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Re: Is this bad? Is it UARS? Flow rate questions
Posted: Sun Dec 08, 2019 7:22 pm
by slowriter
Geer1 wrote: ↑Sun Dec 08, 2019 7:13 pm
slowriter wrote: ↑Sun Dec 08, 2019 6:30 pm
The most straightforward and obvious difference you can see in the FL graphs and numbers. Compare this early one on APAP, with this more recent one on bilevel.
Did you ever try APAP with minimum pressures of 14+? If so did it reduce flow limitation but was just not bearable?
I see your exhalation pressure would have stayed the same(assuming EPR of 3) but inhalation pressure would have been 3 cm higher. I assume the higher inhalation pressure is what reduced the flow limitations and not the increase PS/EPR per say.
That's possible.
I don't think I could tolerate EPAPs that high.
Re: Is this bad? Is it UARS? Flow rate questions
Posted: Sun Dec 08, 2019 7:44 pm
by Pugsy
slowriter wrote: ↑Sun Dec 08, 2019 7:22 pm
I don't think I could tolerate EPAPs that high.
I once did a bipap experiment with 25 inhale and 17 exhale...it was an awake experiment only.
It wasn't much fun but I did it for about 30 minutes. It was done to test out how the Bleep did at really high pressures and it performed flawlessly as I expected.
Think about the forum member attagirl70.....she's using 24 inhale and 20 exhale.
People do get used to some really high EPAPs....with and without some exhale relief.
I know one person using essentially fixed 19 cm with zero exhale relief because adding the drop for exhale relief causes too many centrals. Talk about being caught between a rock and a hard place.
Re: Is this bad? Is it UARS? Flow rate questions
Posted: Sun Dec 08, 2019 7:57 pm
by Miss Emerita
Hi, Apniak. You said, “I've attached an image below of the same night, with flow limitation and respiratory rate.” Unfortunately I didn’t see an uploaded screenshot.
Re: Is this bad?
Posted: Mon Dec 09, 2019 4:41 pm
by miner49er
slowriter wrote: ↑Sun Dec 08, 2019 3:42 pm
Apneak wrote: ↑Sun Dec 08, 2019 12:29 pm
I'm trying to figure out, do I need a BiPap, or a "for her" algorithm, or even a servo ventilation? I'm pretty sure I've got UARS.
Just a few points:
- I doubt the "for her" algorithm would offer any benefit, so I would remove that from your list.
- If you have UARS, you have RERAs, which are effectively flow limitation-induced arousals.
- The closeup you posted shows inspiratory FL, but not arousal. You might do a little more exploring to see if you can identify and quantify those.
- To eliminate RERAs, you need to reduce FL as much as possible.
- To do that, you'd want EPR set at max. If, as appears likely, that doesn't work, then the next step would be a bilevel, which can give you more range to work with.
You might check my thread on UARS. I started on an APAP after UARS diagnosis, but failed that trial, and moved on to a bilevel after a titration study confirmed CPAP wasn't able to control the RERAs. The benefit of that titration study is it gave me and doc EEG-based documentation to confirm what the machine can't: the RERAs.
How does maximum EPR decrease FL? I was reading an older thread on different website where a sleep technician claimed your effective pressure was the lower bound exhale pressure. Wouldn't you just want higher pressure to clear up FL?
Re: Is this bad?
Posted: Mon Dec 09, 2019 4:49 pm
by slowriter
miner49er wrote: ↑Mon Dec 09, 2019 4:41 pm
slowriter wrote: ↑Sun Dec 08, 2019 3:42 pm
Apneak wrote: ↑Sun Dec 08, 2019 12:29 pm
I'm trying to figure out, do I need a BiPap, or a "for her" algorithm, or even a servo ventilation? I'm pretty sure I've got UARS.
Just a few points:
- I doubt the "for her" algorithm would offer any benefit, so I would remove that from your list.
- If you have UARS, you have RERAs, which are effectively flow limitation-induced arousals.
- The closeup you posted shows inspiratory FL, but not arousal. You might do a little more exploring to see if you can identify and quantify those.
