BiPap...VPAP....heated hose..Experiments

Java Time wrote:You mention a minimum of 10, but not what your pressures "average". For comparison to my own situation, I'm wondering if you also tend to stay in the 10s throughout the night or if your average is higher? (I know you occasionally spike to 19 cm, but I'm wondering about "averages")

During the last 6 months using APAP before I started BiPap trial my overall mean pressure was 11.0 cm.
90 % was 12.9 cm. Average peak pressure was 16.3 cm. Just got these numbers from Encore Pro.
AHI was 1.4. Average hours of sleep days used...7 hours even.

Java Time wrote: Do you think BiPap seems so significantly better to you mainly because of
1) the BiPap breathing rhythm / exhale relief? (regardless of pressure)
Or
2) due to your high pressures which make exhaling a little more difficult? In other words, do you think you would still find it as significant if your APAP therapy averaged at a lower pressures?

Number 2... No, as you can see my overall APAP averages really weren't that high or that much above my minimum for the most part. I never needed to use ramp. I never felt 10 cm was difficult at all. I slept right through the pressure increases and never knew they occurred till I looked at the report. So I don't perceive those pressures to be any problem. I have no lung issues. Nothing that would outwardly point to exhaling being "difficult". I can't use less than 10 cm minimum without significant increase in clusters of obstructive apneas so I don't see how my overall average could be any lower to make any sort of difference in my comfort.

Number 1....This one I just don't know. It is much easier to breathe while awake with the BiPap but using APAP was not hugely difficult at all. At least it never seemed to be a problem. I just now check average hours of sleep and in the 5 weeks I have been on the hours of sleep average is 7 hours and 52 minutes. AHI average is 1.9 for those 5 weeks so no real difference. 0.5 overall average one way or the other is insignificant. I don't feel any better with AHI of 1.0 than I do with 4.0.

With all other factors being the same...bed..meds, etc...the only thing I see is roughly an hour extra sleep.
Now why I am getting that extra hour of sleep? I have no idea. Perhaps the ease in the exhale and inhale pressure difference allows me to sleep a little deeper or better. Pure speculation on my part.

On paper with APAP reports my OSA was well treated. No problems with leaks or aerophagia or trouble exhaling or anything that might disturb my sleep other than pain which I have with both machines. No reason to think that changing to BiPap would make any difference at all. All I can say is that for some reason my body likes the BiPap machine's way of handling things better and I do notice a marked difference in how I feel.

Pugsy wrote:...the only thing I see is roughly an hour extra sleep. Now why I am getting that extra hour of sleep? I have no idea. Perhaps the ease in the exhale and inhale pressure difference allows me to sleep a little deeper or better. Pure speculation on my part.

... No reason to think that changing to BiPap would make any difference at all. All I can say is that for some reason my body likes the BiPap machine's way of handling things better and I do notice a marked difference in how I feel.

Thanks for the added info and please keep us informed, it is very interesting!

Personally, I am just finally getting down into the 2-ish AHI range consistently. My first 2 months were averaging 6 AHI (bouncing between 3 and 9 AHI like a ball), but I seem to be getting a lot of things figured out with the help of all my forum friends.

Based on everything you are saying and thinking about how those "natural" breaths are apparently so important to a sound sleep, I'm thinking once I really settle in to a "best case" combined pressure, mask, humidity, etc for a month or so, I may experiment with dropping my minimum pressures slightly lower. My thought is, the lower a person can keep their minimum pressure and still keep everything else under control, the more "natural" and perhaps the more sound your sleep.

However, I suspect I may also have trouble going below 10 cm, as the biggest changes I can see that dropped my AHI over the past couple weeks was raising the minimum and a new mask. I'm thinking it was really the higher minimum pressure that made the difference.

Anyway, your whole APAP/BiPap test is very interesting and thank you for sharing!

Java Time wrote: My thought is, the lower a person can keep their minimum pressure and still keep everything else under control, the more "natural" and perhaps the more sound your sleep.

I certainly agree and that is why I finally settled on the 10 cm minimum....I tried minimums up to 13 back in my experimental APAP days. There was never any significant change in AHI and I was close enough to whatever pressures those super duper events (that would occasionally drive pressures to 18) that they weren't showing on the reports except as a sole random event. So in my case they were prevented.

