1st Night Bi-Pap, high pressures = terrible

[Brando80]

Hi,
   I'd appreciate any insight, just finished my first night on bipap and it was pretty bad, I only slept about 3 hours, wore the mask for 6.5hrs. I've felt terrible all day, bloated, burping, and farting which my kids thought was funny at least, tired and had a headache last night which is unusual .  I'm 39, 6' 1" about 195lbs just diagnosed with severe OSA and CSA in November, my AHI was 47.1 and CAI 19.3. The central events were post arousal and likely physiologic from my understanding. I failed my first CPAP to bipap titration study and went back again for a full night bipap study which showed the best results on pressures of 22/17 with a backup rate of 14. I got an aircurve ST-A with a full face mask. With it on and ramped up I feel like I have a hard time exhaling and it's trying to push another breath in before I finish. Also it stops giving me a breath before I'm done inhaling. Not to mention the mask leaks and wakes me up. I'm a pretty light sleeper. Luckily I'm off work for the next 4 days to try and get a little used to this thing, no way I could wear it and work the next day if this continues. I didnt have very many symptoms, I only got checked because my wife mentioned I had apnea. I felt much better without this thing but for obvious health reasons and the fact that I just spent almost $800 I really want this thing to work. Any tips or tricks to deal with the leaks or feeling likr it's trying to give me much shallower and more frequent breaths than I want? How long should it take to get used to it? 

I'd be glad to posy any info from my studies just not sure what would be the most helpful. 
Sincerely 
Brandon

[Sleeprider]

Hi Brandon, welcome to Apnea Board. Your ST-A is an extremely capable machine, but getting it setup for you is quite a challenge. ST-A is usually provisioned to patients that need assured alveolar volume pressure support. This machine is capable of resolving a number of forms of hypoventilation from restrictive lung disease and serious thorasic weakness along with other conditions. Properly setup, it can avoid obstructive, restrictive and central apnea and hypopnea.

We need to see your settings, and some chart images from your experience with this. Please try to use the OSCAR software to view the data from your machine's SD card data, and if it doesn't work, we can invite you to join our Beta test group where a new version is now being tested that does support your machines. Please contact myself or Bonjour to get access to that new version.

In addition, you can request a clinician setup manual here https://www.apneaboard.com/adjust-cpap-p...tup-manual for your Resmed Aircurve 10 ST-A. I have a copy and will be glad to help you understand it, and to make the kinds of adjustments that will solve the short inspiration time, acrophobia, and other issues. We do need to see copies of your titration study redacted to remove personal information, and we need to better understand the conditions that are being treated. I look forward to helping, and making this a successful and comfortable therapy.

[Brando80]

Thank you for the reply, I’ll get right on that in the morning. Rightly or wrongly I’ve been wearing this thing for about an hr trying to get the mask leaking fixed which woke me up a lot last night  and playing with the settings. I left my insp and exp pressures at prescribed amounts of 22/17 but I turned on the iBR and turned the set  backup rate from 14 to a target rate of 12. That seemed to help elongate the insp and Exp time better than jut turning the set backup rate down to 10 or 11 which I tried first. Seems I like to take fewer larger breaths than this thing was trying to get me. 

 I’m treating OSA with post arousal CAI. No other history or medical problems. No lung disease. I’ll get right on those docs in the morning.

[Sleeprider]

Your machine is capable of S, T, ST, PAC and iVAPS modes.  What is your setting? This will tell me what features are avialable to you, My guess is  you are in ST mode which is a dumb bilevel, and a whole new horizon of possibility with lower pressures is available to you in iVAPS mode which has the intelligent and auto-adjustable pressure support. I will attach a titration guide below which shows you some of the possibilities we can explore, not to mention your time of inspiration is adjustable for both minimum and maximum times.

[Brando80]

Hi,

   Yes it was set-up in ST mode. Last night was a little better, I turned on the iBR feature and that helped a little. Plus I wore it for about an hr trying to get the leaks under control by tightening up the mask. I'm looking forward to looking through the clinician manual. I have a lot of experience managing ventilators for ICU pt's but this sleep apnea stuff is pretty foreign to me. I appreciate the help. Let me know if you need other info, I attached screen shots from my 1st sleep study and the 2 titration studies I have. 

