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Please help! I don't know what else to try with BiPAP (UARS)
#1
Please help! I don't know what else to try with BiPAP (UARS)
Issue:
  • Very rarely make it longer than 60 to 90 min with BiPAP before taking it off in my sleep or waking and not being able to fall back asleep 
  • Even when OSCAR shows a low AHI, I believe I am still having a lot of arousals (confirmed by jerking movements on video)
Background: 
  • Almost no apneas or oxygen desaturations over 4 sleep studies, but usually 20+ RERA index, 20+ spontaneous arousal index
  • BiPAP titration: prescribed 16 IPAP 14 EPAP, but only actually got up to 14 IPAP 10 EPAP during the night (still had RERAs/spontaneous arousals) 
I've Tried:
  • A full range of pressures with over 100 nights of OSCAR data. Have yet to find any consistent patterns. I did get pretty bad aerophagia at some of the higher pressures. I've also tried APAP and CPAP modes, because why not.  
  • I've tried a couple different full face masks and a nosal mask. The current mask I use is pretty secure on my face, I don't think leaking is an issue.
  • Higher pressures tend to result in more Central Apnea events in OSCAR
  • Had really bad aerophagia early on at original prescribed pressure
OSCAR Screenshots are from a recent night, one of the rare cases I made it longer than 90 min. Does my flow rate give any indicators?  Other suggestions?? really appreciate any help!


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#2
RE: Please help! I don't know what else to try with BiPAP (UARS)
You have low AHI and no flow limitation, but AFlex is making your sync pretty awful. The first thing you need to do is update your OSCAR to version 1.2.0 because some of your statistics are simply don't reflect the current version. The second is to turn down your flex reading to 1 or 2. I just assume it is at 3 and that is causing the pretty terrible sync problems. Let's start with that and take a look if it improves what we're seeing in those charts. Nicely done charts and very helpful that you posted them. If anything, it looks like you might tolerate lower pressure.
Sleeprider
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#3
RE: Please help! I don't know what else to try with BiPAP (UARS)
thanks for the feedback! I was actually on Bi-FLEX level 1 in that screenshot. I switched to AFLEX level 1 (ramp time?) last night and got really bad aerophagia. Not totally clear on the difference between them or why I got aerophagia when switching. I'm going to try reducing the pressure tonight and keeping the AFLEX/ramp time at level 1. I do have previous nights with ramp time 0 at various pressures with no success.


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#4
RE: Please help! I don't know what else to try with BiPAP (UARS)
(12-02-2020, 09:09 PM)tiredmikey Wrote: ... confirmed by jerking movements on video

By any chance are these leg jerks? E.g. evidence of PLM?
Caveats: I'm just a patient, with no medical training.
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#5
RE: Please help! I don't know what else to try with BiPAP (UARS)
The sync looks better, and we no longer see that blip of positive flow during expiration. I think you can lower your minimum EPAP pressure which should help with aerophagia. The way your chart is organized, we can't see the settings. It appears you are using EPAP min 11.5, PS min 1.0, PS max 2.0 and Max pressure at 16.5. From what I'm seeing here, I would drop EPAP min to 9.0, IPAP max to 14.0 and use a fixed PS of 2.0 (min=max).
Sleeprider
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____________________________________________
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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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#6
RE: Please help! I don't know what else to try with BiPAP (UARS)
Rider - tried 14 IPAP 9 EPAP last night with risetime=1. I think I misspoke when I said AFLEX above, it's what OSCAR said but FLEX was off and risetime set to 1. I'm a little confused on the PS min and max recommendation since I'm on BiPAP not APAP...BiPAP does not use PS min/max correct? Do you think I should try APAP? I had tried previously only a few times, but I'm not sure I had good settings to start with. Appreciated!


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#7
RE: Please help! I don't know what else to try with BiPAP (UARS)
(12-03-2020, 08:31 AM)slowriter Wrote:
(12-02-2020, 09:09 PM)tiredmikey Wrote: ... confirmed by jerking movements on video

By any chance are these leg jerks? E.g. evidence of PLM?

Some are leg and arm jerks, but I think most are actually my head. My sleep studies don't show significant PLM, but they all show 20-30+ spontaneous arousals per hour. I actually tried a few PLMD medications before with no success (except for klonopin oddly, helped some but I don't want to be on that long term). Now I'm mostly assuming the jerking/twitching is due to UARS but who knows.
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#8
RE: Please help! I don't know what else to try with BiPAP (UARS)
(12-04-2020, 06:30 AM)tiredmikey Wrote: I'm a little confused on the PS min and max recommendation since I'm on BiPAP not APAP...BiPAP does not use PS min/max correct?

PS (pressure support) is intrinsic to bilevel therapy; it's not available in CPAP ;-)

The issue he was noting is that Phillips bilevels allow a range of PS, and if the upper range of that (PS max) is too high, it can lead to centrals.
Caveats: I'm just a patient, with no medical training.
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#9
RE: Please help! I don't know what else to try with BiPAP (UARS)
Your pressure support is 5.0 cm with IPAP 14 and EPAP 9.0. Your predominate event is central, and I think you need to back the IPAP down to 13.0. A rise time of 1.0 is pretty long, but seems to be working okay. I might take that to 0.8. It was throwing me off that are using auto BiPAP in fixed pressure mode.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


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: Please help! I don't know what else to try with BiPAP (UARS)
Oops I definitely got that mixed up. Yes BiPAP fixed pressure mode. the rise time setting of 1 = 100ms, it only gives me the option of 
100, 200, or 300 ms. I'll give the new pressures a try this weekend, thanks!
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