Getting a Bipap, seeking help determining settings

Hey all,


I'm about to get an Aircurve 10 VAuto tomorrow and would like some help titrating!

Currently I use a Resmed Airsense 10 Autoset with pressure 9-11 with EPR 3 and a Dreamwear Full Face Mask. I on average have an 95% FL of ~0.05 and a 99.5% FL of ~0.20. My AHI is generally <1. I have enlarged turbinates, especially the left turbinate. I basically can't breathe in my left nostril, even at my current pressure of 9-11. However, on an experiment, my nostril starts to open at ~17/18 pressure. (Even though I know this information, I haven't raised my pressure above 11 since it's quite hard for me to tolerate during exhale. I'm hoping Bipap will resolve this for me.) I also have a narrow pharyngeal airway as confirmed from CBCT scans, likely from 3 years of mouth breathing. I am still very symptomatic (mostly brain fog, also some fatigue), so I am pursuing more advanced PAP therapy. I believe I have UARS, as I have low AHI but high RDI, and am a normal weight 22M.

I'm planning on doing a few days on my current settings on my new machine and looking at OSCAR as a control to make sure OSCAR is displaying stuff the same as before. Assuming all is normal from that, then I'm thinking about trying my current pressure range, but with a PS of 4 for a week. Then maybe PS of 5 for a week. I haven't seen anyone go higher than 5 PS, so after that I guess I'll have to start raising the min pressure. Does this sound reasonable? I'm guessing based on my experiment in the first paragraph, that I'll start feeling noticeable improvements at a pressure of 17/18, which would be something like a EPAP of 12 and PS of 5 from my setup. Is this experiment and rationale legit? Also, how do I set all other settings that BiPAPs have, such as sensitivity and stuff?

Let me know if you need any other information (e.g OSCAR screenshots). Thanks so much for the help!

Congratulations on the new machine! Your plan sounds reasonable: start by mimicking your current settings, then go from there.

Keep in mind that in EPR-talk, 3 means a drop of 3 when you exhale, while in PS-talk, 3 means an increase of 3 when you inhale. I think your post reflects that but just wanted to make sure.

I would recommend that aside from pressure and PS, you leave the default settings in place for now.

After you generate some data for Oscar with the new machine, please come back in this same thread if you feel like it. Be aware that people are having trouble posting screen-shots, due to the limited capacity of the site, so you might try a service like Imgur and post links to your images.

Fingers crossed that the new machine will help you sleep better!

@Miss Emerita Thanks for the kind words! I am optimistic.

Here's my day 1 of Bipap:

5 min EPAP - 11 max IPAP, 3 PS.
4 humidity
3.0 Ti max, 0.3 Ti min, High Trigger, Med Cycle (sorry I didn't see your comment about leaving default settings)

Here's the first night. Despite having the same pressure settings as before my bipap, it seems my FL is already a tiny bit better than usual (95, 99.5 = 0.02, 0.10) rather than usually it's more like 95, 99.5 = 0.4, 0.20. Though it seems like the algorithm isn't picking up some flow limitation (see screenshot below). Maybe the Aircurve algorithm is just better for me compared to the autoset. Or maybe the Ti max / Ti min / trigger changes are better? Not sure how to tell. Feel about the same, I think.

One other note in particular, my insp/exp times are completely different now. Previously my insp > exp, now it's way the other way around! More details in the screenshots. Not sure how to interpret this. I read something about the cardioballistic effect, but I'm not sure if that's in play here.

Since my pressure isn't even hitting the max of the range during some undetected flow limitation, perhaps I should raise my min EPAP? This happened consistently each REM cycle (as confirmed by apple watch). The REM cycles end early after some number of flow limited breaths, which lead to an event. Any other comments?

Here's some OSCAR screenshots: https://imgur.com/a/AIRXz8V

Another question, how do you detect mouth breathing vs nasal breathing in the flow rate graph in OSCAR? (I have a full face mask). I couldn't find an answer searching this question up.

newuser1002 wrote: ↑

Fri Feb 17, 2023 1:27 am

Another question, how do you detect mouth breathing vs nasal breathing in the flow rate graph in OSCAR? (I have a full face mask). I couldn't find an answer searching this question up.

