new bipap auto machine

Dolpp wrote:Nevermind, I found it all. I was trying to scroll down and didn't realize you had to go page by page. So, pretty much all of my apneas were centrals. In the two weeks i've been using this I am at an AHI average of 15.0/hr. 1.4/hr obstructive and 13.6/hr CA. Recommendations? I am on straight BiPap. 12/8.

Dry mouth can be an indication of mouth breathing. Do you have a bed witness you can ask? I wonder if Mouth breathing might show up as Central apneas as there would be no "airway resistance" when your mouth was open. Does anyone else see Central apneas in the reports during periods of mouth leaks using the new Autos?What was your leak rate during the Central Apneas? If it was high I would address your mouth leak first. A full face mask is the surest way, a chinstrap might work, taping works but has it's risks (and followers).

Don't overlook humidifier adjustments, too much or not enough can make pap therapy less comfortable and effective. Too dry can make your nose a little stuffy causing a need to mouth breathe. Too much humidity can cause nasal moisture/irritation or even "rain out" in the tubing, Tubing rain out can cause problems with the Auto's ability to recognize and titrate for respiratory events.

If you are not mouth breathing, Central Apneas do seem to be a problem. A lower pressure might be better. You could set your machine to wide open settings and let it titrate you. Most BiPAP autos have three basic settings...

Pressure support (the difference between the high and low pressure) in the case of 12/8 the pressure support is 4. Do you feel comfortable with the transition from inhaling to exhaling on this pressure? If you feel comfortable leave this alone for now. You could try more or less pressure support, adjusted to comfort.

Then you have the higher number called inspiratory max or I max (name varies) this is the highest pressure setting you allow. The main reason for limiting this number is poor tolerance of high pressure or to prevent run away titration due to leaks or to prevent overtitration due to central apneas (the new machines like the System One check for central apneas to prevent this).

Then you have the lower number called the Expiratory minimum or E min (name varies), this is the lowest pressure setting you will allow. The main reason for increasing this setting is to overcome obvious obstructive apneas especially if you can tolerate pressure. Being on too low of a starting pressure tends to waste good sleep time waiting for your auto to treat your obvious apneas. In your case central apneas might be the problem so the lowest pressure might be best.

You could try a pressure support of 4, An Imax of 20 and E min of 4?

This means you would start at 8/4. Try 8/4 first. Are you comfortable or do you feel air starved? If you feel air starved you can try a higher E min or a different pressure support setting. Your System One Auto Bipap should titrate up the pressure in response to hypopneas, obstructive apneas and snoring/flow limitation as needed while ignoring central apneas (in theory). It will maintain the same pressure support while adjusting between a minimum of 8/4 to maxiumum of 20/16.

Here are some of the risks....you could have severe apneas on these lower pressures...The auto treats your respiratory events but you have poor oxygen due to an associated health problem (COPD, Heart Disease), It "over titratrates" and causes severe central apneas or over ventilation. You have to take responsibility for these potential risks.

In the sleep lab we usually increase the expiratory pressure in response to obstructive apneas, we increase the inspiratory pressure in response to hypopneas. So if you are having primarily obstructives you could increase the E min, if you have primarily Hypopneas on your reports you could increase the pressure support. We try in have a minimum of 3 for pressure support however we try not to make the difference between the I and E (pressure support) too great as this tends to create a kind of "jolt" of air in transition between inhaling and exhaling, Bi-flex or A-flex on the System One can help with this.

Good Luck

Any one else have any ideas for Dolp's first at home self BiPAP tiration?

I have been on vacation for the last week and a half and switched back to the mouthpiece because I knew I could at least feel okay, and didn't want to be wishing I was sleeping the whole vacation. I'm ready to get back into the PAP now.

I'll try to answer all the questions and thank you very much for the help.

My girlfriend said she has never seen me breathing through my mouth but that doesn't necessarily mean I am not. My software says: "min. in large leak 0.0 min. % of night in large leak 0%." Average leak is between 30 and 36 since I started. I don't know what any of that means. I'd appreciate it if somebody could break that down.

What exactly are the "risks" of taping my mouth?

