need suggestions to lower AHI

1speechpick · Post by **1speechpick** » Mon Jun 14, 2021 8:11 am

Pugsy wrote: ↑
Mon Jun 14, 2021 7:48 am

1speechpick wrote: ↑
Mon Jun 14, 2021 7:42 am
Good morning! I had a titration study done last Friday. Preliminary results indicate Cpap and Auto Bipap did not control the apneas, and I still had desaturations. Apparently I needed an "ST Bipap machine", and will likely need night-time supplemental oxygen.

I have no idea what an "ST bipap machine" is and how that differs from AirCurve auto bipap. Any insight is greatly appreciated.
ST models are bilevel machines that have a timed breath feature that will force you to breathe if you aren't breathing enough on your own.
They won't/can't auto adjust in response to variations in obstructive apneas.
It is a fixed pressure (bilevel) but with a feature that will regulate and force you to breathe...which is a feature the AirCurve 10 VAuto does NOT have.

ST....short for Sustained Timed and it relates to breaths. It is considered a non invasive ventilator since it actually will force you to breathe.

It's odd because I breathe fine on my own during the day with 96-97% oxygen saturation levels. I wonder what is causing me to not breathe on my own at night. The length of time/severity of the apneas? Reduced lung volume when in supine position? Decreased respiratory rate due to apneas?

Pugsy · Post by **Pugsy** » Mon Jun 14, 2021 8:24 am

I would just be wild ass guessing as for reasons....so I won't much. The only thing that comes to mind is hypoventilation syndrome which I don't know a lot about but I thought it also was present while awake.
Are you significantly obese??? Sometimes people who are really obese don't breathe so great when laying down because the lungs can't work so great due to body fat.
I dunno..just a WAG and doesn't mean much. Definitely something you need to be talking to your doctor about.

Where are you located?

If you do have obstructive sleep apnea and do also need a machine with timed breaths....if it were me I would want the ASV model and not the ST model because the ASV model will auto adjust the pressures as needed for the obstructive apneas.

1speechpick · Post by **1speechpick** » Mon Jun 14, 2021 8:31 am

Pugsy wrote: ↑
Mon Jun 14, 2021 8:24 am
I would just be wild ass guessing as for reasons....so I won't much. The only thing that comes to mind is hypoventilation syndrome which I don't know a lot about but I thought it also was present while awake.
Are you significantly obese??? Sometimes people who are really obese don't breathe so great when laying down because the lungs can't work so great due to body fat.
I dunno..just a WAG and doesn't mean much. Definitely something you need to be talking to your doctor about.

Where are you located?

If you do have obstructive sleep apnea and do also need a machine with timed breaths....if it were me I would want the ASV model and not the ST model because the ASV model will auto adjust the pressures as needed for the obstructive apneas.

I'm located in Ohio.

I do have obstructive apneas. I also have a normal BMI (21%). I wonder if it could be related to allergies, asthma, and nasal congestion. Thanks for trying to help.

Pugsy · Post by **Pugsy** » Mon Jun 14, 2021 8:32 am

1speechpick wrote: ↑
Mon Jun 14, 2021 8:08 am
Are there bipap machines that have the ST option and an auto option all in the same machines (obviously not able to use both modes at the same time).

Yep....ASV models

https://www.resmed.com/en-us/healthcare ... ve-10-asv/

While commonly thought of as a machine only for treating central apnea....that is wrong thinking.
It can be used for obstructive apnea as well.

https://www.resmed.com/en-us/ventilatio ... rve-10-st/

Now the ST model with the fixed pressures...more for central apnea only or someone who just doesn't breathe often enough

BUT....the ASV model will do it all if needed. It will auto adjust as need AND breathe for you if you don't breathe often enough ...no matter what reason is causing the person to not breathe often enough.
It does more if needed while at the same time if nothing is needed then it waits until something is needed before it does it.

People often hate the ST forcing a breath with every breath...the ASV waits until you need it.
We see people all the time here with poor results from the ST model. They can't get comfortable with it.

1speechpick · Post by **1speechpick** » Mon Jun 14, 2021 5:58 pm

Pugsy wrote: ↑
Sun Jun 13, 2021 10:40 am
Change PS from 6 down to 4.

