise epap enough to overcome that narrowing, which is what's done with regular cpap, that doesn't have the option of higher pressure support. So, yes, hypopneas can be caused by too low epap.

dcg494 wrote: ↑

Tue Jul 31, 2018 1:30 am

Thanks Pugsy! Tried EPAP min 6, IPAP 9, PS 3-4 but it was a bit uncomfortable with some aerophagia again.. Also, no difference from before in terms of AHI.

You may have to decide which is more important...lower AHI or avoiding the aerophagia monster...and making a compromise.

dcg494 wrote: ↑

Tue Jul 31, 2018 1:30 am

My AHI was lower on CPAP at 7.5 (w c-flex at 2) and I don't know why.

You didn't say how this setting did in terms of aerophagia.
CFlex at 2...you probably got around a 1 cm reduction during exhale..maybe 1.5 if you breathed forcefully.
With 7.5 inhale that brings the exhale (EPAP) down to 6.5 if you got 1 cm reduction.
The slightly more EPAP even with using Flex at 2..is probably what got the AHI a bit lower.

It's all about EPAP as your starting baseline minimum pressure which does the bulk of the work holding the airway open in the first place and sometimes a small 0.5 cm difference can make a rather large difference in results.

If you want to try another setting experiment to get your AHI lower and not feed the aerophagia monster in the process.

EPAP 6.5
PS min 1
PS max 2
IPAP max 8.5
I know it's a very tight range and really restrictive and it may not work but it's something to try before you end up deciding if you are just going to have to figure out which is worse...a higher AHI or the aerophagia.

To be honest...the AHI of 2.31...I would gladly take it if I was feeling decent during the day and the other stuff like snores...let them slide as long as the aerophagia monster stayed away. I know we would like cleaner reports and we can get them with more pressure but the more pressure feeds the aerophagia monster.

Maybe make a compromise now and give things some time...revisit more pressure in 3 to 6 months. Maybe the aerophagia monster will stay away at that time.

Pugsy wrote: ↑

Tue Jul 31, 2018 5:58 am

CFlex at 2...you probably got around a 1 cm reduction during exhale..maybe 1.5 if you breathed forcefully. With 7.5 inhale that brings the exhale (EPAP) down to 6.5 if you got 1 cm reduction. The slightly more EPAP even with using Flex at 2..is probably what got the AHI a bit lower.

Thanks Pugsy, sleepyhead says that Cpap with c-flex at 2 gave me an EPAP max of 5.8 and mean of 5.6. So almost 2cm reduction. Could it be right ?

I'm pretty sure after experimenting a bit more that I indeed do need min EPAP of 6.5 or even 7. With the aerophagia problems, that means I'll have a tight range like you said. 7-8, maybe 9 if I can tolerate it.

On auto-bipap my flow-rate looked best at EPAP 8 / IPAP 11, but then as I said, woke up a few times with some issues.

Will report back after a few days or a week to let y'all know how it goes.

dcg494 wrote: ↑

Thu Aug 02, 2018 7:40 am

sleepyhead says that Cpap with c-flex at 2 gave me an EPAP max of 5.8 and mean of 5.6. So almost 2cm reduction. Could it be right ?

Yes. It depends on how forcefully you breathe. I used a setting of 2 and got almost 2 cm reduction myself. When I tried the setting of 3 it seemed like the timing was just a bit too fast to suit me and since I really wouldn't gain much more of a drop at the setting of 3 I opted to just keep the setting of 2 because pretty much matched my own respiration rate.
With using Flex...that timing thing is just as important as the reduction and in some people maybe even more so.

You are just going to have to play with the little tweaks on the auto bilevel to figure out which takes care of the OSA and doesn't make the aerophagia worse. You will probably have to use a very tight range but nothing wrong with that as long as you sleep decent, feel good and the OSA is decently managed.

Forum member RobySue had to do a really tight bilevel range and sometimes just had to let a few OAs slide because to try to kill them with more pressure ended up causing more discomfort with aerophagia than having an AHI of 2 or 3 caused.
Her minimum EPAP was 4...PS was 4 (both min an max) and her max IPAP was 10...sometimes she would see it max out at 10 but she learned that going higher even briefly caused more discomfort for her and wasn't worth it.
Her sleep was already fragile from insomnia issues unrelated to cpap or OSA...adding in aerophagia increased the likelihood of more insomnia along with feeling like crap from belly issues the next day. Just wasn't worth it to her to use more IPAP. Sometimes just because a machine might want to go somewhere doesn't mean we have to let it go there. Sometimes we make compromises.

Hi Pugsy, all -- wanted to update you on some progress

Finally went up with the PS and IPAP last night. (Tried everything else out first b/c I couldn't seem to find comfortable settings with higher PS and was afraid CAs would go up.)

Last night it took me a while but finally fell asleep with PS at 4. (EPAP 5.5 / IPAP 9.5) Best results on bipap so far!

I cheated a bit with the CAs and took some diamox before sleep. Still surprised to see 0 CAs..! it was around 2/hr every other time I tried PS 4.

So it seems EPAP of 5.5 is enough and higher IPAP is what I need. Last night's settings seem really my cutoff for aerophagia though, so I don't see how I could go up more on IPAP unless I went down with EPAP and up with PS to Min EPAP 5 and PS 5.

Happy for now, will try to get used to this, take a break from all the dialing around. Then I want to finally make the switch to a nasal mask.

Thanks for all the help Pugsy, everyone!