You don't.

That chart looks pretty good! I would ignore the little flurry of events right at the start of the night. How rested do you feel today?

I moved from a ResMed Airsense 10 Autoset to a VAuto and also saw my I:E ratio flip around. I have a pretty pronounced cardioballistic artifacts, and for some reason the VAuto algorithm knows how to avoid misinterpreting those little oscillations above and below the zero line between breaths. CB oscillations weren't obvious in the particular zoomed-in view you posted, but I'm going to guess the same explanation holds for you.

On both machines, there are FLs that the algorithms don't pick up. That isn't a VAuto issue.

If you're comfortable now with your new machine, you can start increasing your pressure support gradually. Go by .2 increments, staying at each new setting for at least 2-3 days before increasing. What you'll be watching for are improvements in your FLs (flagged and unflagged); what you'll be on guard against are increases in CAs.

Keep us posted, would you?

Ah got it, thanks! Glad to hear my I:E ratio flip is probably normal. Would love to keep you posted.

Here's day 2. Based on my insights from yesterday, I increased my min EPAP by 1, since the machine wasn't picking up on some flow limitation, I figured I might as well increase the minimum (effectively raising the IPAP by 1 during flow limited events respectively, namely when the machine sometimes just sits at the minimum of my range during flow limitation).

Full settings for visibility:

6 min EPAP - 11 max IPAP, 3 PS.
4 humidity
3.0 Ti max, 0.3 Ti min, High Trigger, Med Cycle

Bedtime Nasal congestion level: Slightly above average (i.e for me, one nostril essentially fully blocked, other nostril half blocked.) Note: I'll also rate this every day, since I've found over the last few months that my nasal congestion and flow limitation and subjective feeling the next day are all strongly correlated: more congestion -> bad. I want to track this to make sure we don't confound my pressure settings from this variable.

Hours of sleep: 6 (unfortunately..) Same rationale as above.

Results: 95%, 99.5% FL = 0.00, 0.17.

That 0.00 number is great! However, I manually scanned the OSCAR flow rate graph and found many undetected flow limited events. Essentially my entire REM is flow limited, unfortunately. Seems like a misleading flag. Not sure how it compares to previous days, will need to do a more through exploration.

Subjective Experience: A bit more tired than usual, but I think it's mainly caused by my hours of sleep though + slightly above average nasal congestion combo. I never feel good on 6 hours. But my REM sleep was truly quite bad today - I'm keeping an eye on the possibility that the min pressure raise may have somehow worsened it.

OSCAR screenshots: https://imgur.com/a/DCw0aH2

A note on my apple watch sleep stage data - I've found this to be pretty accurate in terms of general sleep architecture (i.e which stage I'm in at any given timestamp). However, the amount of arousals it measures is way undercounting, and the amount in which it undercounts seems to vary between days. So I mainly use it as a guideline to see when my REM is for ease of access to scan OSCAR for those timestamps. Also, the total amount of REM correlates decently well with my subjective experience the next day. Today was quite low for me, but I suspect I would have had way more if I slept more... One more thing, ignore the "Time in Bed" - that's totally off since it just starts automatically at 10:30 pm regardless.


Tonight, I'm thinking about raising my PS (and max IPAP) by 0.6 instead of 0.2, since I feel like I'm far from my optimal at this point, I think can afford to raise this much without going over my optimal threshold. Besides saving time, this should have the main benefit of being able to more clearly tell a difference subjectively - if there is one, it'd be more drastic. I'm thinking about making my increments smaller, to 0.2 later.

Have you found a way to get your machine to be more sensitive to flow limitation and raise pressure faster? Really a shame that it just sits there below the max of the range (in fact, near the minimum..), while I experience flow limitation...

Any comments / observations from your end? Thanks!

It's fine to try going up on PS by .6; let's see what happens. By the numbers your FLs were better with the higher minimum, and if that was comfortable for you, then well and good.

