[Equipment] Aircurve vs Dreamstation Data Recording question

[Sleeprider]

Interesting. You use a Resmed Autoset for a long time before moving to your current BiPAP. There was nothing wrong with your efficacy on the Autoset with an AHI of 1.5-1.75. The pressure support from BiPAP has slightly reduced hypopnea as we would expect, while not increasing any other events. With settings of 7-20 EPR 3, your Autoset was probably set a bit on the low side. Your 90% IPAP on the Autoset was just over 13 cm resulting in therapy pressures of `13.25/10.25, and your result from November was 11/8 so your current settings at 14/9 are actually in the same ballpark, but fixed with more PS. (let me know if the jargon is too much, but I will always express pressure as IPAP/EPAP, PS).

I really can't see the medical need for bilevel, but then again, I use it too, and it compares slightly better than APAP. If it were up to me (an it's not), I would be using Auto Bilevel with EPAP min of 8.0 EPAP max 12, PS 3-5, or on the Aircurve fixed PS at 4. You seemed to do well on the Autoset with EPR 3 and probably the only optimization you might have tried was a slight increase in minimum pressure. Why dd your doctor choose to move you to BiPAP?

[bfry]

What he showed me was a chart from the titration study (below), which he said indicates the need for Bi-Level support. 


Not being that familiar with all of it, later review (once I obtained a copy of the report) seems to show they didn't spend much time titrating the CPAP levels, but went from a low level (6) for some time (lower than my previous CPAP settings) to Bi-Level very quickly thereafter.  They spent the most time at the higher levels of BiPAP support.

What he showed me on the overall report was this chart, saying that the 13/9 proved the best levels for me & that I needed Bi-Level support. Then he showed me my leg movements (different area of the report), and that I had RLS issues that were waking me up far more than my apnea events.


I'm on meds for the RLS, and my wife says I sleep much more still than ever before. But I'm fighting this machine enough, that I want to throw it through the window.

[bfry]

@Sleeprider,
Thank you for the analysis. Yes, I'm finding that while the hypopneas are marginally better on average, the overall AHI hasn't really changed that significantly. I am however, finding that the higher initial pressure is somehow having the effect that I'm opening my mouth at times and the air is flowing out that way. The doctor's response was to add a chin strap to the mix. Funny thing is, I never had that problem with the CPAP. The only other thing I can attribute it to is the addition of the RLS medication possibly putting me in a more relaxed state.

What I find real interesting about that issue is that the PR doesn't seem to pick up those events. My wife says the noise is pretty loud when it happens, and sometimes I even whistle a bit. I can tell in the morning when it's happened a bit, because my mouth is dry as a bone & my sinuses hurt, though occasionally that is because I let the humidifier go dry. Dr. says change the water every day, but 1. that's a waste of water, and 2. I forget to do it until I'm in bed & hosed up. The side-mounted water chamber on the Airsense always provided me a visual reminder that I don't get with the Dreamstation.

As for the pressure settings, I agree completely with your assessment and recommendations. I had thought of increasing the base pressure to the 90%-95% range & dropping the max, but didn't want to mess with it while I was deployed. (stress times and varying opportunities for sleep don't make for good times to titrate IMHO.) I don't know how much the PR buys me, but I'm willing to give that up & go back to the CPAP if my doctor won't work with me on returning the BiPAP & moving over to the ResMED.

@Walla Walla,
I appreciate your input as well. Tricare can be a pain to work with at times, but you really can't beat the coverage and cost.

[Sleeprider]

Your titration chart shows that an EPAP min of 7.0 resolves all obstructive apnea, but hypopnea did not disappear until you had a PS of 5.0 or EPAP of 9.0. This tells us you could use an Aircurve 10 with a fixed PS of 5, using EPAP min 7.0 and EPAP max of 9.0. This would give you some lower pressure in auto mode. You had a single hypopnea at both 12/7 and 13/7, and no events during titration at 13/9 and 14/9.

This is one of the cleanest titration reports I have ever seen, and the conclusions of your doctor are clearly well-founded. There is room to move around, or even use a different machine, but the pressure ranges outlined here are based on solid evidence. The only think I'll caveat that with is that every hour of every night presents some differences, so while the titration showed no events at 13/9 and 14/9, you still will have some flags. I think it's important that you feel well rested and comfortable as well, so if the pressure is causing you to experience more leaks, that may be more disruptive that the negligible additional events suggested by your historic CPAP results. Your median pressures have increased by as much as 5-cm without a significant change in efficacy, so I think that says a lot. Your starting pressure used to be 7/4, which is clearly too low, but helps explain your feelings as you start a night at 14/9 now (twice as much).

[bfry]

Based on the study, the settings were 13/9, but I think they must have changed them remotely, as I just checked it and it's on 14/9.
Full settings:
AutoB = On
IPAP = 14
EPAP = 9
PS Min = 4
PS Max = 5

Smart Ramp = Off
Ramp Time = 20 min
Ramp Start = 4
Flex = Off
Rise Time = 3

I think I'll yank the modem now.

[Sleeprider]

So you are starting at 13/9 and can move to 14/9 or 13/10. That's not a lot of movement for auto mode. Your results are good, but numbers are not everything and I have often coached people to take a small hit in AHI for a return in comfort. Up to you, but your results don't change much with a lower pressure start as suggested above. Seriously, your AHI was less than 1 in your example from both CPAP and BiPAP, and the differences in pressure are appreciable.

[bfry]

Very true, and I agree. I think it needs to be lowered. That's why I'm going to yank the modem & adjust the settings myself.
Thanks again for your knowledge and support.

[ajack]

To me from your chart, they chose ipap14/epap9 PS5 because of apnea and the o2 reading, this setting fixed your apnea and gave you 93%
I wouldn't go less than 14/9.

for auto I would have min epap 9 min PS 5 and the max a few cm higher for a start.
You could keep this difference and raise the 9 to 10 and the 14 to 15, if you want to increase pressure for OA and H.

[Walla Walla]

There's nothing wrong with the O2 levels!

[Sleeprider]

To me from your chart, they chose ipap14/epap9 PS5 because of apnea and the o2 reading, this setting fixed your apnea and gave you 93%
I wouldn't go less than 14/9.

for auto I would have min epap 9 min PS 5 and the max a few cm higher for a start.
You could keep this difference and raise the 9 to 10 and the 14 to 15, if you want to increase pressure for OA and H.

Ironically, even at the minimum CPAP pressure evaluated, the minimum O2 at 95% was higher than with titrated BiPAP, even with 30 hypopnea and 2 OA.  As Walla suggests, none of these O2 levels are really a concern, and it's odd that they are generally lower with higher pressure.  I think where efficacy is assured, lower pressures that allow less sleep disruption has merit.