Settings for aircurve 10 vauto to fight aerophagia ?

[koy23]

Admin note:  attached screenshots from this thread have been removed

Hi all,
I tried using airsense 10 autoset for 1.5 months, and my conclusion is:
I need a pressure of somewhere between 9.5 to 12.5 
I can't have more then exhale pressure of 4 otherwise I start swallowing air (max 4.6) 
So I was using the machine with min pressure of 8 max of 10 and epr 3. But still not enough pressure and swallowing air.

You could see all my graphs here :
http://imgur.com/a/7OBbu5Z

I have very low AHIs but my problem is I keep waking up through the night ( it seems that my awakenings decrease when I increase the pressure but I'm not able to pass 10) 
I think my awekeawake are because of RERAs ( I have LPR and it's inflammation areound larynx so air flow is actually less then it was, so my body is still trying harder to breath with normal airflow so it wakes me up) 
I would like to set pressure from 10-13 but I can't becsube the aerophagia.

So I changed my machine to an aircurve 10 vauto.
My question is what setting do I use? 
Is there an issue to have a high PS? 
I was gonna use max epap: 4
Max ipap: 13
PS : 6

My goal have ipap somewhere between 10 to 13 and keep epap to 4.
Is that too big of a gap? Is there an issue to have PS 6 to 9 ? 

Also could you also tell me what to set the other settings? Till trigger cycle.

Thanks

[Sleeprider]

I think a PS 6-9 is too aggressive, and you should experimentally build up to it. Start with the machine in Vauto mode and set pressure support to 4 and IPAP max at 12. Let's see where that takes us and then we can try higher PS. We will use PS for hypopnea and flow limits and if we get too many CA events, we have found a limit.

[koy23]

I think a PS 6-9 is too aggressive, and you should experimentally build up to it.  Start with the machine in Vauto mode and set pressure support to 4 and IPAP max at 12.  Let's see where that takes us and then we can try higher PS.  We will use PS for hypopnea and flow limits and if we get too many CA events, we have found a limit.

Thanks for your reply, if I use PS 4 and Max ipap 12, that means I start at 8. Correct ? 
It is not enough based on my experience with different settings with the APAP.
I'll have very low AHI, but my air flow is still somehow obstructed maybe 30% maybe 20% I'm not sure but my brain will keep waking me up in rem cycles.
I need to start with pressure maybe 9.6 or 10 , and I need my epap to stay at 4.
Why is the PS bigger than 6 an issue? 
What is the safe limit ? 
Thanks.

[Sleeprider]

I think a PS 6-9 is too aggressive, and you should experimentally build up to it.  Start with the machine in Vauto mode and set pressure support to 4 and IPAP max at 12.  Let's see where that takes us and then we can try higher PS.  We will use PS for hypopnea and flow limits and if we get too many CA events, we have found a limit.

Thanks for your reply, if I use PS 4 and Max ipap 12, that means I start at 8. Correct ? 
It is not enough based on my experience with different settings with the APAP.
I'll have very low AHI, but my air flow is still somehow obstructed maybe 30% maybe 20% I'm not sure but my brain will keep waking me up in rem cycles.
I need to start with pressure maybe 9.6 or 10 , and I need my epap to stay at 4.
Why is the PS bigger than 6 an issue? 
What is the safe limit ? 
Thanks.

In Vauto mode with EPAP min 4.0, PS 4 and IPAP max 12, you start at 8/4 and the machine self-titrates upwards.  You can set a narrower window by reducing IPAP max.  If we determine you don't trigger centrals with PS 4, we continue to increase PS so at PS 5.0 you would start at 9.0/4.0.  It is the max IPAP that limits pressure, but the minimum EPAP plus PS that determines your starting pressures.  Rememer VAUTO MODE!

[koy23]

I think a PS 6-9 is too aggressive, and you should experimentally build up to it.  Start with the machine in Vauto mode and set pressure support to 4 and IPAP max at 12.  Let's see where that takes us and then we can try higher PS.  We will use PS for hypopnea and flow limits and if we get too many CA events, we have found a limit.

Thanks for your reply, if I use PS 4 and Max ipap 12, that means I start at 8. Correct ? 
It is not enough based on my experience with different settings with the APAP.
I'll have very low AHI, but my air flow is still somehow obstructed maybe 30% maybe 20% I'm not sure but my brain will keep waking me up in rem cycles.
I need to start with pressure maybe 9.6 or 10 , and I need my epap to stay at 4.
Why is the PS bigger than 6 an issue? 
What is the safe limit ? 
Thanks.

In Vauto mode with EPAP min 4.0, PS 4 and IPAP max 12, you start at 8/4 and the machine self-titrates upwards.  You can set a narrower window by reducing IPAP max.  If we determine you don't trigger centrals with PS 4, we continue to increase PS so at PS 5.0 you would start at 9.0/4.0.  It is the max IPAP that limits pressure, but the minimum EPAP plus PS that determines your starting pressures.  Rememer VAUTO MODE!