- To eliminate RERAs, you need to reduce FL as much as possible.
- To do that, you'd want EPR set at max. If, as appears likely, that doesn't work, then the next step would be a bilevel, which can give you more range to work with.
You might check my thread on UARS. I started on an APAP after UARS diagnosis, but failed that trial, and moved on to a bilevel after a titration study confirmed CPAP wasn't able to control the RERAs. The benefit of that titration study is it gave me and doc EEG-based documentation to confirm what the machine can't: the RERAs.
How does maximum EPR decrease FL? I was reading an older thread on different website where a sleep technician claimed your effective pressure was the lower bound exhale pressure. Wouldn't you just want higher pressure to clear up FL?
Yes. Effectively, EPR (and PS) allows you to tolerate higher inspiratory pressure.
I did want to add a bit to my response to geert's question.
When they do the bilevel titration, they first raise the EPAP until they eliminate obstructions.
They then raise the IPAP until they eliminate hyponeas and RERAs.
Beyond comfort (which is critical to good sleep), I'm not sure if there are other benefits to the EPAP/IPAP gap. Everything I've suggests there is.
Re: Is this bad?
Posted: Tue Dec 10, 2019 1:03 am
by Geer1
slowriter wrote: ↑Mon Dec 09, 2019 4:49 pm
Yes. Effectively, EPR (and PS) allows you to tolerate higher inspiratory pressure.
I did want to add a bit to my response to geert's question.
When they do the bilevel titration, they first raise the EPAP until they eliminate obstructions.
They then raise the IPAP until they eliminate hyponeas and RERAs.
Beyond comfort (which is critical to good sleep), I'm not sure if there are other benefits to the EPAP/IPAP gap. Everything I've suggests there is.
Here is a titration protocol guide I was looking at the other day.
https://www.sleepapnea.com/downloads/10 ... fGuide.pdf
Page 11, they raise EPAP until obstructions are eliminated. IPAP is then raised to eliminate partial obstructions (flow limitations). This makes sense as the EPAP is required to maintain an open airway and then IPAP helps open the airways further during inhalation (and the pressure difference helps speed up air intake).
I believe it is the higher pressures that are reduced your flow limitation, I don't see how increasing PS/EPR would do that(unless doing so raises pressure as it did in your cause).
I do think there are at least theoretical benefits to a larger PS/EPR though and that would be more effective CO2 clearance. If you have a flow restriction that does not expand with increased pressure then the only way to increase flow through that passage is to increase the pressure differential as simply increasing the pressure does not change the differential pressure which is what determines flow. Higher PS/EPR does change the differential pressure though and it can make breathing more efficient. This is the same effect that can cause centrals in some patients (too effectively clearing CO2 leading to the brain thinking it doesn't need to breath).
Re: Is this bad?
Posted: Tue Dec 10, 2019 6:25 am
by slowriter
Geer1 wrote: ↑Tue Dec 10, 2019 1:03 am
slowriter wrote: ↑Mon Dec 09, 2019 4:49 pm
Yes. Effectively, EPR (and PS) allows you to tolerate higher inspiratory pressure.
I did want to add a bit to my response to geert's question.
When they do the bilevel titration, they first raise the EPAP until they eliminate obstructions.
They then raise the IPAP until they eliminate hyponeas and RERAs.
Beyond comfort (which is critical to good sleep), I'm not sure if there are other benefits to the EPAP/IPAP gap. Everything I've suggests there is.
Here is a titration protocol guide I was looking at the other day.
https://www.sleepapnea.com/downloads/10 ... fGuide.pdf
Page 11, they raise EPAP until obstructions are eliminated. IPAP is then raised to eliminate partial obstructions (flow limitations). This makes sense as the EPAP is required to maintain an open airway and then IPAP helps open the airways further during inhalation (and the pressure difference helps speed up air intake).
I believe it is the higher pressures that are reduced your flow limitation, I don't see how increasing PS/EPR would do that(unless doing so raises pressure as it did in your cause).