Now when I dropped down to 9.5 minimum the clusters returned. Given my history of REM stage sleep being "worse" for OSA and the fact that on the reports the clusters sure appeared in what appeared to be related to sleep cycle and normal REM pattern, I felt comfortable in blaming it on REM. Clusters at 9.5 gave me AHI in the 4 to 5 range. Not horrible by any means but I noticed when I had the clusters I seemed to feel much more draggy during the day. Minimum of 9 would give me AHI in 5 to 6 range with little stronger clusters.

My original titration study pressure RX was 8 cpap. AHI was double digit with that pressure and I felt absolutely horrible. My titration study was a full night but I slept horribly or not at all. Only got about 156 minutes of sleep total and of those minutes maybe 6 to 10 in REM (don't remember exactly). I think that I simply didn't have enough time in REM to get a good handle on those events pressure needs. Maybe it was also one of those nights that the super duper strong events didn't show up for whatever reason. Even on the APAP there have been nights when I had essentially no pressure increases at all beyond the normal little probes. During my experimenting with APAP days I did try to see of sleeping position made any difference in events or pressure needs. Supine sleeping didn't seem to change anything. I still saw my "normal" pattern.

So how does this related to BiPap? Beats me. With EPAP 9 and IPAP 13 it is going to roughly average 11 cm but the times at 13 probably do a better job holding the airway open just in case those super duper REM events show up. I was concerned at first that when opting for straight bilevel that those 18 cm needing events would be a problem but they don't seem to be. I did do a short time when first starting this with EPAP of 8...yep, some clusters, not huge but they were there. So the EPAP pressure has to be high enough to do a decent job just like minimum pressure on the APAP.

Also bear in mind that when I say it is easier to breathe this way..this was a choice based purely on my perception of it while awake. Not that the other was all that difficult, just that this is easier. Initially my only thought was "OMG, this is so nice, I want this every night". Pure comfort. Feeling better or sleeping better never entered my mind at first. I thought I had come to the "this is as good as it gets" point on the APAP and accepted it. Feeling like I was sleeping better on BiPap was just a pleasant bonus. Would a ResMed machine with 3 cm EPR reduction give me similar results? I have no idea at all. I have never had a chance to try a ResMed machine. EPR and BiLevel pressure drops aren't the same animal but maybe it would be close enough, I honestly have no idea.

What it all amounts to is that I stumbled on something that felt really good to me while I was awake so I was greedy and wanted it all the time...and in my desire for "OMG, I want this all the time while awake" I got lucky and fell into something that lets me sleep a bit longer and feel better.

BTW for all those newbies tempted to "experiment" because someone else has done so and so and got such and such results. Wait a while before yielding to the temptation. Other than my first couple of weeks finding that my AHI was needing more than 8 cm and dialing in to 10 min and finding that 20 max worked and I didn't mind the pressure changes...I let things settle in for about 4 months before I started my various experiments with the minimum up to 13 and such. Also unless my experiment resulted in something horrible (like my recent turning off AFlex experiment) I would stick with things for about a week before evaluating my next move. There is some truth in "give it time to settle in". Even with this BiPap experiment.. my AHI at first was 4 to 5, then 3 to 4 and now down to 1 to 2 in roughly 5 weeks with no changes at all the last 4 weeks.

Update: I continue to do very well with BiPap and heated hose. Last night was very cold and bedroom much cooler than living room where thermostat was set to 60 degrees. Bedroom sticks out and gets north wind pretty much and not much insulation. Old farmhouse thing. It gets cold in there.

Other news....It won't be long and I will have a ResMed VPap auto to experiment with.

Heated hose continues to prevent rain out even with no hose cozy. Still using the barrel cozy to help with exhaled breath condensation in the nasal pillow itself.

I continue to average around 8 hours of sleep if no outside factors mess it up. I still continue to "feel" better and still have no real clue why.

Data wise I am still trending downward in the event department. Found out that I can probably blame most of my snore clusters on my little Pug dog who snores something awful and likes to sleep with his chin on my shoulder. He is spending more time under the covers now to keep warm and my snore clusters have disappeared.

Thought I would post a report. Last night is a good example of leak scale making things look worse than they really are in SleepyHead. Encore Pro is set to show unintentional leak only. So I really only had very minimal leak but SH looks worse because of scale.



same report in SleepyHead and the Leak line for it is below the report.