Brando

---

That Oscar app is great. Here are the screen shots from the last 2 days. I took it off last night at 0300 because my mouth was really dry, then put it back on for an hr after I put the kids on the bus. 
Brando

[Sleeprider]

I read your sleep study, and somehow you got the wrong machine, but it will work to resolve what appears to be complex apnea. I'm surprised you were not put on ASV. Did your doctors ever explain anything to you about what they are trying to do with this therapy? Anyway, they titrated you to 22/17 and for 80 minutes you didn't have any apnea or hypopnea events. We have seen this in titration studies before, and it is always an error because of the way we know the events are triggered and the fact they are not repeatable or linear in response to pressure. It would be interesting to see the recommendation section.

If you're game for trying something different, I'd like to have you try the iVAPS mode with EPAP min 5.0, PS min 4.0 and PS max 20.0. Based on your most recent chart, your spontaneous respiration rate is 13 BPM, and you will have to enter your height for the ventilation rate. Turn off ramp. With these settings, the machine will start at relatively low bilevel pressure of 9.0/5.0. During titration, this pressure resulted in 5 CA, 0 OA, and 6 H events. The machine will automatically titrate the EPAP upward if you experience OA events. It will use the dynamic pressure support between 4.0 and 20.0 to automatically prevent CA and H events. We may need to fine-tune these default settings after seeing results, but they should be very comfortable and prevent the events we are seeing in S mode at 22/16 pressure.

You have the most sophistiated machine on the market, and I think it was dispensed by error (who knew ST and ST-A are really different?). You can take advantage of the adaptive pressure support and intelligent algorithm of this machine, and improve your life pretty dramatically, or keep your current approach until someone on your medical team figures out this isn't working. You should have been dispensed ASV (adaptive servo ventilation), but you got the iVAPS. Might as well use it.

[Brando80]

Hi,
   You know I had the same thought, that the ASV might be better but wasn't sure as this isn't my area of expertise. You know I think I have a warranty period where I may be able to change it out, wonder if thats worth it? Lord knows it was expensive, my insurance doesn't cover DME as a tier one coverage, it's tier two which is $1,000 deductible then an 80/20 plan. I'm all for trying those new settings, something about my titration study and the pressures I was prescribed didn't sit well with me but like I said I  don't have expertise in this area. I really appreciate it and am a little more optimistic. 
Thanks 
Brando

[Brando80]

Hi,
  Here are the recommendations from the 1st and 2nd titrations. A different physician read the 1st one versus the second one. I contemplating asking about an ASV before I got this machine but read somewhere that the ASV couldn't go up over a pressure of 20 and since my upper range was over that I wasn't sure. I may get a second opinion depending on how this goes. 
Thanks 
Brando

[Sleeprider]

Both analyses cite the potential need for ASV. You need one, no ifs ands or buts. Your ST-A is the most expensive machine on the market and retails higher than ASV. You should request the prescription for ASV and ask for a swap. If that fails, you can take your prescirpiton and request a swap with Supplier #2. They have lightly used and new ASV machines, and will give you a generous offer for your ST-A, most likely a straight trade provided you don't have high use hours on the machine.

Your machine was dispensed in error. You should have gotten ASV, but what you got was NOT a ST machine either. It will treat central apnea. I think as long as you've got the iVAPS in hand, you should try out the settings I outlned above, and let's see what happens. If we can't get this machine to deliver comfortable effective therapy, I'll be surprised, but you still have a very valuable machine that will be exchanged for ASV if you have the prescription.

We have a wiki that describes the usual path to advanced positieve pressure semachines http://www.apneaboard.com/wiki/index.php...P_Machines I think this second titration intended to prescribe a fixed bilevel machine with 22/17 (PS 5) settings. The settings were doomed to fail because no bilevel without backup rate is capable of treating real complex or central apnea. You got an advanced bilevel that is capable of being used with individuals with severe issues including thoracic paralysis, where the machine performs full-time non-invasive ventilation. ASV is the ideal choice because you don't need a full-time ventilator. Talk to the doctor. If these titration costs are coming out of pocket, you can ask for the prescription without further clinical testing. The ASV is capable of automatically titrating, and you should not make more boat payments for the clinic.

[Brando80]

Thanks, I'll give it a shot. I'm also going to contact my pulmonologist, what's the most concise argument or research I cab give them to support my case that they messed up? 
Thanks 
Brandon