I do think there are at least theoretical benefits to a larger PS/EPR though and that would be more effective CO2 clearance. If you have a flow restriction that does not expand with increased pressure then the only way to increase flow through that passage is to increase the pressure differential as simply increasing the pressure does not change the differential pressure which is what determines flow. Higher PS/EPR does change the differential pressure though and it can make breathing more efficient. This is the same effect that can cause centrals in some patients (too effectively clearing CO2 leading to the brain thinking it doesn't need to breath).
Yes, I think that all makes sense.
So at minimum PS and EPR allows one to balance the need for higher inspriratory pressure to combat the RERAs, with the higher expiratory pressure intolerance that comes with it. If you can't sleep at the higher pressures, then what's the point, after all?
But while I can't find the medical study references at the moment, I do think the gap also makes for more efficient breathing, as you note.
This is only two data points, but below are two closeups from my experience: one is on CPAP at a fixed pressure of 12 (and EPR 3). The other is on bilevel, with EPAP of 6 and PS of 6, so IPAP of 12. In other words, they are the same pressure on inspiration.
Notice a difference? Does the difference matter?
Caveats: the vauto machine does have other breathing-related settings that may influence the flow graphs, beyond pressure. Also, there's a gap of a couple months.
- Screenshot from 2019-12-09 06-30-07.png (9.81 KiB) Viewed 14580 times
- Screenshot from 2019-12-09 06-32-11.png (10.01 KiB) Viewed 14580 times
Re: Is this bad? Is it UARS? Flow rate questions
Posted: Wed Dec 11, 2019 10:25 am
by Apneak
fixed looks better tbh
Re: Is this bad? Is it UARS? Flow rate questions
Posted: Wed Dec 11, 2019 10:55 am
by slowriter
Apneak wrote: ↑Wed Dec 11, 2019 10:25 am
fixed looks better tbh
fixed is the bottom one; bilevel top
Re: Is this bad? Is it UARS? Flow rate questions
Posted: Wed Dec 11, 2019 12:44 pm
by Apneak
slowriter wrote: ↑Wed Dec 11, 2019 10:55 am
Apneak wrote: ↑Wed Dec 11, 2019 10:25 am
fixed looks better tbh
fixed is the bottom one; bilevel top
really? That's amazing. how would less epap deliver a smoother curve? I thought that when you had squiggley curve, you weren't getting enough pressure on that part. I may just have to get a bpap. Have you noticed a difference in day time symptoms?
Re: Is this bad? Is it UARS? Flow rate questions
Posted: Wed Dec 11, 2019 1:07 pm
by slowriter
Apneak wrote: ↑Wed Dec 11, 2019 12:44 pm
how would less epap deliver a smoother curve?
Less resistance to breath out against? The bottom of the curve is expiration.
Apneak wrote: ↑Wed Dec 11, 2019 12:44 pm
Have you noticed a difference in day time symptoms?
Yes, but my improvements have been really gradual, and get reflected in things like waking up less and sleeping longer.
Re: Is this bad?
Posted: Fri Dec 13, 2019 11:09 pm
by miner49er
slowriter wrote: ↑Tue Dec 10, 2019 6:25 am
Geer1 wrote: ↑Tue Dec 10, 2019 1:03 am
slowriter wrote: ↑Mon Dec 09, 2019 4:49 pm
Yes. Effectively, EPR (and PS) allows you to tolerate higher inspiratory pressure.
I did want to add a bit to my response to geert's question.
When they do the bilevel titration, they first raise the EPAP until they eliminate obstructions.
They then raise the IPAP until they eliminate hyponeas and RERAs.
Beyond comfort (which is critical to good sleep), I'm not sure if there are other benefits to the EPAP/IPAP gap. Everything I've suggests there is.
Here is a titration protocol guide I was looking at the other day.
https://www.sleepapnea.com/downloads/10 ... fGuide.pdf
Page 11, they raise EPAP until obstructions are eliminated. IPAP is then raised to eliminate partial obstructions (flow limitations). This makes sense as the EPAP is required to maintain an open airway and then IPAP helps open the airways further during inhalation (and the pressure difference helps speed up air intake).
