Granny7 - Newly Diagnosed- Looking for Help

[Gideon]

UARS, by any chance do you have a BiPap in the house?

UARS is definitely possible, you have a number of flow limits that are not close to being resolved, and UARS is about flow limits. Dr. Krakow uses the term UARS so people, doctors too, don't go it's just flow limits, don't worry about them.
The first thing I would have you do is increase your EPR but you are maxed at 3, thus the question about BiPaps in the house.


I'd like you to try higher pressure. Start with
Pressure=11
Max pressure=20 just to open it up for testing.
Let's see what this does to your obvious flow limits. Expect a further increase.

Among other things this should help build a case for a BiLevel.

[Granny7]

Before we get into a more extended discussion of UARS and flow limitation, you have a reading assignment http://www.apneaboard.com/wiki/index.php..._and_BiPAP  There is improvement visible from the use of the collar, and your inclined sleeping position certainly contributes to the problem. UARS is usually related to an upper airway restriction to airflow, and ENTs are specialists that usually deal with this, often with surgery, because that is what they do best.  The article discusses using bilevel pressure support to assist inspiratory flow.

Thanks, I need homework. I've really missed it since grad school. Seriously, thanks again for your help. Hope I  don't need surgery. Somewhere along the line I learned a little about surgery for apnea and as I recall it's pretty painful and often doesn't work.

[OpalRose]

Just following this thread, and my feeling is to keep any surgery on the back burner. That should be a last resort.

I like the suggestion of trying out a Bipap if you have access to one.

[Granny7]

GideonUARS, by any chance do you have a BiPap in the house?

Nope. Just a second airsense 10 Autoset that is in use. I do have a spare rice cooker

I'd like you to try higher pressure.  Start with
Pressure=11
Max pressure=20 just to open it up for testing.
Let's see what this does to your obvious flow limits.  Expect a further increase.

Among other things this should help build a case for a BiLevel.

Did you see my post from the first night? The pressure was set at 5-20 per my prescription and the pressure went to 17 but to my inexperienced eye it doesn't seem like the higher pressure did much for the flow limitations. I'll post it again so you don't have to search. I'll try 11-20 but need to deal with my mask issues first. I'm not sure I can where this mask again tonight. I have an appointment  to get an F&P Vitera on Tuesday.

Thanks for your help.

[Sleeprider]

I wanted to clarify that an otolaryngologist is a specialist many of us get referred to if we bring up the subject of UARS. While these doctors are the best at diagnosing the causes of upper airway resistance, they have a strong inclination toward surgical solutions that can be painful, invasive and have relatively low return on investment in terms of efficacy vs pain. Another option is the gastroenterologist that can dig into the GERD problem. So ENT vs GENT https://www.excelental.com/tag/enterolog...erologist/ You have a difficulty that has put you into an inclined sleep position that is adversely affecting your sleep and health. Only you can decide the best path forward, but I hope to avoid surgery. Bilevel positive air pressure allows for lower pressure and better breathing without invasive procedures, so that is why we are pointing that direction at this point. The insights that specialists can bring in terms of diagnosis of a problem is helpful in making decisions. Just don't jump at the first offer.

[Granny7]

Last night my household nerd suggested I try sleeping flat in spite of my GERD to see if the inclined position was an issue. It appears from last night that it is. I wore the collar again. I compromised between what Sleeprider and Gideon recommended and set the pressures to 8-16 and left EPR at 3. I hope that’s OK with you guys. To me the flow limits look much better and my AHI was only 3.58. But my RDI was 5.15 RERAS were a lot lower than the previous nights. (See, I read my assignment.) I had to take the mask off after a little over 4 hrs because of pain. I woke up between 3:45 and 4 and was awake for the rest of the time. So I don’t think the last hour represented better therapy.

Sleeprider, I don’t understand your comment “Bilevel positive air pressure allows for lower pressure and better breathing without invasive procedures”. It appears Dr. Krakow uses a bilevel machine but his pressures are 12.5-25. Also, if I understand correctly you and Gieon use bilevel machines with pressures of 9-18 and 9-25 respectively. So the lower pressures are around what you’ve recommended for me but the high ends are much higher. Am I missing something?

Also, were you suggesting that bilevel therapy may improve my apnea therapy even if I continue to sleep in the inclined position? My Dr. has recommended surgery to correct my GERD but it has some long term consequences that concern me.

Here’s my chart from last night. Again, thanks for all the help. I hope I’m not taking up too much of your time but there are no good sleep Drs. near me. My husband went to the one who’s supposed to be the best but he says he’s not sure the guy knows how a CPAP works. He now sees the nurse practitioner who has little interest in discussing data other than asking about AHI. He’s thinking of just switching to our family Dr. to eliminate what seems to be a pointless annual visit.

[Sleeprider]

These results look better, with a lot less appearance of positional clusters.  Let me see if I can make my statement that bilevel pressure allows for lower overall pressure and better breathing, make a little more sense.  Your pressure tops out at 16/13 (IPAP/EPAP) and your 95% flow limit is still 0.35, which is high and reflects a lot of respiratory effort.  My bilevel settings are minimum EPAP 9.0, maximum pressure 18 and PS 4, so I start at 13.0/9.0.  That is not very different from your median pressure of 12/9, but the additional pressure support which nearly eliminates my flow limitation makes my breathing much freer and easier so I don't experience the arousals and events you do. My 95% pressure is about 16/12 and that might appear to be higher than yours, but it "feels" lower.  My time at the peak inspiratory pressure is very brief, so I get more exhale pressure relief and more inspiratory pressure support or assistance.  I will put one of my charts below yours showing how the mask pressure rises with inspiration and falls with expiration and creates the feeling that pressure is lower than what you experience.  Since my flow limits are nearly completely treated by this pressure support, my pressure does not often rise to the maximum set pressure.

[Gideon]

For me my high pressure doesn't matter because my flow limits are controlled and thus my pressures for rise as a result.
I should update my profile, my current settings are 11-25 PS=6. I run a higher PS than most here, mostly to resolve my flow limits. My original prescription was 19 fixed, my machine a brick that could only produce 18 which means my pressures average considerably lower than the 18 I originally used because of the PS I use.

[Granny7]

Thanks for the clarification, Sleeprider and Gideon. Melman says he's always impressed by both the dedication and depth knowledge you both have. No new data today. Too sore from the mask. I'll pick up the F&P Vitera mask that Dave recommended on Tuesday. I hope he or someone else who uses it will jump in with tips for adjusting it. I figure if it causes irritation too I will have two masks with different contact points to alternate. Lincare offers only one free exchange so if that doesn't work I'll need to get something without insurance. I see my Dr. tomorrow on another issue but hopefully I can get her to discuss my apnea issues.

[Sleeprider]

Granny, I'll just say the respect is mutual. Melman tends to stay in his lane of microbiology, but his instincts are good on the CPAP stuff. If anything, he is very conservative in the absence of confirming data. Not a bad thing. FWIW, he fits in well with his fellow nerds here.