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[Treatment] New to Forum: Need Advice on Auto Bipap
#1
New to Forum: Need Advice on Auto Bipap
Hi! I would like to seek some help as I have been on Dreamstation for more than a year now and getting quite frustrated with the specialist. AHI rarely drops below 5 and the lowest i ever got was around 4. 

It seems specialist just keep insisting that no pressure adjustment is required since machine is on auto but seeing so many experts on this forum giving great advice helping so many lower their AHI was wondering if anyone would be kind enough to have a look at my daily report. I'm hoping that this will help me feel better and less tired. Thank you in advance for your time.


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#2
RE: New to Forum: Need Advice on Auto Bipap
Cleene, welcome to the forum. The problem with your settings is the extrememly wide range of settings for pressure and pressure support.  In my experience, A Dreamstation simply cannot increase EPAP proactively with such a high range of pressure support (2-8). You are better off doing a proper manual bilevel titration, then use that information to select settings that allow the BiPAP to adjust within a narrow range, close to that optimized titration.  

With a minimum EPAP of 5.5, we see you still have obstructive apnea and hypopnea. This infers a need for higher minimum EPAP for OA, and higher minimum pressure support to deal with H events.  At this point my suggested starting settings are EPAP min 6.0, Max Pressure 16.0, PS Min 3.0, PS Max 4.0.  If you try these settings and then post your results, we can do further refinement.  The basic approach to fine-tuning titration is shown in the Resmed recommended titration protocol below.  Philips also has a protocol, which I'll display, but I have found the Resmed approach is more logical and works better.  Note, we use the BiPAP S protocol, but can leave you in Auto Mode for flexibility, however the observations and response to events is the same as S mode.  In both titration protocols, EPAP is increased for obstructive events, and this means EPAP min with a BiPAP Auto, and IPAP is increased for hypopnea, flow limitation or snores, and this means increase PS min. The key to this, is we will increase EPAP Min until OA is acceptable, and PS min for all other events except CA. I do not want you to use more than 1-cm range in the auto pressure support as this feature creates a lot of uncertainty over how to address events and I actually prefer fixed pressure support (PS min = PS max) for titration purposes.

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Sleeprider
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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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#3
RE: New to Forum: Need Advice on Auto Bipap
Hi Sleeprider! Thank you so much for the prompt response. I really appreciate all the information you provided it was very insightful and I'm sure a lot people on this forum will find it helpful. Saved!  Big Grin  

I actually found Philips protocol for Auto Bipap long time ago and I made the adjustments but got a really bad AHI around 10 something so I quickly reverted back to default settings. So right now I do not feel too confident about doing my own titration, I'm concerned that I might make it worse lol.

Enclosed is the new daily report using the settings you advised. Thank you again for taking the time to review my report.


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#4
RE: New to Forum: Need Advice on Auto Bipap
(03-06-2020, 10:10 AM)Sleeprider Wrote: Cleene, welcome to the forum. The problem with your settings is the extrememly wide range of settings for pressure and pressure support.  In my experience, A Dreamstation simply cannot increase EPAP proactively with such a high range of pressure support (2-8). You are better off doing a proper manual bilevel titration, then use that information to select settings that allow the BiPAP to adjust within a narrow range, close to that optimized titration.  

With a minimum EPAP of 5.5, we see you still have obstructive apnea and hypopnea. This infers a need for higher minimum EPAP for OA, and higher minimum pressure support to deal with H events.  At this point my suggested starting settings are EPAP min 6.0, Max Pressure 16.0, PS Min 3.0, PS Max 4.0.  If you try these settings and then post your results, we can do further refinement.  The basic approach to fine-tuning titration is shown in the Resmed recommended titration protocol below.  Philips also has a protocol, which I'll display, but I have found the Resmed approach is more logical and works better.  Note, we use the BiPAP S protocol, but can leave you in Auto Mode for flexibility, however the observations and response to events is the same as S mode.  In both titration protocols, EPAP is increased for obstructive events, and this means EPAP min with a BiPAP Auto, and IPAP is increased for hypopnea, flow limitation or snores, and this means increase PS min.  The key to this, is we will increase EPAP Min until OA is acceptable, and PS min for all other events except CA. I do not want you to use more than 1-cm range in the auto pressure support as this feature creates a lot of uncertainty over how to address events and I actually prefer fixed pressure support (PS min = PS max) for titration purposes.