Bear in mind that one night doesn't really provide a basis for drawing conclusions, since sleep is naturally quite variable from one night to the next. It's good you're keeping track of things like congestion and total sleep time; be sure you also note how rested you feel the next day.

I use a fixed EPAP of 5, which fully addresses my moderate obstructive apnea, and I use PS of 5. For some reason, during the first part of the night, I still see a fair number of little dents in my inhalation flow rate curves; then later in the night the curves round nicely. I suspect it would be unrealistic to expect all or even most breaths to look look ready for the textbook on good sleep breathing.

Be aware that any device lacking an EEG capacity is not going to give you terribly reliable information about REM.

I'll be curious how it goes with PS of 3.6.

Miss Emerita wrote: ↑

Sat Feb 18, 2023 9:12 pm

It's fine to try going up on PS by .6; let's see what happens. By the numbers your FLs were better with the higher minimum, and if that was comfortable for you, then well and good.

Bear in mind that one night doesn't really provide a basis for drawing conclusions, since sleep is naturally quite variable from one night to the next. It's good you're keeping track of things like congestion and total sleep time; be sure you also note how rested you feel the next day.

I use a fixed EPAP of 5, which fully addresses my moderate obstructive apnea, and I use PS of 5. For some reason, during the first part of the night, I still see a fair number of little dents in my inhalation flow rate curves; then later in the night the curves round nicely. I suspect it would be unrealistic to expect all or even most breaths to look look ready for the textbook on good sleep breathing.

Be aware that any device lacking an EEG capacity is not going to give you terribly reliable information about REM.

I'll be curious how it goes with PS of 3.6.

Agreed, except I think my apple watch is surprisingly accurate at detecting when my REM is. It very highly correlates with when I have flow limitation, which makes sense according to my hypothesis that my enlarged turbinates causes my flow limitation, and the fact that turbinates increase even more during REM. The apple watch isn't very reliable at detecting RERAs though, it systematically underestimates them, and the degree of which it underestimates seems to vary per night.

Day 3-6 post (Friday 2/17/23 - Monday 2/20/23).

Day 3: Increased PS by 0.6. Day 5: removed humidity. Day 6: Increased max IPAP to 16

Overall,
6 min EPAP - 16 max IPAP, 3.6 PS.
0 humidity
3.0 Ti max, 0.3 Ti min, High Trigger, Med Cycle

OSCAR: https://imgur.com/a/4w0itNB

On day 6, I actually did hit past my old IPAP maximum, peaking at 14. Though it also seems I had more intense flow limitation that day than usual, not sure why. Any thoughts there? I don't see any patterns in the data and don't feel notably different, but I might be missing out on some signal though with my untrained eyes, so would appreciate your thoughts.

To me, it doesn't seem like increasing my PS by 0.6 did much. I believe that supports my overall hypothesis, that I won't feel much different until I hit the IPAP range of like ~16 ish, since that is the pressure I need to actually be able to breathe through my nose with my enlarged turbinates.

One note of interest - after starting the Bipap for the past 6 days, I now sometimes randomly wake up after ~7 hours of sleep at roughly 10 am (possibly correlating with events? Unsure about this). I can think of two explanations. 1. Maybe I always have been waking up, often, (e.g RERAs) but just am not conscious of the awakenings since I was so sleep deprived. Now I'm slightly less sleep deprived, so I am more sensitive to awakenings. 2. It's also possible that my circadian rhythm has just been more regular this week. Occam's Razer perhaps suggests explanation 2.

Possibly you're waking up after 7 hours because your body has gotten all the sleep it wants? How are you feeling

Your IPAP is probably not going to get up to 16 on its own. You would need to increase your minimum EPAP and/or your PS. I continue to be somewhat skeptical that at 16 the pressure will somehow push your turbinates back, but your experience suggests your plan is worth an experimental try.

Try PS of 4, keeping your minimum EPAP at 6. Give it a couple of days, and if all is well, then try increasing your minimum EPAP to 7. Make sense?