Change the minimum of 4 to 8 (for now anyway...I suspect you will need more but I think 4 to 8 is a chunk to adapt to as it is so lets start with modest increase).

Change the maximum to 25....the machine won't go there if it doesn't need to but you are maxing out for prolonged periods with the current maximum as it is. It wants to go higher....lets see just how high and what happens when it does.

This won't likely be a quick fix but just a start.
But gotta start somewhere.

PS of 4 is a more "normally" used setting ....PS of 6 can cause some hyperventilation feelings in some people and I don't like to see it unless there is real physical need for it in terms of lung volume issue. I think going to 4 will be more comfortable for you.

So we back up and start with more "normal" settings and see what happens.

Newbie here. I think I understand that increasing IPAP allows more air to come in to keep the airway open during inspiration. What does increasing the minimum EPAP from 4 to 8 do? Also, what does decreasing the PS from 6 to 4 do?

Pugsy · Post by **Pugsy** » Mon Jun 14, 2021 6:11 pm

EPAP actually does the bulk of the work holding the airway open in the first place and preventing the obstructive apnea from happening.
That's the whole idea of cpap....preventing the obstruction if at all possible.
During the actual obstructive event the machine does absolutely nothing because it can't generate enough pressure to blow through the obstruction. Simply can't be done...it won't go high enough fast enough to blow the airway open.
Now once the airway is back open then the machine uses the algorithm to help it decide if maybe it needs more EPAP to better hold the airway open and stop future collapses.

IPAP helps out but EPAP does the bulk of the work...it's always been that way.

PS is just the difference between EPAP and IPAP.

Why did I opt for PS of 4 to start with...simply because it is the most common starting point if you were in a sleep lab setting and I don't know your respiratory history or function ....and it's normally extremely safe to advise using. There are potentially situations where 6 PS might be contraindicated and I am not comfortable advising that much PS at this time since I don't know all your history.
I choose the known safer option...and it might work just fine.
You definitely need more EPAP and to add 6 PS on top of what EPAP you probably are going to need....It's a lot to deal with in terms of comfort at the least and potentially could cause a problem. I sure don't want to cause a problem.

I didn't know you were having the in lab study and are so current with your discussions with your medical team. They have access to information that I don't have. All I know to do is suggest what I would do for myself if I were in your shoes but didn't have direct help from the medical care team.

1speechpick · Post by **1speechpick** » Mon Jun 14, 2021 6:16 pm

1speechpick wrote: ↑
Sun Jun 13, 2021 11:10 am

Pugsy wrote: ↑
Sun Jun 13, 2021 10:40 am
Change PS from 6 down to 4.

Change the minimum of 4 to 8 (for now anyway...I suspect you will need more but I think 4 to 8 is a chunk to adapt to as it is so lets start with modest increase).

Change the maximum to 25....the machine won't go there if it doesn't need to but you are maxing out for prolonged periods with the current maximum as it is. It wants to go higher....lets see just how high and what happens when it does.

This won't likely be a quick fix but just a start.
But gotta start somewhere.

PS of 4 is a more "normally" used setting ....PS of 6 can cause some hyperventilation feelings in some people and I don't like to see it unless there is real physical need for it in terms of lung volume issue. I think going to 4 will be more comfortable for you.

So we back up and start with more "normal" settings and see what happens.
With numbers like these, do you think I'd do better with CPAP instead of Bipap?

I took a two trial runs this afternoon on changing the bipap.
1. PS 4, max IPAP 19, min EPAP 6: felt like I was breathing fairly comfortably.
trial 2. PS 4, max IPAP 25, min EPAP: felt like it took longer to breathe out and wasn't as comfortable. Which setting would have made it less comfortable?

Pugsy · Post by **Pugsy** » Mon Jun 14, 2021 6:26 pm

Your max IPAP setting doesn't even factor into how things should feel until you are asleep and the machine increases EPAP to force IPAP up.

When you start with the minimum EPAP of 6 and PS of 4 you will experience IPAP of 10...the max setting is irrelevant until you go to sleep and the machine senses obstructive apneas and decides to increase the pressure.
When the EPAP goes up because the machine is fighting obstructive stuff....it forces IPAP up always by the 4 cm setting (if that is what is being used).
If for some reason the machine thinks IPAP should be increased then it will drag EPAP up with it with the difference always being the PS setting.
The majority of the time...it is EPAP that the machine will want to go up and thus EPAP pushes IPAP up.
EPAP does the primary amount of work.