Pugsy wrote:Update: I continue to do very well with BiPap and heated hose.
Other news....It won't be long and I will have a ResMed VPap auto to experiment with.

I continue to average around 8 hours of sleep if no outside factors mess it up. I still continue to "feel" better and still have no real clue why.

Data wise I am still trending downward in the event department.

Thank you for continuing to share this information. I have been waiting for the latest update! As a PRS1 user, like you used to be, this experiment of yours is extremely interesting. Your results are impressive!

When my 5 years is up, I may try to find a way to get on Bi-pap even if I need to pay the difference!

On to another experiment. VPAP....I have never used a ResMed machine of any kind and thanks to another forum member I have a chance to see what all the other ResMed users experience.
BiPap is the PR S1 BiPap Auto
VPAP is the ResMed S9 VPAP Auto

Just arrived today so tonight is my first night.

My only complaint about the PR S1 BiPap is that in Auto mode, while awake...I am stuck with a minimum of 2 cm pressure support. No matter what IPAP maximum is...when first masking up and starting the machine the only "difference" available is the default 2 cm. I like the comfort of 4 cm difference while awake. It is not a deal breaker though. Just my own person preference strictly for awake ease in breathing. Though the 2 cm difference is quite easy to adjust to....just not "perfect"

The ResMed S9 VPAP allows me to adjust that pressure support so that I can have Auto mode at the same settings of my straight BiPap mode EPAP 9..IPAP 13..so I get the 4 cm difference that I like while awake.

Only thing that I can report right now is that I did briefly experiment with the machine in straight CPAP mode. Using 10 cm with EPR of 3 to see what EPR feels like compared to BiPap with a 3 cm difference in EPAP and IPAP because technically it is same amount of pressure relief. EPR does NOT feel like the 3 cm difference in BiPap with the same settings (EPAP 7 and IPAP 10). BiPap is much more dramatic and gets into sync with my own breathing rhythm much quicker.
Have not tried the VPAP with those settings yet but I will.

Noise? Hard to say because I only hear my own breathing with either machine. I will have to ask my husband how it sounds to him to get a better idea. BTW..the BiPap that I have is the newer firmware version with the back light LCD screen and the latest firmware...so it should be the "improved" quieter model.

If anyone has any specific comparisons that they would like to address, just let me know.
I fully expect that my therapy will be effectively treated by either machine and I am mainly doing this so I can documented the other differences between the brands as I perceive them. More details as I have them.

did you try it on straight Bi-pap? Or was it always on auto?

cflame1 wrote:did you try it on straight Bi-pap? Or was it always on auto?

I used the PR S1 in Auto mode for the first 2 nights I had it 9 EPAP & 20 IPAP & PS of 4.(IPAP never went over 16 ). This was when I figured out I was stuck with the PS of 2 cm while awake until events drove the pressure up

Then I changed to straight BiPap mode with EPAP 9 & IPAP 13 because I just liked how it felt while I was awake. So I have about 6 weeks using PR S1 BiPap in straight BiPap mode.

Pugsy,

Here's another thing to think about during your grand BiPAP/VPAP experiment

If you ever have Aerophagia, has it decreased on BiPAP?

I was reading some DeltaDave and RobySue's posts about Aerophagia (which fortunately I don't seem to have, knock wood, although I do have the classic things that, per the article discussed below, apparently pre-dispose me toward Aerophagia including GERD, a relaxed esophageal sphincter and my daily use of omeprazole).

DeltaDave pointed to an article
1) (http://www.sleepreviewmag.com/issues/ar ... -10_02.asp) that included
RELIEF AND TREATMENT
For adult CPAP users, relieving CPAP-related aerophagia may involve reducing the intraesophageal pressure on the LES (eg, by elevating the head of the bed or by avoiding eating soon before bedtime); avoiding substances such as caffeine and nicotine that induce the relaxation of the LES; and reducing the pressure within the airway. In the latter approach, some people find relief from CPAP-related aerophagia by using an autotitrating CPAP machine. How autotitrating CPAP therapy reduces aerophagia in some people is unclear."