Miss Emerita wrote: ↑

Wed Feb 22, 2023 10:51 am

Possibly you're waking up after 7 hours because your body has gotten all the sleep it wants? How are you feeling

Try PS of 4, keeping your minimum EPAP at 6. Give it a couple of days, and if all is well, then try increasing your minimum EPAP to 7. Make sense?

Sorry for the late response! Looking back, I'm not feeling much better, I think it was just my circadian rhythm for those few days.

I did a few days of min EPAP to 7, then another two days of min EPAP to 8. Overall, I don't think it's making much difference overall unfortunately. Looking into the details of my sleep graphs, I think it may have even gotten a little worse...? (though the FL statistics are the same as before). More details and hypotheses in the following post.

Day 7 - 24 Post (2/21 - 3/10)

Really sorry for the delay! TLDR: My sleep got much worse, now having ~5 AHI instead of < 1 with tons of OAs and very weird flow rate curves, but I don't think it's because of increased pressure or increased PS. I feel slightly, but certainly noticeably, more brain-fogged and fatigued. More details below.

Initial settings:
6 min EPAP - 16 max IPAP, 3.6 PS.
Humidity "Off"
3.0 Ti max, 0.3 Ti min, High Trigger, Med Cycle

Final Settings:
8 min EPAP - 16 max IPAP, 4.4 PS.
Humidity "Off"
3.0 Ti max, 0.3 Ti min, High Trigger, Med Cycle

Changelog
2/21 Increased min EPAP from 6 to 7 and changed humidity from "Off" to 4.
2/24 Removed humidity - from 4 to "Off".
2/26 Increased min EPAP from 7 to 8.
2/28 Increased PS from 3.6 to 4.4.
3/2 Started using plastic bottom retainer.
3/3 Increased PS from 4.4 to 5.0
3/6 Decreased PS from 5.0 to 4.4 (felt a bit scared having such high PS. Figured since I wasn't seeing many benefits, I'll just bring it back down for now). Also, finally washed my bedding and vacuumed, for the first time in 3 weeks (not good, I know).
3/7 Put my breathe right strips higher than before, from middle of nose now to upper nose pretty close to my eyes.
3/8 Started using Dymista instead of Nasacort + Azelastine.

OSCAR: https://imgur.com/a/xqkL5pr

Note: I made my FL scale to 0-0.5 instead of 0-1.0. Also, feel free to ignore the user flags. I was experimenting to see if I can find a better metric than FL since I believe my FLs are being undereported by OSCAR, but I couldn't find a suitable metric. I now believe the number of spikes in the flow rate graph now most closely approximates RERAs and am using that. Though all of this feels irrelevant compared to my more glaring problem of increased OAs right now..

1. What is causing the stark increase in OAs and new weird breathing? I started having lots of mostly clustered OAs beginning on 3/2 and happening every day since then. I'm very confused on what caused it. Although it seems like a stretch, notably the one change that happened on 3/2 is that I got a plastic bottom retainer (instead of a "permanent retainer", which is a thin metal strip behind my bottom teeth, which I had previously). I'm guessing the plastic bottom retainer is now forcing my tongue further back, causing OAs that I've never had before. Does this sound right to you, or do you have an alternative explanation? Other possibly relevant detail: On this day, I also replaced my plastic top retainer for the past 6 years with a new plastic top retainer from a different brand.

• I don't think it's the increase in pressure or increase in PS, since 2/28 and 3/1 are totally normal. Specifically the issues start on 3/2.

• I think it's positional apnea/FL, but I don't think it's random. It's been happening consistently ever since 3/2. It has never happened before then. There is definitely a root cause that can be identified.

• However one piece of counterevidence - to test my hypothesis, I took off my retainers last night (3/10). Yet, it did not solve my issue - AHI of 6.8... Perhaps my tongue got used to the new position...? That would be very sad.. how do I reverse this?

2. Analysis of the the new OAs and weird breathing close ups: What does my flow rate now going down to -40 instead of -20 for a significant portion of the night mean? Does the flow rate graph suggest this new issue is positional-related?