I understand what you are saying, thing is when with the APAP, i was setting the machine from 8-10, and it was averaging 8.5 to 9.5, barely pass 9.7. but that was still not enough to keep me asleep the whole night plus the air swallowing. So i wanted to at least start from 9.5 and let it titrate to 12, but to start at 9.6 i have to set the PS to 5.6.
Should i just try that tonight and see if i get CAs ? do they show right away or it takes many days to develop? and how big of a gap is usually safe ?

thanks

[Sleeprider]

If you want to jump in and try high PS, go for it. If your sleep is disturbed, you can back off. I'm trying to give you a disciplined and conventional approach to titration that will identify the pressure that are effective and comfortable. It might take a couple more nights to get there, but you will arrive. I have no idea what kind of events you experience or why you have moved to bilevel other than aerophagia.

Maybe you can tell me what higher pressure support is expected to accomplish? You said:
"So I was using the machine with min pressure of 8 max of 10 and epr 3. But still not enough pressure and swallowing air."
Not enough pressure for what?
If you can't tolerate higher EPAP then fixed pressure (S-mode) may be your friend. This lets you set the IPAP and EPAP pressures and they will not change through the night. You can set EPAP at 4 and select an IPAP pressure like 9.6 and see how that works out. Keep in mind, pressure support does not prevent OA events. It reduces flow limits and hypopnea. OA is controlled by the EPAP pressure.

[koy23]

If you want to jump in and try high PS, go for it. If your sleep is disturbed, you can back off. I'm trying to give you a disciplined and conventional approach to titration that will identify the pressure that are effective and comfortable.  It might take a couple more nights to get there, but you will arrive.  I have no idea what kind of events you experience or why you have moved to bilevel other than aerophagia.  

Maybe you can tell me what higher pressure support is expected to accomplish?  You said:
"So I was using the machine with min pressure of 8 max of 10 and epr 3. But still not enough pressure and swallowing air."
Not enough pressure for what?
If you can't tolerate higher EPAP then fixed pressure (S-mode) may be your friend. This lets you set the IPAP and EPAP pressures and they will not change through the night.  You can set EPAP at 4 and select an IPAP pressure like 9.6 and see how that works out.  Keep in mind, pressure support does not prevent OA events. It reduces flow limits and hypopnea. OA is controlled by the EPAP pressure.

Sleeprider, thank you for being patient, i am learning more as i am reading, i just saw your diagram of how to titrate that you sent to another user. 
I understood that you want to start with min EPAP that prevents OA, and then go no more than 4 above it to set IPAP.
Based on my APAP usage, and the graphs in the link i posted, i think i was getting OA when IPAP was anything less than 7 and EPAP was 4. when i increased the pressure from 7.6 min to 8.8 max with epr 3 on the APAP, the OA disappeared, but i was still waking up each night 4-5 times in REM and getting fragmented sleep. i tried this for like 4-5 days, and decided that it could be because RERA's so i increased min pressure to 8 and max pressure to 10 with EPR 3 still. first night i woke up like 2 times only, then 3,4,5th the awekenings were little more but still less fragmented that the 7.6 to 8.8 range. My problem was the aerophagia started to show up. 
So from reading the forum, i saw that a solution for aerophagia other than reducing pressure was using a BiPAP, so i got the aircurve 10 vauto today.

i want to try a min pressure of 9.6 to max 11 (IPAP) but keep EPAP at 4, that was my plan till i saw that PS should stay under 4. and that is my main question in this post, is there a way to achieve higher IPAP pressure while keeping EPAP pressure at less then aerophagia ? (4) i am asking this because i learned aerophagia happens from the EPAP pressure that is high is that correct ? the higher EPAP pressure the more aerophagia can result ?

i need to sleep a continuous sleep(like i used to 6 months ago before i get the apnea) the fragmented sleep keeps me like a zombie the whole day!
i also learned to sleep on my side(tennis ball) because i noticed my OA needs more pressure on my back while on my side it is less than 7(IPAP).

so based on all that talking and graphs, how can i increase pressure (somewhere between 9.6 to 13) while keeping aerophagia at bay? 

P.S: i also bought an oximeter to check if i have sPO2 drops and that is what wakes me up, but it my SPO2 was normal right before each awekening, ( always in REM).

thanks

[Gideon]

My approach to your issues is to formally titrate you to an effective level that manages your Obstructive Apneas with EPAP on an Air Curve and utilize Pressure support that will control your Flow Limits and Hypopneas.  All this while making sure that your pressures do not rise high enough to trigger your Central Apneas.

On a quick review of your previous charts I believe that this can occur at fairly low EPAP and Pressure Support.

I haven't stepped in because I thought you might be insistent on trying higher pressures.

The choices are to try a conservative slow approach or randomly try values that make no sense on solving the issues that you are trying to resolve.

BTW SR is as good as they get at doing this though he will never admit that.

Fred

[koy23]

Thanks BonJour, i'm not insisting on anything i'm just tryingg to get a good night sleep, i just mentioned my experience in the last month and a half.
I have all the respect for members who advice here, and i am waiting for SE response on my last post.

What i could understand of what you also said is to set EPAP to 4, and set PS to 4 and max IPAP 12 or 13. and watch for aerophagia and CAs, if any happen, i need to reduce IPAP, and maybe PS also to 3. correct ?

[Gideon]

Honestly I would set EPAP Min to 4
PS to 3 (Based on what I saw in your charts)
IPAP Max to 12 

Then adjust on night 2.  I suspect that IPAP max will be set lower than that.

Fred