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How were your ears with those settings?

Your OA number was a very respectable 0.67. OA has to be treated with EPAP, but everything below OA on the graph should respond to IPAP which can be increased by increasing either EPAP or PS. I interpreted your earlier posts to indicate that the whole point of switching you to BiPAP was to see if reducing EPAP helps your ear issues. In that case, and if your ears were fine with those settings, you might consider leaving the EPAP low unless your OAs get worse and making very small bumps in PS and IPAP to pull the hypopnea number down.

adin67 wrote:Maybe I should do small adjustments, what do you think

Yep, small adjustments. How is the ear thing doing?

Obviously a little more EPAP and IPAP is needed. Not unexpected given what you were using with the APAP.
The report isn't horribly horrible though. The Clear Airway events we set them aside for now. The snores and flow limitations showing up are indicative of not quite enough pressure being used to stent the airway open and that would be the EPAP pressure.

I would try 0.5 more both for EPAP and IPAP or even 1.0 if you want to try it and ears are okay.
I would leave PS alone.

Pugsy wrote:I would try 0.5 more both for EPAP and IPAP or even 1.0 if you want to try it and ears are okay.
I would leave PS alone.

Or that. When in doubt listen to Pugsy!

Hi there, my ears are just fine. I think to adjust the Ep ->7 and the Ip -> 11(i don't know what to do with the Bi-flex level, now it set to 2).

adin67 wrote:(i don't know what to do with the Bi-flex level, now it set to 2).

BiFlex just "smooths" the transitions between EPAP and IPAP, so set it to what feels most natural for you. 0 feels like a very abrupt shift to me. 3 feels a little too "soft" at the start of the exhale, almost like the pressure disappears for a moment at the start of the exhale and then comes back in the middle of my exhale and I find that very distracting. Although, if ear problems are your issue, I suppose it is possible the smoother pressure transitions of the higher BiFlex settings may help prevent air from getting forced up into them.

We need EPAP for the FLs and snores...so that's why a little more EPAP. IPAP won't help much with FLs and snores...been there and done that with my own bilevel machine and allowing max IPAP of 20...it just won't kill them like a little more EPAP will. Often just a little 0.5 increase in EPAP will kill those pesky snores and FLs.

BiFlex is exhale relief and if 2 feels good...leave it that way. That's strictly a comfort thing. You can try the other settings to see if one of them feels better to you. It's more of a breathing rhythm thing and really doesn't impact the events all that much but might impact how well you rest or sleep if you are more comfortable or not. While we want to effectively prevent the airway collapse we also want to be comfortable while doing it because more comfort usually means better sleep in general.

IPAP in this situation unless the ears start to become a problem is really more for comfort as it is so much easier to inhale and exhale with PS of 4 than it is with 1 or 2....side benefit is that IPAP helps with hyponeas. At least that is how I feel about it.
We are trying to find something that is more comfortable for you and not trigger ear issues.
Your situation is a bit unique because we are wanting to not do anything to trigger ear issues which I think is more apt to be related to IPAP than EPAP. To have a more better idea who was to blame for the ear issues we would need to see several APAP reports and see where the pressure wanted to stay at.

If ears become problematic...I would suggest looking at IPAP first and limiting that maximum to start with.
Finally..sometimes we just have to compromise and allow maybe a few little things to happen if killing them creates more of a problem with the ears.
Your report from last night...isn't horrible and would be an acceptable compromise if that should happen.

Also...there is a lot of truth to "give it time" with this machine. When I first started bilevel therapy my first report looked at lot like yours...so I increased the EPAP just 1 cm and got a decent report..not spectacularly great but decent..so I left it there for 6 weeks...my AHI reduced by 50% over that 6 week period with no changes to anything.

Pugsy wrote:We need EPAP for the FLs and snores...so that's why a little more EPAP. IPAP won't help much with FLs and snores...been there and done that with my own bilevel machine and allowing max IPAP of 20...it just won't kill them like a little more EPAP will. Often just a little 0.5 increase in EPAP will kill those pesky snores and FLs.

