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Help Finding the Ideal BiPAP Pressure Settings?
#1
Question 
Help Finding the Ideal BiPAP Pressure Settings?
Good day everyone!

I'm relatively new to the world of sleep apnea and was diagnosed with the disorder in early winter of 2018; I have obstructive and central apnea.

I'm writing this post because I have an appointment with the sleep specialist in 2 weeks and my apnea is hurting my ability to perform at work. My sleep apnea therapy is covered by insurance but I cannot tamper with the settings myself. Instead I have to submit the best possible prescription suggestions to my doctor.

I'm here in the hopes that someone can help me determine a good suggestion for the doctor. 

In case you find my post too long to read, I have put my questions in bold for quick reading.

Background information: I was working overnights (midnight to 8am) for almost a year and it was absolutely destroying my health! After several months, my employers have agreed to allow me to work from 4pm to midnight, however my sleep apnea is still between 6AHI and 16AHI. Sad

It seems as though the more tired I am before going to bed, the worse my apnea is!
In your opinion/experience, is this related to obstructive or central apnea?

To be fair I am only on my second trial prescription from the doctor but I hope that by coming here with questions, I can submit a better prescription request to my doctor. The sooner I get my apnea under control, the better!

On that note, I am wondering:

Is it possible to have an AHI below 5 even if one goes to bed late?

I hope that my doctor can provide me with a prescription that allows me to go to bed at 1:30am or even 2am so that I can keep my current hours at work and feel/perform my best.

Carrying on,...

I was on medical leave for a week in July. During that time off work, 
my AHI number dropped below 5 a few times with a record low of 2.1. However this only occurred during ideal conditions, for example:

- Going to sleep with the sun setting and waking with the sunrise and,

- During a vacation where I had zero stress

Unfortunately my AHI numbers never go below 6 when these conditions are not met. The normal range for my AHI numbers is between 6 and 13, especially with the new work schedule (4pm to midnight).

I'm currently using the Philips Dreamstation (BiPAP) and the current (trial) settings are:
- Auto BiPAP 

- Max IPAP 15
- Min EPAP 8 PS 3 cm

Unfortunately my AHI numbers never go below 6 when these conditions are not met. The normal range for my AHI numbers is between 6 and 13, although last night it went as high as 16!

In addition when I go to bed and put the mask on, I feel as if I'm lacking air to begin with. I've noted the settings when this happens, they are: 8 cmH2O - 11 cmH2O

In order to feel comfortable I sometimes try to artificially force the machine to start at 12 by leaking the mask for a few moments, but this still doesn't feel like quite enough air. 

Side note: I think that I have a relatively high VO2 max as I am a young adult who does a lot of cardio (easily 1 - 2 hour runs plus 1 hour on the bike, all in a day). I think my lungs just want more air.

In any case I was wondering what your thoughts were if I asked the doctor to set the minimum cmH2O setting to 13 as a starting point for inhelation? 

Also: are there dangers to setting the air pressure too high and if so, what are they?

I have woken up several times gasping for air and noted that the air pressure was at the current maximum setting of 15 cmH2O. 

I feel that BiPAP helps with my central sleep apnea because my headaches have gone away ever since I was given the BiPAP machine (trial).

However the air pressure never seems strong enough. If we could set the air pressure high enough (anywhere between 16 cmH2O and 20 cmH2O), I think it might resolve my obstructive apnea.

But how can I figure out the best settings to request from my doctor?

The settings that I'm thinking of suggesting to the doctor are:
- AutoBiPAP (for central sleep apnea)
- Min EPAP: 13
- Max IPAP: 18

Final note: I have downloaded the SleepyHead (version 1.0.0-beta-2) software and uploaded my data. The AHI numbers don't match those shown on my Philips Dreamstation. However I can provide more screenshots of the data if that helps. : )

Thank you for any help provided!!  Grin


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#2
RE: Help Finding the Ideal BiPAP Pressure Settings?
Welcome to the forum.

First, you can change the settings yourself, I think that you are choosing not to and that is ok.

1. You have a strong indication of a form of positional obstructive apnea that I doubt your doctor will recognize or know how to fix.  This is a chin tucking  (see the clusters of Obstructive apnea in your charts.  The best fix is a loose-fitting soft cervical collar, just tight enough to not tuck your chin underneath the cervical collar.  I'm pretty sure that your doctor has not heard of this and will likely disapprove of this.  But it works!!  Read this wiki article  http://www.apneaboard.com/wiki/index.php...onal_Apnea
A rolled towel under your chin (roll a necktie in the middle then tie it around your neck to hold it in position.)   This WILL make a very big difference!!!

This will prevent your pressure increases that are occurring from this positional apnea. Then see how the Central Apnea follow the pressure increases because you have stopped the pressure increases I expect your Central Apnea to be significantly reduced.

