How do I make the case for BPAP?

[SleepingFish]

Okay talked to my doctor, she said to talk to my pulmonologist.

Don't really have one, so getting setup with one. Let's see if I can get them to help me sort out BPAP

[Sleeprider]

That is severe Class 2/Class 3 Flow limitations. Bilevel would help. If you're working with your doctor, focus on your lack of comfort and intolerance of CPAP due to inability of CPAP to resolved these mid-inspiratory obstructions without pressure support. The key-word is "CPAP intolerance" which is a basis for approving bilevel. These flow limits significantly, but not fully resolved in the example above where you were using 18/15 pressure. As you can see, with pressure at 12/12 your flow limits have greatly increased to 95% of 0.18 and you have lost over 100 mL of tidal volume. Inspiration/expiration (I:E) time is now 2.64:1.64, vs 2.08:1.68 (0.62:1 vs 0.81:1). Both are flow limited, but worse with lower pressure and no EPR / PS and normal is greater than 1:1 to 3:1. You clearly benefit from pressure support, and would do better with the higher pressure support available from something like an Aircurve 10 VPAP-S or Vauto. Leak rate remains poor.

We know that bilevel works for this kind of upper airway resistance, and improves both efficacy, volume, the qualitative sleep. All of the evidence is in your hands if you can figure out how to present it. The option to self-treat with bilevel could prove the concepts here with the proof needed to show a doctor the benefits. I would suggest you start with a conversation emphasizing that while you do not have severe apnea, your respiratory flow rate is very disrupted or restricted. This leads to anomalies in your sleep respiration and numerous arousals which make normal functioning difficult. Your AHI meets the criteria for "efficacy", but your problems with sleep quality related to severe flow limitation are significant. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4688581/

To make it easier to see flow limitation in your Flow Rate graph, you should add a dotted line at the zero-flow crossover. To do this, right-click the Y-axis near the Flow Rate title and select Dotted Line at zero. Everything above the line is inspiration, and below the line expiration. It will help you to visualize the anomaly in your respiration.

[Sleeprider]

Just saw your last post. The are sending you through the specialist channel. Is you insurance great, or should you just do this?

[SleepingFish]

Does Aircurve 10 VPAP-S go past the 20ish pressure limit of my machine?

It gets harder and harder to keep a mask from leaking the higher my pressure is.  8 is easy.  12 is easy some days, bad other days.  18 is terrible and I can hardly make it through the night.  Won't even more pressure just make it more uncomfortable?

[SleepingFish]

Just saw your last post. The are sending you through the specialist channel. Is you insurance great, or should you just do this?

My insurance is more or less normal for private insurance in the US. A pretty high level blue cross / blue shield plan. Normal white-collar type job insurance. I think a specialist visit will be like $40 or somesuch.

I suspect they will deny whatever I get prescribed, so will have to fight. But can try!  If I lose, then I just buy my own.

[Sleeprider]

Resmed VPAP goes to 25 cm. You won’t need it, but you will definitely need the pressure support. With your COAP you get up to 3 cm. Therapeutic PS is 4+. PS act to replace respiratory effort during inspiration and follows your effort with increasing pressure. This prevents the tissue occlusion by providing higher pressure at the critical moment inspiratory flow is increasing and prevents negative airway pressure that collapses tissues from occurring. Your airway collapses as your respiratory effort increases flow and PS prevents that. With CPAP you get pressure to stem the airway, especially in the transition from exhale to inhale. VPAP does that, but dynamically increases pressure during inspiration to stent the airway when people like you need it.

FWIW your problem is not pulmonary. Your lungs are apparently healthy and you have plenty of thoracic strength to breathe. Your problem is collapse of the upper airway during inspiration. That is the expertise of an ENT otolaryngologist.

[SleepingFish]

My lungs SHOULD be in good shape. I am 40 and can go out and run 10 miles on demand.  Pretty sure it is structural related to being a mouth breather and a bad airway structure.

So an example of being setup on VPAP would be like a pressure of 10/20 or something? 20 pressure on the inhale, but only 10 on the exhale? So I get extra help breathing in without the effort on exhale?

[gainerfull]

You don't experience aerophagia with your pressure that high?

[Sleeprider]

An example of being setup on VPAP depends on whether you use S or Vauto. We would look for the minimum EPAP pressure the prevents OA events, and that is pretty low in your case, then start with PS 4. What we would like to do is keep pressure low enough to prevent obstructive apnea, but use pressure support to treat the flow limits. It's a really simple titration protocol that we can optimize in just a couple sessions. A used machine can be very affordable, but you have to take some precautions to ensure you get what you pay for. I have done it several times and always came out with a good result. I'm still using a backup Vauto I bought on Craigslist (SearchTempest) from Littleton Colorado.