I believe it is the higher pressures that are reduced your flow limitation, I don't see how increasing PS/EPR would do that(unless doing so raises pressure as it did in your cause).
I do think there are at least theoretical benefits to a larger PS/EPR though and that would be more effective CO2 clearance. If you have a flow restriction that does not expand with increased pressure then the only way to increase flow through that passage is to increase the pressure differential as simply increasing the pressure does not change the differential pressure which is what determines flow. Higher PS/EPR does change the differential pressure though and it can make breathing more efficient. This is the same effect that can cause centrals in some patients (too effectively clearing CO2 leading to the brain thinking it doesn't need to breath).
Yes, I think that all makes sense.
So at minimum PS and EPR allows one to balance the need for higher inspriratory pressure to combat the RERAs, with the higher expiratory pressure intolerance that comes with it. If you can't sleep at the higher pressures, then what's the point, after all?
But while I can't find the medical study references at the moment, I do think the gap also makes for more efficient breathing, as you note.
This is only two data points, but below are two closeups from my experience: one is on CPAP at a fixed pressure of 12 (and EPR 3). The other is on bilevel, with EPAP of 6 and PS of 6, so IPAP of 12. In other words, they are the same pressure on inspiration.
Notice a difference? Does the difference matter?
Caveats: the vauto machine does have other breathing-related settings that may influence the flow graphs, beyond pressure. Also, there's a gap of a couple months.
Screenshot from 2019-12-09 06-30-07.png
Screenshot from 2019-12-09 06-32-11.png
inhale looks about the same.. exhale looks smoother with bilevel. did this effect your amount of centrals or overall sleep quality though?
Re: Is this bad?
Posted: Sat Dec 14, 2019 8:09 am
by slowriter
miner49er wrote: ↑Fri Dec 13, 2019 11:09 pm
inhale looks about the same.. exhale looks smoother with bilevel. did this effect your amount of centrals or overall sleep quality though?
For a period of time, I did experience increased centrals with the higher PS. But at a certain point they just went away. I now regularly have an AHI below 0.5, and often 0.
I've been using the Dreem headband (
more on this), so I generally have a pretty good idea of what sleep staging, sleep onset, wake ups, etc. look like.
Long term trend (as in, there are daily or weekly deviations): better and longer sleep.
Of course, there are so many variables it's impossible to say how much of it is dependent on the bilevel and the higher PS, vs other variables.
Re: Is this bad?
Posted: Sun Dec 15, 2019 11:53 am
by miner49er
slowriter wrote: ↑Sat Dec 14, 2019 8:09 am
miner49er wrote: ↑Fri Dec 13, 2019 11:09 pm
inhale looks about the same.. exhale looks smoother with bilevel. did this effect your amount of centrals or overall sleep quality though?
For a period of time, I did experience increased centrals with the higher PS. But at a certain point they just went away. I now regularly have an AHI below 0.5, and often 0.
I've been using the Dreem headband (
more on this), so I generally have a pretty good idea of what sleep staging, sleep onset, wake ups, etc. look like.
Long term trend (as in, there are daily or weekly deviations): better and longer sleep.
Of course, there are so many variables it's impossible to say how much of it is dependent on the bilevel and the higher PS, vs other variables.
ok thanks foir the info. we seem to be in the smae boat. i wonder what my tritation pressure would be.
Re: Is this bad? Is it UARS? Flow rate questions
Posted: Fri Dec 27, 2019 8:48 pm
by slowriter
slowriter wrote: ↑Wed Dec 11, 2019 1:07 pm
Apneak wrote: ↑Wed Dec 11, 2019 12:44 pm
how would less epap deliver a smoother curve?
Less resistance to breath out against? The bottom of the curve is expiration.
Apneak wrote: ↑Wed Dec 11, 2019 12:44 pm
Have you noticed a difference in day time symptoms?
Yes, but my improvements have been really gradual, and get reflected in things like waking up less and sleeping longer.
I was watching again
this video for another reason, but think this ties back to this discussion. If I understand Krakow correctly, the squiggly line on the CPAP fragment I posted is evidence of expiratory intolerance.