Me vs The Mighty AutoBiPAP

The third night with the AutoBiPAP in AUTO mode proved the most interesting yet.

The Mighty AutoBiPAP scored first at three hours into the match with its high pressure cramp inducing aerophagia; a painful jab to the stomach which kept me out of the arena for nearly an hour walking off the painful cramps before I could crawl back to bed and resume the match.

Sure that this night's round would be won by the machine, I was determined to tough out the fight to its conclusion at dawn. The machine was tenacious; insisting that I take more air and higher pressure. In desperation, at 4:30, when I just couldn't, I reset the machine momentarily with its OFF button, gaining, it seems, the critical advantage. The air became sweet again; at a much lower pressure, it even had Flex action, enabling me to breathe normally, at least for a little while.

The machine stubbornly persisted, however, and within ten minutes or so had achieved maximum pressure again despite my deliberate attempts to just breathe normal. Thankfully, near 5 am, it was time to conclude the match. I was even willing to give the night's round to the machine, certain that it had bested me. Little did I know that Encore Pro would score the results differently and award a technical knock-out in my favor.

It seems that in the final minutes of the match the machine literally lost its mind. Unwittingly, by my mere efforts to breathe normal, I had broken the machine's algorithm. The Mighty AutoBiPAP had decided, for reasons perhaps known only to its programmers, that I was having apneas while lying in bed fully awake and had ratcheted up both IPAP and EPAP to their upper limits and simply kept them there, forcing me, like a fish swimming upstream, to breathing vigorously against the pressure. Encore Pro data shows that this happened three times during the night.

Although I'm still struggling to interpret last night's results, it is clear the machine got stuck in this high pressure condition three times last night. I suspect mask leaks played a part, for the data shows that leakage increased somewhat as pressure increased. Otherwise, except for when it got stuck-on-stupid, and except for being a little slow to respond to apneas, the AUTO mode seemed to do a good job of minimizing apneas. This is independently confirmed by oximeter data.

Other interpretations appreciated.

Here's a plot of the Encore Pro data broken into two segments (before and after the aphagia episode):



The AHI for the night is clearly distorted due to all the events which occurred when the machine stayed at max pressure.

Here are the oximeter results:


Regards,
Bill (feeling victorious, but willing to partner with the beast again tonight)

Your pressure max is 10? That's not very high. Maybe you should raise the max to 12 and see if you have fewer apneas.

NightHawkeye wrote:It seems that in the final minutes of the match the machine literally lost its mind. Unwittingly, by my mere efforts to breathe normal, I had broken the machine's algorithm. The Mighty AutoBiPAP had decided, for reasons perhaps known only to its programmers, that I was having apneas while lying in bed fully awake and had ratcheted up both IPAP and EPAP to their upper limits and simply kept them there, forcing me, like a fish swimming upstream, to breathing vigorously against the pressure. Encore Pro data shows that this happened three times during the night.

Bill, why not run a test for a few nights by setting the machine to the constant pressure mode with pressure = 10 cm? I assume the machine will still give some exhale relief. 10 cm is very tolerable for me with the C-flex on my REMstar Pro II set at 2. If you do this you will take the variable pressure out of the results.

Just a thought.

Jerry

Bill, why not run a test for a few nights by setting the machine to the constant pressure mode with pressure = 10 cm?

I agree with your thought, Jerry. I'm having to take small steps here though. I tried a lower CPAP pressure a week or so ago and found out that my sinuses clogged so badly that I couldn't exhale through my nose. I've made progress since then but, based on the past couple of night's data, obviously not enough.

I honestly had no idea when I started this a few weeks ago that congestion was going to be a big problem. It's not during the day and I don't do anything special for it. I ordered a full face mask though and figured I'd just breathe through my mouth whenever congestion became a problem. Wrong! My sinuses have been clogging with the higher pressures, only thing is I have to wake up before I can open my mouth to breathe. (How's that for a kick in the pants - just like apnea.)

If I thought just seeing an ENT would fix this, I'd do it tomorrow. I expect ENT's operate like most other physicians though, including sleep docs; the better prepared the patient is going in, the more effective the treatment. I really don't know what I need yet, so I'm not real well prepared.

I am stepping up the sinus treatment again tonight. A simple saline rinse got me close to being able to handle 10 cm, but I'm going for "Hydropulse Irrigation" tonight and I've also got the Aussie heated hose on order to help with humidity, but don't know how long it will be before it arrives. In the mean time maybe I should even invest in a room humidifier to prehumidify the air before it hits the Remstar humidifier. (My wife complains about our dry air sometimes anyway.)

Hopefully tonight will provide further progress, Jerry.

Regards,
Bill (continuing to inch forward)

The Mighty AutoBiPAP scored first at three hours into the match...
...Sure that this night's round would be won by the machine... The machine stubbornly persisted... I had broken the machine's algorithm.

Love that "man versus machine" theme! LOL!

Leak rates look very acceptable to me. So do SpO2 readings. However as guest above stated: it looks as if your pressure limit of 10 cm is not enough to address those measured apneas (on the night your OA index ran 19.1. Normally I would be inclined to agree with guest. Looks like you need to raise you maximum pressure a bit to clear those unaddressed apneas.