From another article DeltaDave's referenced:
2) There is a University of Washington study (click on the PDF of "Aerophagia and Gastroesophageal Reflux Disease in Patients using Continuous Positive Airway Pressure: A Preliminary Observation" reported in the "Journal of Clinical Sleep Medicine" here http://www.aasmnet.org/jcsm/ViewAbstract.aspx?pid=27278)
"DISCUSSION
This pilot study revealed a positive association between aerophagia and GERD symptoms and GERD-related medication use in patients using CPAP for SDB (Sleeep Disordered Breathing)...
Interestingly, CPAP reduces GERD symptoms in SDB patients predominantly through increased intraesophageal pressure, with higher CPAP pressures causing greater symptom relief.17-19 Therefore it appears the same air pressure that relieves GERD symptoms by forcing refluxate back into the stomach also has the potential to cause aerophagia in susceptible individuals...
Current treatments for aerophagia, such as avoiding bedtime meals, propping the head of the bed, and reducing mean airway pressure with autotitrating PAP, are marginally effective."


I understand "autotitrating PAP" may not be the same as BiPAP, but the fact that BiPap allows more pressure relief seems like it would lead to a reasonable discussion with your doctor about getting BiPAP as a strategy to reduce Aerophagia. If the doctor isn't sure, you could suggest he use you as a "test case" and they will report back to the doctor on the results!
It is possible that people with CPAP who have significant Aerophagia could use the applicable sections of these research articles to justify their doctor putting them on BiPAP.
Just a thought, but an article out of "Sleep Review - The Journal For Sleep Specialists" or the "Journal of Clinical Sleep Medicine" may help a patient convince a doctor into prescribing the more expensive BiPAP machine.

Java Time wrote:If you ever have Aerophagia, has it decreased on BiPAP?

I have been fortunate and only experienced aerophagia, of any significance, twice while using any cpap machine. First time was with a trial of the Innomed Hybrid. For some reason my brain thought since mouth was covered that it was okay to swallow copious amounts of air. I was sick the whole next day with belly pain and nausea from it.

Second time was when I experimented with turning AFlex off (normally used setting of 2) and that experiment was a disaster. Documented here...viewtopic.php?f=1&t=67883&p=631376&hili ... mb#p631376 It is quite clear that the runaway pressures likely caused my aerophagia that night. I was physically ill the next day after this experiment.
Even on APAP (when I would occasionally hit 18 cm for short periods of time) I have never had so much 20 cm of pressure and I have no doubt it was the high pressure blowing open my LES.

So I am not a good indicator on Bilevel machines to gauge how much BiLevel will impact the reduction of aerophagia. I do suffer from GERD that has not improved on any xpap therapy. So no better or worse in the GERD department.

Given that exhale relief with the bilevel machines is sooooooooo much easier than regular cpap or apap exhale pressures, I can sure see where someone with a less than tight LES would/could be afforded some relief from aerophagia. How much relief? Well it depends on some of the other factors too which are open for discussion. SleepingUgly has aerophagia pretty bad and so far Bilevel hasn't help her much. Robysue uses a bilevel machine and still will have some aerophagia when she spends just a little time at higher pressures (for her). So it is going to be highly individual in regards to amount of relief (if any) that bileve will offer.

I do think that for anyone having a problem with aerophagia, and sleep quality because of it, should at least have the opportunity to see if bilevel will help them. Doesn't matter what pressures trigger it..be it 8 cm or 19 cm. BiLevel machines are a little more expensive but not hugely more expensive. Over the life of the machine it becomes pennies and I think that patient comfort, compliance, therapy and sleep quality should be the mitigating factors in machine choice and not solely based on cost.

My continuing VPAP thoughts. 3 nights with the VPAP in Auto mode. Min EPAP 8 and Maximum IPAP now to 15 and PS 4. Couple of reports below. Pressure variations again do not disturb my sleep. I had kinda worried about this when doing the System One BiPap in straight bilevel mode. Wondering if the improvement I perceived on BiPap was related to prior APAP pressure variations that might have bugged me and I didn't know it. So I think I can rule out any pressure variations being a disturbing or mitigating factor on my hours of sleep or how I feel.

I mentally toss out any CA or central events with either machine. Not enough of them to worry about even if they are real and neither machine would do anything with them anyway. I do have nights with more centrals (on both machines) than these reports show.