My suggestions would be 
Auto BiLevel for versatility in treating Apnea
Min EPAP = 7 (to keep the pressure down to avoid central apneas)
Max IPAP = 12 (this limits the IPAP to minimize Central Apneas caused by higher pressures)
PS= 3.0-4.0   (this forces bilevel)
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Soft Cervical Collar
Mask Primer
Dealing with a DME
Organize Charts
Attaching Charts

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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#3
RE: Help Finding the Ideal BiPAP Pressure Settings?
Thank you bonjour!  Grin

For now I'm definitely not changing any of the settings myself, but in the future (after all the paperwork has been filled), I may adjust the settings in order to optimize results. : )

Thank you so much for tipping me off about the positional obstructive apnea! It made a huge difference on my AHI scores! FYI, I was consistently getting anywhere between 6AHI and 16AHI.

On the first night of taking your advice, I went from 16AHI to 4.9AHI!  Grin 

I didn't use a neck brace as I don't yet have one. Instead I used a traveler neck pillow (the type often used by passengers on planes)

However after seeing the lovely 4.9AHI score I took a nap (with the BiPAP and travel neck pillow), and my AHI jumped to 5.9! Huh

I was a bit confused, so I decided to give it a full day's rest and the same scenario played itself out:
- Overnight sleep: 4.9 AHI
- Woke up for an hour
- Went back to sleep: 5.9AHI

Huh

I've attached screenshots of the troublesome timeframe where my AHI jumps to 5.9AHI.


Also I've noticed that the machine's air pressure hits a maximum of 15 cmH2O. I know that you suggested the following settings:

Min EPAP = 7

Max IPAP = 12 
PS= 3.0-4.0 

I'm a total beginner here, but if the machine is maxing out at 15 cmH2O while I'm having apnea events, I'm confused as to why we wouldn't want to increase the max pressure to 16, 17 or 18? 

It's true that I have a lot of clear airway events, and I also don't know what to do in order to correct them.


Dont-know

As a reminder, the current settings on the machine (a Philips Dreamstation) are:
- Auto BiPAP 

- Max IPAP 15
- Min EPAP 8
- PS 3.0 cm

Finally -- for reference sake -- here is my original idea of a proposal to the doctor:
- AutoBiPAP
- Min EPAP: 13
- Max IPAP: 18

What do you think of my original idea?


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#4
RE: Help Finding the Ideal BiPAP Pressure Settings?
Finally -- for reference sake -- here is my original idea of a proposal to the doctor:

- AutoBiPAP
- Min EPAP: 13
- Max IPAP: 18

What do you think of my original idea?

OK, we can run up your CAI score and minimize your obstructive score and prove the "necessity" for a $4500 ASV machine.
http://www.apneaboard.com/wiki/index.php...P_Machines

It is very likely that you are here because someone referred you here because after reviewing your OSCAR daily charts and/or your Sleep Studies they felt that you are a candidate for an Advanced PAP machine such as one of the Bi-Levels. There are two paths to treatment and the choice is yours.


Path 1: The path that you were thrown into whether you realize it or not. That is to treat your apnea, whatever types of apnea that you have, with the machine they gave you, a CPAP, preferable an auto-CPAP either the ResMed or the Philips Respironics machines. New members of the forum come here looking for help with intractable apnea and discomfort from these problems. The forum members and "gurus" are very good at optimizing therapy to reduce these problems, and increase comfort with the therapy.

Path 2: Take the often difficult and lengthy journey to procure an advanced PAP machine. The new member that has been advised they have central or complex apnea needs to be aware that optimizing may provide significant immediate relief from symptoms and improve AHI, but improved therapy results can disqualify them from higher levels of therapy (ASV), that might be possible without this self-optimization. Sometimes individuals resolve central and complex apnea with CPAP and find long-term comfort, however, if results are inconsistent, or produce good AHI but not comfort or relief from other symptoms, The forum optimization should be discontinued as soon as possible to avoid disqualification from higher levels of therapy.This path frequently requires failing at CPAP, then failing at BiLevel E0470, before succeeding at ASV E0471

For Complex Sleep Apnea the Medicare requirements for issuing an ASV machine.

  • Therapy Optimization should be discontinued and the original settings, from the doctor, restored.

  • Titrate to minimize OSA, that is the obstructive AHI to less than 5 per hour. This typically is raising EPAP or pressure until obstructive AHI is less than 5 per hour, we expect this to make the Central and Complex Apnea worse thus failing the current treatment

  • Record the central apnea-central hypopnea index (CAHI) (looking for greater than or equal to 5 per hour and greater than 50% of total AHI)

  • Document the presence of at least one of the following symptoms: These symptoms are specifically noted by Medicare. These are key symptoms that we look for by asking "How do you feel?". Do not limit your answers to the following and do not fabricate the answers.

  1. Sleepiness, "How do you feel?"

  2. Awakening short of breath, "How do you feel?"

  3. Difficulty initiating or maintaining sleep, "How do you feel?"

  4. Frequent awakenings, or "How do you feel?"

  5. Nonrestorative sleep, "How do you feel?" Nonrestorative sleep is defined as the subjective feeling that sleep has been insufficiently refreshing

  6. Snoring, Can be documented on OSCAR

  7. Witnessed apneas Most of us have this one with our significant others

Is this what you want to do?  This is the direction that you are taking your settings.
I was trying to optimize your current machine, find the sweet spot so to speak.  You ask what the optimum machine is, I haven't answered because I haven't determined it yet.  In general APAP is better/more flexible than CPAP, ResMed is Better/more flexible than Philips Respironics, Bi level auto without backup is more flexible than APAP.  ASV can treat, actually treat Central Apnea.  The other machine just avoid it, minimize pressure variance, minimize Flex/EPR and minimize pressure.  To treat your obstructive events we do the exact opposite.  

