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Failed CPAP, APAP, now on to BiPAP... help please!
#1
Failed CPAP, APAP, now on to BiPAP... help please!
Hey all!

I'm a pretty frequent poster on (oops - edit), but thought to come here for some opinions from your educated minds as well. I have seen through many Google searches that UARS is discussed on here pretty often, so hopefully someone will have some advice to finally get me some proper rest.

Bit of a background: I'm 29 years old, 5'11", hover between 170-180 lbs., work out regularly, and feel like crap regularly as well. No history of surgeries, hospitalizations, or any medical conditions other than an anxiety disorder diagnosed in 2014 (go figure). I had a sleep study in 2017 that indicated an AHI of ~3 and an RDI of 13. The ENT told me "all those symptoms you're having? you're actually fine, don't worry about it" and that was that. Good job, Dr. ******. 

By summer 2019 I was feeling increasingly worse, and I was finally diagnosed with UARS. My risk factors are maxillary and mandibular retrognathia, narrow maxilla and mandible, and a high arched palate. My treatment plan is to undergo Surgically Facilitated Orthodontic Treatment (SFOT) to bring the palate down and widen my jaws, followed by MMA to bring the jaws forward if SFOT doesn't provide enough relief. Since January, I have tried the CPAP (which I used for a few nights before realizing I should have bought an APAP), then the APAP for a few months with no relief of symptoms, and now I'm onto the BiPAP in conjunction with a mandibular advancement device and a cervical collar. I'm just hoping for some relief of symptoms while waiting for surgery.

Here's a link to the past few nights using BiPAP with descriptors. Please let me know if I should post it on here instead, but I figured it's pretty easy to read that way. I'm happy to post anything else, just ask  Smile 

https://imgur.com/a/pgieBEu
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#2
RE: Failed CPAP, APAP, now on to BiPAP... help please!
Hi UARS.DDS and welcome to Apnea Board.

Just like other new members, standard beginning to remedy apnea and sleep issues here is that if you get your sleep study detailed report for your personal record. Since you're legally allowed to obtain a copy, I'd ask for the detailed multi-paged version. Once you've obtained it, post all the pages redacted of personal data.

Second step is to get OSCAR, a free reporting tool created by AB members. Using your SD card from the CPAP, you can upload data into OSCAR and post a chart in accordance to my signature link in reference to that.

There's an experienced group here on AB that will give pointers on everything regarding apnea, from the DME to masks. There's other wiki articles that describe many aspects to be aware of. Best to you on success. BTW those above requested data posts should be kept within this thread, as it pertains to helping you gain successes.

PS you need not post OSCAR screenshots via imgur, you just add them via Attachment below the post box before finalizing the post.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#3
RE: Failed CPAP, APAP, now on to BiPAP... help please!
Thanks Dave!

Here is the original report from 2017:

   

   

   

I also did a High Resolution Pulse Oximetry test in 2019 for three nights. Here is one of the nights:


Attached Files Thumbnail(s)
   
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#4
RE: Failed CPAP, APAP, now on to BiPAP... help please!
Here are night 1, night 2 (last night), and this morning on the BiPAP. Ignore the EPAP, PS settings on the left side of the screenshots, they got jumbled up in Oscar.

Night 1: EPAP 13.0, PS 5.0.

   

Night 2: EPAP 12.0, PS 8.0.

   

This morning: EPAP 14.0, PS 4.0.

   

Ti Max: 2.0 s
Ti Min: 0.3 s
Trigger: High
Cycle: Very Low (I had it on medium the first night, but felt like the machine was "taking away my breath" too quickly).

Night 2 with PS 8.0 resulted in inspiratory flow curves looking like this:

   

And the reason I have my EPAP set pretty high is because I suffer from expiratory apneas. They look like this:

   

Curious to see what y'all think Smile
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#5
RE: Failed CPAP, APAP, now on to BiPAP... help please!
Which of the pressure setting configurations did you feel the most comfortable and rested when sleeping with it?

I myself have not used a VAuto, but there's a good sized portion here that do. Some of them also happen to be our setting gurus. I'll defer to them on recommendations on settings. You may have done so already, so my apology, but let's focus for the time being on answering "how do you feel?" in regards to VAuto usage.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#6
RE: Failed CPAP, APAP, now on to BiPAP... help please!
I can help you with one small part of what you've reported. To quote you

"Ti Max: 2.0 s
Ti Min: 0.3 s
Trigger: High
Cycle: Very Low (I had it on medium the first night, but felt like the machine was "taking away my breath" too quickly)."

The Ti min/max are Resmed's default settings. When I first used my Aircurve I had a similar experience to you in that the machine wanted to switch to exhalation mode before I was ready and like you it felt as if the machine 'was taking my breath away'. The default for Trigger and 'Cycle' were set at medium.