I put my humidifier at 5 (the highest it will go) and haven't changed it and I get no "rain out"

I'm not sure how to change the settings on my machine. It is set at 12/8 straight cpap from the DME. I have another appointment on june 4,with my sleep doctor who I think is very knowledgeable and with my DME. if i change my setting what do I tell them? Should I wait? I still want their input. I'm not sure what to do....

I'd appreciate anymore recommendations.

Dolpp wrote:My girlfriend said she has never seen me breathing through my mouth but that doesn't necessarily mean I am not. My software says: "min. in large leak 0.0 min. % of night in large leak 0%." Average leak is between 30 and 36 since I started. I don't know what any of that means. I'd appreciate it if somebody could break that down.My understanding is that on a System One the leak rate includes the normal exhalation rate so those numbers look good. To be sure you could try to find the built in leak rate for your particular mask but they all run around 35-45 lpm. It mostly depends on mask type. Unless your girlfriend is a very deep sleeper, mouth leaks often wake the bed mate so this is also good. So combined, mouth breathing seems unlikely.

What exactly are the "risks" of taping my mouth?If your nose gets stuffy you can't get enough air, power outage you'll re-breath your own air because you can't open your mouth (that's why a full face has the one way safety flap added a couple of years ago), Off chance you wake up having to vomit (you get the picture). Plenty of people tape with good results. I would recommend a full face if needed. You seem Okay in regard to mouth breathing.

I put my humidifier at 5 (the highest it will go) and haven't changed it and I get no "rain out"Sounds good, adjusted to your comfort. Some versions of the System One can put out more humidity by manually setting the humidifier control with an additional "secret hand shake" but if you don't feel dry, stuffy, or cold then this should be a good setting.

I'm not sure how to change the settings on my machine.To access the provider mode screens:Once the device is powered, the home screen appears (it is a large box on the screen with four little boxes you choose from by turning the control wheel). Turn the wheel to toggle between the four options and highight "setup".
Once setup is highlighted press and hold both the control wheel and ramp button on the device for at least 5 seconds (pretty simple, considering there are only 2 buttons).
You will hear a quick double beep and the provider mode screen will appear, you are now in provider mode!!

It is set at 12/8 straight cpap from the DME. I have another appointment on june 4,with my sleep doctor who I think is very knowledgeable and with my DME. if i change my setting what do I tell them? Should I wait? I still want their input. I'm not sure what to do....Your doctor and DME may not be happy with you. It depends on your people. Some are Ok some get angry.

I'd appreciate anymore recommendations.

As it doesn't seem your mouth breathing, Central apneas seem to be the problem. Less pressure might lower central apneas. Less pressure might increase obstructive apneas and hypopneas, so it's a call. You can make a small change and see how it goes, or give your auto wide open settings starting as low as possible and let it titrate you. The nice thing about the System One Auto is that it shouldn't increase the pressure in response to Central apneas. My previous post explains it in detail. I hope this helps you.

Anyone else have a central apnea problem on BiPAP and then titrate yourself with a Sytem One Auto BiPAP? How did it go? How did you do it?

Any other recommendations from people? That was a lot of good advice I'm going to take it all in, but would like to have more advice. I'm very analytical and the more information I can get the happier I am. My main concern is that my doctor said that the centrals would go away as I got used to the BiPap. Does that seem right? Has anybody ever experienced with that? If I can get rid of the centrals it would bring my AHI down to less than 2 I could live with that. But I hate to use this thing for 4 weeks trying to get used to it when it might not be right to begin with. Especially when using my oral appliance gets me feeling good. Not good enough but good. So far this BiPap is very disappointing with how tired I am. Very frustrating.
Thank you.

Dolpp wrote:Any other recommendations from people? That was a lot of good advice I'm going to take it all in, but would like to have more advice. I'm very analytical and the more information I can get the happier I am. My main concern is that my doctor said that the centrals would go away as I got used to the BiPap. Does that seem right? Has anybody ever experienced with that? If I can get rid of the centrals it would bring my AHI down to less than 2 I could live with that. But I hate to use this thing for 4 weeks trying to get used to it when it might not be right to begin with. Especially when using my oral appliance gets me feeling good. Not good enough but good. So far this BiPap is very disappointing with how tired I am. Very frustrating.
Thank you.