However, you sound convinced those recorded apneas are not really apneas----and that since they are not really apneas you don't need your pressure all the way up to 10 cm. The algorithms do rarely register "false positives" when trying to measure obstructive apneas. Asthma events, for instance, can trigger "false positives" for obstructive apneas. The night your OA index ran 19.1, you experienced what your Remstar thought were a cluster of obstructive apneas for over an hour. Another possible way that long strings or clusters of "false positives" for apneas may register are vocal chord spasms. In both cases (asthma or vocal chord spasms) the airflow amplitude is actually reduced such that it meets the criteria for AutoBiPAP scoring of apneas. In the case of vocal chord spasms, it is really debatable whether this is an apnea "false positive" or merely an obstructive apnea of a different etiology.

In any event my inclination would be to take guest's suggestion and tentatively raise the maximum pressure. Jerry69's experiment sounds like a pretty reasonable experiment too.

NightHawkeye, that really was a funny read! Thanks for the laugh!

If experiments in raising the maximum pressure or trying single fixed pressure don't bring AHI joy, pour over the discussions in the link below for more insight into what PAP'er has brought up. Silent GERD with vocal cord dystonia is a possibility that could account for those recorded blocks of apneas:

Nov 05, 2005 subject: SUCCESS AT LAST-GERD,420E, PRILOSEC AND BENADRYL -SWS's thoughts on loonlvr's massive clusters of events.

. . . it looks as if your pressure limit of 10 cm is not enough to address those measured apneas . . . However, you sound convinced those recorded apneas are not really apneas----

Thanks for the feedback PAP'er. In light of your comments I went over the charts again and you may be right, at least for the biggest block of recorded apneas. The apneas after about 4:10 am are not real, yet the machine just ran the pressure up anyway - twice in fact. (The pressure reset was me turning the machine OFF momentarily.) Because of this I initially assumed that the apneas from about 3:40 until 4:05 were not real either. The oximeter data shows desaturations across this time though so apparently they were real! Also, this string of apneas follows the same pattern I've been seeing during later stages of sleep at lower pressures.

The big question, as everyone has pointed out, involves raising pressure. For the time being, I think I've taken it as far as my sinuses will allow. I definitely had some blockage last night, but I'm unsure how much it affected the results. (It did limit my ability to sleep though.) My plan is to attempt a thorough irrigation this evening and run the machine at the same settings again.

Really appreciate the comments PAP'er.


Regards,
Bill (having to peel back the layers of the onion one at a time - metamorphically speaking)

Looks like my post came in as Guest again. . .

Anyway, thanks Rested Gal Laura for the link. I've been on the lookout for something to account for clustered apneas.

Also, I stumbled across your story yesterday, about your sleep study with SleepyDave - interesting reading. I'm going it largely on my own here too, but for a different reason - my sleep study was "unremarkable". It recorded apneas alright, but only at the very end of the study so the overall AHI was low. The only reason the doc wrote a prescription for me was that I had oximeter data taken at home showing strings of de-sats happening.

BTW, guess I'll have to seriously investigate your link. My sleep doc wanted to put me on an antacid medication too. (So far I've resisted that - tried Prilosec once a few years ago and it seemed to just make things worse.)

Regards,
Bill (with too many things to follow up on, yet thankful for the advice)

I agree about the desats, Bill. While they don't go below 90% your slight SpO2 dips do happen to coincide with your Remstar recording apneas. If they're not apneas then they're asthma or perhaps vocal chord spasms.

You mentioned Prilosec made things worse. I should mention that some acid reflux medicines have what is called a rebound effect. If you use them for a while, then discontinue for a night or two... they will rebound. In other words they will make things worse after you initially discontinue using them. You would thus need to use your Prilosec every day in order to avoid the rebound affect. Indeed your acid reflux might be at the heart of those episodic strings of recorded apneas.

Sounds like you just may need to get accustomed to positive pressure before you can comfortably raise your maximum pressure? What does your doctor think so far?

You mentioned Prilosec made things worse.

Yep. I think I tried it for about a week. That was a few years ago already. At the time the "heartburn", or whatever it was, was more or less constant. The one thing that worked amazingly well was Pepto-Bismol, which I also avoided taking - but only because I'm allergic to aspirin, which is in it. I kinda reserved Pepto-Bismol as a silver bullet.

Indeed your acid reflux might be at the heart of those episodic strings of recorded apneas.

Interesting theory. Because of osteoporosis, I have been viewing things as an acid-base disturbance. A largely alkaline diet definitely helps. I've also learned recently that respiration profoundly and very quickly can affect the acid-base balance, so my thinking has been along the lines that correcting the apnea might help this as well.

What does your doctor think so far?

It's been almost a month since I saw him, when he wrote the BiPAP prescription. Had to postpone the appointment for this week. I'll be especially interested in hearing what he has to say about the fact that on xPAP therapy my body temperature at night immediately returned to the normal range, rather than being profoundly hypothermic. Unlike most other docs, he actually does listen (a wonderful attribute in a physician). I'm just not sure how much he can add at this point. The diagnostic ability of most physicians seems to be limited to rather narrowly constrained areas, and so far my symptoms haven't fit very well within such constraints. I do have an appointment in a couple of weeks. If nothing else, maybe he'll consider rescoring the sleep study for insurance purposes.

Regards,
Bill (now opening the box with the Grossan Nasal/Sinus Irrigation System)