Now you want the machine to spontaneously react to changes between inspiration and expiration rather than have it decide for you based purely on settings. And yes, one way of doing this is to set the trigger to 'high' sensitivity but understand that once the two seconds are up it's going to change regardless.

There is a more effective way and that is to raise the Ti Max. When I sleep I inhale for longer than two seconds so I raised the max setting to 2.6 seconds (30% more). I also did the same as you which was to make my trigger setting as sensitive as possible. This worked like a charm.
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#7
RE: Failed CPAP, APAP, now on to BiPAP... help please!
(04-09-2020, 06:44 PM)SarcasticDave94 Wrote: Which of the pressure setting configurations did you feel the most comfortable and rested when sleeping with it?

I myself have not used a VAuto, but there's a good sized portion here that do. Some of them also happen to be our setting gurus. I'll defer to them on recommendations on settings. You may have done so already, so my apology, but let's focus for the time being on answering "how do you feel?" in regards to VAuto usage.

I would say I didn't feel very good after the first or second nights (EPAP 13, PS 5; EPAP 12, PS 8), but this morning I felt well rested after my 3-4 hours at EPAP 14, PS 4.

I'm going to try EPAP 14, PS 4 for the whole night tonight.


(04-09-2020, 08:11 PM)holden4th Wrote: I can help you with one small part of what you've reported. To quote you

"Ti Max: 2.0 s
Ti Min: 0.3 s
Trigger: High
Cycle: Very Low (I had it on medium the first night, but felt like the machine was "taking away my breath" too quickly)."

The Ti min/max are Resmed's default settings. When I first used my Aircurve I had a similar experience to you in that the machine wanted to switch to exhalation mode before I was ready and like you it felt as if the machine 'was taking my breath away'. The default for Trigger and 'Cycle' were set at medium.

Now you want the machine to spontaneously react to changes between inspiration and expiration rather than have it decide for you based purely on settings. And yes, one way of doing this is to set the trigger to 'high' sensitivity but understand that once the two seconds are up it's going to change regardless.

There is a more effective way and that is to raise the Ti Max. When I sleep I inhale for longer than two seconds so I raised the max setting to 2.6 seconds (30% more). I also did the same as you which was to make my trigger setting as sensitive as possible. This worked like a charm.

Wow, thank you!

So do you have it at:

Ti Max 2.6s
Ti Min 0.3s
Trigger: High
Cycle: Very Low

?
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#8
RE: Failed CPAP, APAP, now on to BiPAP... help please!
OK certainly keep trying that EPAP 14 PS 4 then. Let's see what trend you can make of it. I think you're on the right track from holden4th's suggest.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#9
RE: Failed CPAP, APAP, now on to BiPAP... help please!
I think you're getting good help here, so I'll limit my comments to the concern over expiratory obstructive apnea. The wave-forms you showed, indicate that following inspiration, you occasionally hold your breath. Expiratory flow limitation and apnea are extremely rare, and I'm not sure the best solution is to keep EPAP pressure high. This could coincide with changes in position or REM sleep, but it is a physical closure of the airway while holding a breath, and pressure is not going to resolve that. A form of expiratory apnea that we have seen is palatal prolapse (you can look that one up). Your evens do not appear like PP events which are normally preceded by some expiratory airflow which is suddenly cutoff by the soft tissues at the back of the palate suddenly obstructing the nasal airway.

You seem to have some low-level chronic leaks with your nasal pillows. They are generally below the large leak threshold. These may be pressure related since you were using exceptionally high pressure support and relatively high EPAP pressure. What size nasal pillows are you using and have you tried alternatives? Keep an eye on the statistical summary of flow limitation. I think you are over-doing the pressure support at 8 cm, and as long as the 95% flow limitation is less than 0.1, results are usually acceptable. Your were 0.0 with a maximum of 0.05.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#10
RE: Failed CPAP, APAP, now on to BiPAP... help please!
Hey Sleeprider,

Thanks for your response.

I use the size large P10 mask (small, medium do not work at all) with lansinoh. Used to use the Bleep which was great (absolutely zero leaks) but results were inconsistent - they'd come off my nose during the night sometimes. Thinking of trying the P30i as I like the idea of the hose being on top of my head instead of in front of my face, but for now I'm happy.

holden4th - the suggestion to change Ti max to 2.6 seconds was amazing! I breathed much better. Thank you.

Attached are my results for last night - got AHI below 1.0 and felt good this morning. Let's see if I need an afternoon nap!

   

And here is a zoom-in of the cluster of obstructive apneas, which coincide with some flow limits.

   
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