So far overall AHI (with or without central index) is about the same with either the VPAP in auto mode or BiPap in straight mode (9/13 pressures). So far still sleeping longer with either VPAP or BiPap for some reason and I do notice feeling a little better than on APAP (not that on APAP was horrible). So I guess my body does really like that extra hour or so.
I am using SleepyHead software. I am used to it and it suits my needs. ResScan shows same information but just like with Encore...SleepyHead hugely faster and since I am used to it, easier for me.
Leak spikes are likely nasal pillow movement. No dry mouth at all so I doubt open mouth. Whatever the cause, short lived so I don't worry about them. They don't seem to disturb my sleep.

I am planning on trying straight CPap with EPR at 3 just to see what happens and how it feels. Since I already know EPR of 3 isn't nearly as sweet as Bilevel on either machine..kinda hard to get up the guts to do it since I am spoiled. Might as well get that experiment over with so plan on doing it tonight.

Pugsy wrote:I am planning on trying straight CPap with EPR at 3 just to see what happens and how it feels. Since I already know EPR of 3 isn't nearly as sweet as Bilevel on either machine..kinda hard to get up the guts to do it since I am spoiled. Might as well get that experiment over with so plan on doing it tonight.

What a diligent lab rat you are, Brenda...and an excellent reporter!

I didn't do straight CPAP last night. Had a bad day yesterday for other reasons and then my husband (truck driver) ended up close enough to the house that he could spend the night at home for a change. I had to go get him last night (it was late) and then take him back to the truck this morning (early) so I just couldn't face a for sure short night with questionable new pressure and possible worse sleep.

So I will try to shoot for tonight.

I got 6 hours of sleep last night. Slept well. Minimal minor awakenings due to pain. Cold and rainy here and that always equals my back and pelvic pain acting up more than usual. Feel quite decent so far this morning and will see when/if the need to nap shows up later today. Haven't checked data yet. Normally I don't check data until the evening. I try to eliminate the possibility of less than ideal data creating a bad day in my head.

Pugsy wrote:Normally I don't check data until the evening. I try to eliminate the possibility of less than ideal data creating a bad day in my head.

That is a great quote, should probably be added to the "newbie" page.

I check my PRS1 "7 day averages" each morning, but I'm trying really hard to only look at the detailed data once or twice per week. This helps me stay disciplined to not make more than "one change per week" in how I'm using my machine.

Thanks again for the updates and good luck as you return to your grand experiment this evening.

Okay, Straight CPAP night. All set up. EPR of 3 fulltime. so opted for cpap 12 cm so gives me 12 inhale and 9 exhale.. I played with 1 just for a few minutes.. I could feel the difference but it wasn't horrible. EPR 3 gets me close to the bilevel settings of 13/9 I have been using on the PR S1 Straight BiLevel. I haven't tried straight bilevel yet on the VPAP.

I did briefly set the VPAP in straight Bilevel mode 12 IPAP & 9 EPAP with easy breathe on just to see if there was much of a difference. It is quite easy to exhale with and I quickly got into a rhythm that had minimal effort involved.
Straight CPAP with 12 cm and EPR of the offered a similar feeling but it was not quite as easy to get into the breathing rhythm when no effort is perceived. I still felt some resistance in exhale that I did not feel during bilevel at same settings. The exhale response timing seems to be near perfect with the bilevel and with straight cpap the exhale doesn't sync in with my own rhythm as easily. I am sure while sleep this would be a non issue.

So CPAP with 3 EPR is sort of close in how it feels (while awake) to Bilevel straight pressures given a 3 cm different but not quite the same. There is a difference. Bilevel lets me breathe exactly like I am breathing now with zero effort. Perfectly in sync with my own breaths. I felt just a bit rushed when using CPAP and EPR. Not a deal breaker but bilevel offers a wee bit more of something that lets me within 2 breaths not even feel like I am breathing against a machine at all.

I am tired...my six hours of sleep left me about 6 PM wanting to nod off but I didn't. I will try to get to bed soon.
I have not done straight cpap ever. Even my first machine I used APAP 8 min and 10 max. So this is a first.

So the differences are there. I can feel them. EPR isn't bad at all while awake. But it isn't the same as Bilevel relief. Similar but not the same. Some people would likely not notice much difference but I am looking for differences because that is part of the experiment. Properly set up bilevel will sure spoil a person.

EPR and AFlex on the APAP....no comparison. EPR is just a drop...Aflex lets me again feel the breathing rhythm is more natural....not forced. But then I have been using AFlex for 2 1/2 years, anything else will fee weird for a while. So that comment comes with a grain of salt.