Hey Pugsy, just trying to further my education if you don't mind... The Journal of Clinical Sleep Medicine Titration Guidelines say, "CPAP (IPAP for patients on BPAP) may be increased from any CPAP (or IPAP) level if at least 3 min of loud or unambiguous snoring are observed," and "Upward titration of IPAP and EPAP ≥ 1 cm H2O for apneas and IPAP ≥ 1 cm for other events over ≥ 5-min periods is continued until ≥ 30 min without breathing events is achieved." Respironics guidelines and documentation refer to increasing EPAP for snoring but IPAP for Flow Limitations.

Is this just one of those situations where real life experiences often don't reflect the theory, so experience tells us EPAP handles snores and flow limitations better than IPAP, despite the guidelines, or am I missing another part of the theory?

djhall wrote:Is this just one of those situations where real life experiences often don't reflect the theory, so experience tells us EPAP handles snores and flow limitations better than IPAP, despite the guidelines, or am I missing another part of the theory?

Yeah, when real life hasn't read the manual.
Also common sense comes into play.
In general we have been told that EPAP for obstructive stuff and IPAP for hyponeas.
Snores and FLs are normally an indication of some sort of upcoming collapse of the airway....which may or may not grow up to be an obstructive apnea or hyponea but from what I have seen with my own reports and other peoples...EPAP is sort of like APAP minimum pressure and those pesky snores and FLs go away real easy with just a little more EPAP or APAP minimum.
Stent the airway open better at the base level and those little early signs of an impending collapse just don't happen.
Now how much of it might also depend on is the collapse part of exhale or inhale...I never could figure out how to get a handle on that and to be honest...that's digging real deep and IMHO why not just fix it the easy way first if it needs to be fix.

I have some examples somewhere (will try to dig them out if I have time and show you) where I had more snores and FLs than I wanted...bilevel machine...EPAP at 9 and PS of 4 (my favorite) with available max IPAP at 20...so the machine could have used IPAP to kill the FLs and snores..but it didn't/couldn't/didn't even try. So IPAP couldn't/didn't prevent them and it had lots of room to do so. Maybe it has to do with the response time.
When I increased the EPAP to 10...poof the FLs and snores all but disappeared.
So EPAP fixed it...IPAP never did anything all that exciting. It wasn't like I was using fixed bilevel either. I have almost always used auto adjusting pressures because my REM stage sleep event sometimes take steroids and are particularly difficult to deal with..not always but sometimes. I sleep right through some big changes in pressure and have no unwanted side effects like aerophagia or ear problems or stuff like that.

Past experience has shown me time and time again that minimum APAP or EPAP minimum...seems to be the most critical setting in not just my situation but in the others that I have helped. Get that minimum APAP (or EPAP minimum) set optimally and the top end doesn't really have to do much.

I prefer PS of 4...3 isn't too bad and 5 isn't either but above 5 PS, I have seen correlation between higher PS and emergence of complex sleep apnea in more than an occasional person. Now most often it has been when PS was fix (like ResMed machine) and people try PS of 7 to 10....which can make a person feel like they are hyperventilating and when looking at the high number of centrals...I guess they did. So that's why I like to keep PS around 4 or so...just as a precaution. Less chance for unstable breathing O2/CO20 exchange causing centrals.

So that's why I suggested a little more EPAP...past experience with hundreds and hundreds of ugly reports that turned beautiful despite what the manual might say would maybe work better.
In this situation here with potential ear problems I was really torn with the suggestion to add 1 cm to IPAP and it may not have been the ideal thing to do but 4 PS is more comfortable than 3 PS but OP here may have to use 3 PS.

I will see if I can find those images when I increased the minimum EPAP last fall in response to just a little more "clutter" than I wanted to see. Clutter being FLs and snores mucking up an otherwise nice looking report. I felt fine, slept fine...just didn't like the clutter. If increasing the EPAP had presented a problem like aerophagia or whatever...I would have just learned to live with the clutter. While it isn't pretty...I felt no different on those nights than I did when I had nice clean no clutter reports.
My number one goal has always been good sleep first...feel decent...and not a perfect AHI or beautiful report.
That's why I don't freak out with a little leak either. It doesn't wake me up...not big enough or prolonged enough to really impact therapy and trying to fix a leak often causes more sleep disruption...so the cure is worse than the disease and I see no need to try it.