A setting of 6 EPAP with PS of 4....should feel the same while awake no matter what max IPAP is set at because max IPAP isn't going to kick in while awake....unless it is a mental thing..which could happen but physically max IPAP is out of the picture while awake and experimenting.

1speechpick · Post by **1speechpick** » Mon Jun 14, 2021 6:28 pm

Pugsy wrote: ↑
Mon Jun 14, 2021 6:11 pm
EPAP actually does the bulk of the work holding the airway open in the first place and preventing the obstructive apnea from happening.
That's the whole idea of cpap....preventing the obstruction if at all possible.
During the actual obstructive event the machine does absolutely nothing because it can't generate enough pressure to blow through the obstruction. Simply can't be done...it won't go high enough fast enough to blow the airway open.
Now once the airway is back open then the machine uses the algorithm to help it decide if maybe it needs more EPAP to better hold the airway open and stop future collapses.

IPAP helps out but EPAP does the bulk of the work...it's always been that way.

PS is just the difference between EPAP and IPAP.

Why did I opt for PS of 4 to start with...simply because it is the most common starting point if you were in a sleep lab setting and I don't know your respiratory history or function ....and it's normally extremely safe to advise using. There are potentially situations where 6 PS might be contraindicated and I am not comfortable advising that much PS at this time since I don't know all your history.
I choose the known safer option...and it might work just fine.
You definitely need more EPAP and to add 6 PS on top of what EPAP you probably are going to need....It's a lot to deal with in terms of comfort at the least and potentially could cause a problem. I sure don't want to cause a problem.

I didn't know you were having the in lab study and are so current with your discussions with your medical team. They have access to information that I don't have. All I know to do is suggest what I would do for myself if I were in your shoes but didn't have direct help from the medical care team.

Pugsby: You'll never know how much I appreciate all of your time, information, and efforts. These doctors prescribe settings and I'm not sure they always pay attention to what they are doing. The doctor is the one who prescribed a PS of 6. The minute I changed it to 4, I was able to breathe better on the machine! You've given me of information to understand what the settings are actually doing so I can be a real participant in my own health care.

Pugsy · Post by **Pugsy** » Mon Jun 14, 2021 6:46 pm

If for some reason the doc thinks there is a medical need for PS of 6...you can always work your way up to it if you just have to use PS of 6. He may have thought it would be more comfortable. I don't know his reasoning but if for some reason later it is determined that you physically need that much ventilation for some unknown reason... there are ways of getting there by going up in smaller increments so you can adjust more easily.

I tried it just for grins once...didn't like it at all. Now my lung function is normal so I don't need that extra ventilation but if for some reason things changed and I needed it then I would just work up gradually to the higher PS.

1speechpick · Post by **1speechpick** » Mon Jun 14, 2021 7:03 pm

Pugsy wrote: ↑
Mon Jun 14, 2021 6:46 pm
If for some reason the doc thinks there is a medical need for PS of 6...you can always work your way up to it if you just have to use PS of 6. He may have thought it would be more comfortable. I don't know his reasoning but if for some reason later it is determined that you physically need that much ventilation for some unknown reason... there are ways of getting there by going up in smaller increments so you can adjust more easily.

I tried it just for grins once...didn't like it at all. Now my lung function is normal so I don't need that extra ventilation but if for some reason things changed and I needed it then I would just work up gradually to the higher PS.

I looked at the doctor's script and she ranged the PS from 4-6. I have mild asthma. Does that make any of the settings we've talked about contraindicated?

Pugsy · Post by **Pugsy** » Mon Jun 14, 2021 7:20 pm

Mild asthma...no.

If you had told me severe COPD or some sort of neuromuscular disease or damaged lungs....maybe.

If he actually wrote a range of PS....then we are good for now.
There are bilevel machines that will do a range of PS...but the ResMed VAuto isn't one of them and the ST model won't either.
The only bilevel that I know of..and not in the ASV category which does offer a range...is the Respironics BiPap/bilevel auto mode machine and right now Respironics may not even offer a bilevel in the DreamStation 2 line since it is so new and with all the hooplah over the recall of the older than DreamStation 2 machines...you wouldn't want one of those anyway.

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