3. Overall - besides this stark increase in OAs weirdness, which I'm guessing is independent of my initial issue of flow limitations, this increase in pressure and PS doesn't seem to have helped my flow limitations / presumed RERAs (spikes in flow rate graph) much. This aligns with my initial hypothesis - that my nasal congestion from my increased turbinates requires a very high IPAP of 16-17 at its worst to actually open up. Since I haven't reached that level yet, I have not seen much benefits, since when my nose is completely blocked, my 12.4 or 13 IPAP (8 + 4.4 or 5) is insufficient.

Other secondary observations:

• On 2/24, I used Afrin on my left nostril, making it completely clear in the morning. It was still pretty blocked at night right before sleeping though. More than ever before. Yet my FLs didn't seem to be reduced. I'd imagine that even if my right nostril was blocked, my left nostril being open should be sufficient to not have FLs. Since I still had FLs, maybe my ultimate hypothesis of my enlarged turbinates -> FL is wrong... Seems unbelievable though, since I have so much other evidence supporting the hypothesis. Maybe my left nose wasn't actually fully cleared throughout the night from Afrin. It's possible that since turbinates swell during REM, just because they are clear upon awakening doesn't necessarily imply it's not swollen during REM.

• On 2/26-2/28 and 3/7-3/9, I can breathe clearly through my PAP mask upon first awakening in the morning now (previously, one or both of my nostrils would be congested to some degree.) Presumably, this is from the increased pressure. Also, my allergy and humidification optimization may be contributing as well. Though exactly like above, it is possible that since turbinates swell during REM, just because they are clear upon awakening doesn't necessarily imply it's not swollen during REM. Indeed, I still have some flow limitation in OSCAR.

• On 3/4, drank lots of alcohol but somehow had way more dreams. This is surprising, since alcohol is supposed to suppress REM sleep to some extent. And, it should act as a vasodilator, making my turbinate nasal congestion worse. Maybe alcohol -> increased fragmentedness of sleep -> remember dreams more. Alternate hypothesis (though seems unlikely): alcohol acting as a depressant -> less PLMD -> better sleep? I had RLS as a kid (and still have it now to a lesser extent), so this is theoretically a possibility.

Impending changes:

• Going to try some more nights without the retainers. Maybe some different pillow heights. Maybe a bolster to encourage side sleeping more. Maybe a soft cervical collar (not sure if this would help with tongue positioning though). I need to fix my OAs...

• Going to try an alaxo airway nasal stent to guarantee my nose stays open.

• Interested in trying to literally video record my night to have this information to cross reference with my OSCAR data. This would be useful to see my sleeping position, matching RERAs to flow rate patterns, movements, snoring, nasal vs mouth breathing. I really should have done this a long time ago - there's so much useful data to be gained here. Any recommendations on how to best do this?

Would love your thoughts on these points and any other observations you may have!

newuser1002 wrote: ↑

Sun Mar 12, 2023 5:38 am

Note: I made my FL scale to 0-0.5 instead of 0-1.0. Also, feel free to ignore the user flags. I was experimenting to see if I can find a better metric than FL since I believe my FLs are being undereported by OSCAR,

OSCAR reports what Resmed reports.
Resmed has a very clear definition of flow limitations.

Do you have one of your own?

To ozij: It's my understanding that ResMed uses a "flattening index" to identify flow limitation. I've also had the impression that this method may not pick up other flow limitations that we can see in the flow-rate graph. For example, in my flow-rate graph, I can see lots of dents in the top of the inhalation curve that go unflagged, and it's my understanding that those dents reflect some flow limitation. I'd love to learn more, ozij, so let me know if this seems off.

To the OP: I think you're making too many changes in quick succession to judge what does or doesn't make a difference to your sleep. Pick some settings and the other variables you've changed, and then stick with them for a week. Sleep can be very different from one night to the next, so you need to be looking a trends, not data for just a night or two. When you make a change, make no other changes at the same time. That way you can isolate the effects of that change, if any.

It can be hard to have a subtle problem with getting restful sleep, but I worry that you may be going down too many rabbit holes. For that reason, I wouldn't recommend video-ing yourself during your sleep.