Thus we cap max pressure lower than we would otherwise, use a narrow band to prevent pressure variance, and minimize Flex/EPR to minimize pressure variance to avoid central apneas while still adequately, but not optimizing treatment for obstructive events.

I am not convinced that an APAP is the best machine for you.  You are on Path 1, the changes you desire put you on Path 2.  I have not yet eliminated in my mind Path 1 as a viable option for you.  Your choice not to make changes does limit the data available to determine which path is best for you.  It is your choice not mine though.   Which way would you like to go.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Soft Cervical Collar
Mask Primer
Dealing with a DME
Organize Charts
Attaching Charts

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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#5
RE: Help Finding the Ideal BiPAP Pressure Settings?
FWIW my AHI numbers really didn't mean much to the pulmonary team on getting me to an ASV beyond the PSG showing 124 CSA to 24 OSA. However my "How do you feel?" answers did count greatly. And I squeaked about it OFTEN by calling lots.

Coffee
Dave

I'm not a doctor in real or fictional life. My posts include opinions based upon user experience regarding CPAP therapy and should not be considered medically professional direction or advice. Even a 1,000 mile trip requires a good first step. My recommended first steps include getting good walking shoes, 1 great cup of coffee, and a good GPS.

Wiki Info for Beginners
OSCAR Chart Organization
Mask Primer
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#6
RE: Help Finding the Ideal BiPAP Pressure Settings?
Thank you once again for an insightful response, bonjour!  Big Grin

I hadn't seen my options as two paths, the way you laid them out. I would say that my goal is simple:

To cure my complex sleep apnea.
By that I mean: to actually cure my central and obstructive apneas. I was unaware that ASV existed or what it was until reading your response and doing a little research to do more. It is definitely an option that I would like to try!


I've been wary about changing the settings up until now because the therapy and machine are covered by my insurance. However my priority is my health and quality of life. If you think that we can actually cure my central and obstructive apneas, then I'm open to your ideas! : )

I've done a quick search on how to change the settings and 
tonight I'll set the machine to the settings that you suggested and share the results in this discussion. 


I should mention that I was initially provided an APAP ResMed Airsense 10 with the following settings: 5-15 cmH2O.

While it provided some relief I was still suffering from headaches, poor mood, woke up feeling exhausted, frequently woke up gasping for air and/or woke up the next morning with the mask thrown off the bed.

It was a start but highly ineffective. Taping the mask to my face did little to help the situation.

In addition the ResMed water tanks that I was renting (as part of the trial process) were old and used. 
They kept leaking water all over my desk and books, which is why I switched to a Philips Dreamstation, as per the recommendation of friends.

After conducting some research on my own, I suggested the use of a BiPAP machine to help with my central apnea and the doctor agreed that we could try it.

The BiPAP has provided some relief, especially with regards to reduced headaches.

Unfortunately I still have some (minor) headaches, wake up gasping for air, wake up feeling groggy and sometimes very, very tired. For the most part my mood has improved but as mentioned the new average for my AHI is between 6 and 13.

*Although with a neck pillow I'm now looking at an AHI of 5.9.

I'm alone, so no one can tell me if I snore or not but I have woken myself up at least once due to loud snoring.

I'm really excited to see what you'll have to say after I post the results with the new settings, tomorrow! : )
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#7
RE: Help Finding the Ideal BiPAP Pressure Settings?
My goal is to quickly see if you are lucky and can get satisfactory results with your current machine. WHEN THAT FAILS, the push is to qualify for an ASV machine if you wish, and it sounds like you do.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Soft Cervical Collar
Mask Primer
Dealing with a DME
Organize Charts
Attaching Charts

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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#8
RE: Help Finding the Ideal BiPAP Pressure Settings?
Sounds good to me!

Like I said I'm open to all suggestions and will share all results. 
If an ASV isn't needed, that's ok too.

Thanks again!  Big Grin
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#9
RE: Help Finding the Ideal BiPAP Pressure Settings?
Alright so I slept a night with the following settings:

BiPAP (Phillips Dreamstation)
Min EPAP: 7 
Max IPAP: 12
PS: 3.0-4.0 

My AHI on the LCD screen showed 5.9 and I have attached screenshots of all the readings from the Daily view in OSCAR.
Do you want to see all of the readings or should I only be sharing specific ones?

Also, last night was the first time that I slept using an actual (foam) neck collar, rather than a travel neck-support.


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#10
RE: Help Finding the Ideal BiPAP Pressure Settings?
Apologies for posting twice today, but I've been in an awkward pattern lately:

I tend to wake up and my AHI is almost always 5.9, precisely as seen in my previous message.
Then I go back to sleep an hour later, and my AHI is always between 6 and 7.

I don't understand why this happens but if it helps -- screenshots of the second sleep session are attached below.


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