Hi Sleeprider, hope you had a great weekend. To reduce OA and Hypopnea I tried to adjust the pressure myself by increasing the EPAP min and PS to 7 and 4-5 respectively. The Hypopnea went down and OA stayed the same, however the CA went up significantly, which I think might be the highest I ever had. 

Enclosed screenshot. Not sure whats going on and this is making me nervous going to revert back to EPAP 6 and 3-4 PS min and max.


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#5
RE: New to Forum: Need Advice on Auto Bipap
The CA events are now half of the total AHI, so I think the next step is to reduce the pressure support. We will start with PS min 3.0 and PS max 3.0. Everything else can remain the same. It might help to know what was in your original diagnostic sleep study. If you have a copy and can redact personal information, we can take a look and see if central apnea was detected ahead of starting therapy.
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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: New to Forum: Need Advice on Auto Bipap
(03-09-2020, 09:01 AM)Sleeprider Wrote: The CA events are now half of the total AHI, so I think the next step is to reduce the pressure support. We will start with PS min 3.0 and PS max 3.0.  Everything else can remain the same.  It might help to know what was in your original diagnostic sleep study. If you have a copy and can redact personal information, we can take a look and see if central apnea was detected ahead of starting therapy.

Enclosed sleep report. Thanks for the advice I will keep the EPA at 7 and PS min max at 3 and see how it goes. Looking to post the next report.  Thanks


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#7
RE: New to Forum: Need Advice on Auto Bipap
The study reassures us that any CA events in current therapy are treatment onset, so i think we're on the right path. The only other tool at our disposal is called "enhanced expiratory rebreathing space" (EERS), and it has show considerable promise in reducing therapy on set CA events as well as increasing tidal voluem and minute vent. We have a wiki on that subjet if you want to look at it.
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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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#8
RE: New to Forum: Need Advice on Auto Bipap
(03-09-2020, 10:24 AM)Sleeprider Wrote: The study reassures us that any CA events in current therapy are treatment onset, so i think we're on the right path.  The only other tool at our disposal is called "enhanced expiratory rebreathing space" (EERS), and it has show considerable promise in reducing therapy on set CA events as well as increasing tidal voluem and minute vent.  We have a wiki on that subjet if you want to look at it.

Hi Sleeprider! It seems my CA went down considerably after adjusting the PS min and max to 3. I just noticed from the report that my EPAP is at 8, I must have accidentally up'ed it without realizing. I was meaning to retain it at 7. Enclosed report from last 2 nights, do you think we should make further tweaks or is this good enough?

Also do you think at this CA rate I still need to try EERS?

Thanks.


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#9
RE: New to Forum: Need Advice on Auto Bipap
IMHO ride it out. I actually want you to have 'some' centrals, to drive your body into readjusting your apneic threshold on CO2 levels. We want it to be at a lower level of CO2 in your blood. This is the traditional 'therapy' for treatment-emergent central apneas, give it 2-3 months to adjust then look at it. Now don't wait 2-3 months to look at it, keep an eye on it. Your AHI should be ok here. Now if you feel this is really bothering your sleep that is different. Or if it is persistent over 3 months, that is a bit different.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
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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: New to Forum: Need Advice on Auto Bipap
There is no reason to try EERS since the reduction in pressure support resolved the problem. As Bonjour suggests, events will gradually diminish anyway. This looks like very good therapy solution for you, and I agree you can take some tme before deciding on further changes.
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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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