You might see a reduction in central apneas as one get used to a pressure but they should fade over time if they are gonna go away. I think you might be having pressure related central apneas?

Anybody else have any suggestions? Has anybody out there actually seen central go away after getting used to a machine?

I asked a fellow sleep tech about less central apneas after getting used to your pressure? She reminded me how often you see a central apnea after an arousal (sleep disturbance). These kind of centrals might go away if you have less arousals (get used to the pressure).

On the other hand sometimes you see central apneas that cause arousals and/or desats. Sometimes you see more of these as you increase the pressure.You increase the pressure because you have too many hypopneas or obstructive apneas but before you get to an acceptable AHI you start to see central apneas that cause arousals or desats. If you go lower you have too many hypopneas/obstructives... you increase then you get too many centrals so we call this "complex sleep apnea". They make a special pap unit for this (ASV or Vpap adapt).

Do you have this? I could only tell by reviewing your titration sleep study. Maybe you have post arousal centrals and this is why your Doctor thinks they will go away?

According to my last sleep study with the BiPaP, all of my apneas were Hypopneas with arousal but it doesn't say anything about if they were before or after. The only other apneas I had were centrals that started when I got to my pressure of 12/8 but that is when my hypopneas went down considerably. It doesn't say anything about the arousals with the centrals.

Like i've said before I never had any centrals in any of my sleep study (4 so far) except for this last one my only one with the BiPaP

Last night I fell asleep without putting my mask on and woke up about 4 am and put it on so I got about 2.5 hours with it on, when I checked my numbers today it they were:
CA:39.3 RERA: 6.5. The only thing I noticed that I did differently was I tried to sleep on my stomach which is how I normally sleep. Any thoughts? My last diagnosis without CPAP or anything was 27 all hyponeas with arousal.

Went to my sleep doctor today for a 1 month follow up appointment with the BiPaP machine. I went in there thinking if I don't get the answers I want or if he doesn't seem like he is on my side than I was going to just titrate myself and go at it alone. He, of course, didn't give me the answers I wanted but mentioned that my compliance is too low and that Aetna uses the medicare guidelines which state that during the 60-90 days of usage I have to be at 80% compliance with at least 6 hours a night. Or they will take the machine away. Now I don't know what to do. He wants me to stay at the same pressure and just stay the course, but then he said maybe try the oral appliance with the BiPaP but without adjusting the pressure. Stay at 12/8. Anybody have any thoughts on this? I have another appointment in 2 weeks to see my compliance.

Well if he is giving you the hardline I would be hesitant to make my own adjustments. He may get angry and declare you "non-compliant". As I understand it Medicare requires at least 4 hours per night for 70% of nights for 30 nights, not sure where he is getting his numbers.

I would tough it out, get compliant before I did anything on my own. Using your oral device with your BIPAP might help.

Does anybody have any experience using an oral appliance in conjunction with pap? I'm hesitant to start because I would think using the oral appliance would mean I would need less pressure. if I do it at the same pressure my thought is I'm going to see a lot more centrals. Which is what o don't want. Any thoughts?

Dolpp,

I am having similar experiences with Bipap as you. I began having centrals when I raised pressure to 13 in an effort to eliminate some obstructive apneas. For me centrals began at settings 13 inhale, 9 exhale.

I have since lowered pressure to 10 inhale, 9 exhale and have much better results - AHI < 3.0. I do not know from my experience if higher pressure induced centrals would have gone away at some point. I did not want to wait to find out.

Key for me is to stay off my back when sleeping. I use a back pack to prevent rolling onto my back. If I roll onto my back then my pressure is not high enough at 10/9 and I will have more OA's. However, if I increase pressure and have centrals then it's a catch 22 for me.

I use a full face mask (Forma). This mask also holds my chin up which is an additional benefit for me.

I know it's counterintuitive to lower the pressure to get better results by that is what is happening for me so far.

I have also tried dental appliance and got similar results = AHI of 15 - not good enough. I believe I can optimize Bipap to work well enough for me that it should not be necessary to combine biPap with dental appliance.