Edit: A little bit of clutter clusters discussed in this thread
viewtopic.php?f=1&t=89894&p=826177#p826177
As you can see sometimes the pressure increased and sometimes it didn't and clutter happened despite the machine being able to go to 20 IPAP...so IPAP couldn't prevent it. Only way to have more IPAP baseline in my situation would be to increase PS and I don't like to do that..it isn't as comfortable and more PS might trigger some centrals so increasing EPAP is more comfortable in the long run and gets the job done. So since I am lazy and really like my comfort...I go with what is easy and more comfortable with less potential risk (even though small risk) for creating breathing instability issues.

Ahhh... okay, I'm seeing a couple things I didn't before, and I like the concept of using EPAP to address snores rather than riding so close to the edge of collapse and relying on IPAP to temporarily open the airway back up on inhale. I have to admit, I'm still having trouble conceptualizing how FL is different than H in anything other than the severity of the collapse, and therefore why it wouldn't respond the same way to pressure settings.

One big thing I am noticing is that I need to be more aware of a tendency to over complicate things that don't need to be. I get comfortable enough with the concepts and jargon that I see I have a tendency to say things like "increase IPAP" when in my head that means "increase IPAP if on fixed bi-level, or increase IPAP Max or PS Max if your auto is regularly hitting either limit, or if neither of those apply then raise either PS Min or Min EPAP (along with Max IPAP if necessary) depending on whether you have both settings and if so which you find most comfortable and triggers the fewest CAs." All those should result in higher IPAP pressures actually delivered either all the time or at least when the machine currently hits the PS Max or IPAP max limits, and it dons't even occur to me that someone might interpret that as "raise Max IPAP even if the machine isn't currently hitting it anyway". I tend to avoid simplifying that to "raise Min EPAP" for fear that I'm leaving out a lot of potentially viable alternatives and also giving the impression I lack a full understanding of the subject, but along the way I forget the advantages of providing advice that is concise, clear to understand, easy to do, and almost always effective.

djhall wrote:I'm still having trouble conceptualizing how FL is different than H in anything other than the severity of the collapse, and therefore why it wouldn't respond the same way to pressure settings.

I hear you...It was/is hard for me to wrap my head around some of those little things. I finally just decided that FLs could just as easily be obstructive apneas in the making and not just hyponeas and thus would likely be better prevented from a base standpoint than the IPAP increase. Maybe it's because of the timing need for the machine to do its increases in both EPAP and IPAP. In a sleep lab with a live tech in attendance that tech can increase the IPAP in the blink of an eye..the machine can't do that (except my S9 adapt which is a whole different story). So maybe on paper yeah...those FLs and snores should have IPAP address them but maybe the timing is such that it just can't be done as effectively as simply having more EPAP holding the airway open better to start with.

I do try to keep my ideas as simple as possible because most newbies don't understand what is going on behind the scenes and to be honest..they don't really care (except for people like you and me) so I don't go into a lot of detail unless someone asks.
I find it confuses a lot of people. I will hit the high points but that's about it unless someone wants to know more.
I try to adhere to the KISS principle whenever I am dealing with newbies. Most of the time they just want an idea to try...they don't really care where I came up with the idea...whether it was from reading something or I just pulled it out of my butt (which I have done on occasion when all else fails )
They don't care why so much as they care IF and idea works.
I think you will find that in 9 out of 10 situations EPAP or in the case of APAP minimum...those are the most critical settings to come up with. ....Assuming of course we are dealing only with plain jane OSA....complex or central sleep apnea really muddies up the waters.

There's so much about this therapy that doesn't always follow the books or the manual.
Like some people need more pressure with a full face mask than with a nasal mask. In theory it shouldn't matter...x amount of pressure should be x amount of pressure no matter how it is delivered (assuming leaks not compromising things) but I have seen too many verified reports where people can use 2 or 3 cm less pressure with a nasal mask than they have to use with a full face mask to get the same acceptable reports. And way too different to blame on a one night fluke. I have seen consistent verification from some people who tested long term. It doesn't always work out that way for everyone but sometimes it does...so I tell people it is possible to not have to use quite as much pressure with a nasal mask....not guaranteed for sure but possible.