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[Treatment] Treating UARS with CPAP and bilevel
RE: Treating UARS with CPAP and bilevel
The standard recommendation here, which I only repeat, is based on the Resmed titration guidelines (and used during my titration study, actually): when titrating bilevel, start at a PS of 4. I made just that recommendation in the past couple of days.
 
And in that titration approach, you raise PS beyond that if you need to (for example, have hypopneas or FL that seems to disrupt sleep), and doing so doesn't cause significantly increased CAs.

I don't believe I've ever advocated anything else, the one exception being I questioned your chastising of sherwoga for bumping his PS by more than is typical, which is not the same as recommending it myself.
Caveats: I'm just a patient, with no medical training. And my first experience with xPAP was fairly recent. So I'm somewhere along the path of a steep learning curve.
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RE: Treating UARS with CPAP and bilevel
I agree that pressure or pressure support helps with some flow limitations but not others, depending on the source.

a couple things about fow limitation. one is that the machines (at least resmed) as I understand it, flag flow limitations in comparison to some x minutes prior, which means if one is chronically flow limited, the machines might never see it. instead we have to scroll through the flow rate looking for flat/slanted, jagged peaks on inhale. chances are there will be more fl than flagged.

second, I think it's worth distinguishing between passive and non-passive flow limitations. this is speculation on my part based on observing apap, asv and vauto responses to flow limitations between my periodic limb movements and is consistent with what tarah and Geer1 are saying. according to this theory a passive flow limitation occurs as a result of slack muscles induced by sleep. these are manageable by some form of pap. non-passive flow limitations are are structural (deviated septum, small airway) or forced to some degree by ourselves (chin tucking, sharp inhale, grunt after a periodic limb movement, talking/coughing in sleep). I frequently moan/grunt after a periodic limb movement. in my experience with plm at least, the machines' response with higher pressure/pressure support is totally ineffective in overcoming these non-passive flow limitations, regardless of the pressure settings and the 3 machine modalities that I've tried.
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RE: Treating UARS with CPAP and bilevel
I'm not sure if people are chasing flow limitations, or chasing feeling well.  I think it's worth a shot to increase PS and see if it helps with feeling and sleeping better.
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RE: Treating UARS with CPAP and bilevel
Hi!
Did you notice that the peak of your mask pressure shifted to align with the peak of your flowrate on a breathe by breathe basis when you increased trigger sensitivity to very high?
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RE: Treating UARS with CPAP and bilevel
No. Shifted in which direction? To the left?
Caveats: I'm just a patient, with no medical training. And my first experience with xPAP was fairly recent. So I'm somewhere along the path of a steep learning curve.
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RE: Treating UARS with CPAP and bilevel
Shifted such that the peak of the inspiratory pressure is at the peak of the flowrate during inspiration. I think that's the point of the trigger changes, right? To change when during the inspiration the maximum support is delivered?
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RE: Treating UARS with CPAP and bilevel
That's my understanding; yes.
Caveats: I'm just a patient, with no medical training. And my first experience with xPAP was fairly recent. So I'm somewhere along the path of a steep learning curve.
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RE: Treating UARS with CPAP and bilevel
(02-19-2020, 12:52 PM)Geer1 Wrote: My grandfather's median flow limitations are as bad as slowriter's peak flow limitations yet he sleeps ok. His flow limitations are so bad that I believe they limit his ventilation but they don't cause significant arousals and he sleeps like a log even considering what most of us on here would consider bad cpap results. Is there room for improvement, certainly but I will never chase 0 with him because it isn't necessary.

As someone who is trying to figure out if FL are the cause of my unrestorative sleep, what you say there is a great example as to how frustrating this can be. I think that many people out there who feel refreshed in the morning might not actually get technically great sleep, meaning, they have multiple arousals, which is normal, even a wake up for two, which is also normal, but for some reason they are able to sleep like a log and get enough deep rest/sleep so that that other stuff doesn't affect them badly. Which makes me think that it's a matter of "sensitivity," for myself and many others, who might sleep similarly to those people "on paper", but are missing whatever it is that knocks those people out enough for it not to matter. 

Of course, there are people who sleep well, and feel great, too. I'm extremely envious of them, believe me. I just agree with the idea that moderate FL themselves may not necessarily be the problem, but rather one's level of sensitivity to them. In which case, regarding the sensitive sleeper, even getting FL down may not give them restful sleep, because of the disruptive nature of PAP therapy itself. Kind of a no win situation for such people. I think I may be one of them. :/

Anyway, just brainstorming, not trying to say anything definitive. 

Personally, I am going to try to get my FL down with my Autoset at EPR 2, because EPR 3 is uncomfortable. If I can't get them down with EPR 2, I'm kind of screwed, because if I can't comfortably do EPR 3, there's no way I could move up to 4 or higher with a bilevel. It's frustrating. But this isn't my thread, I just wanted to jump in and (hopefully) add a little to the discussion.
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RE: Treating UARS with CPAP and bilevel
(02-25-2020, 04:28 PM)jomama Wrote: ... Which makes me think that it's a matter of "sensitivity," for myself and many others, who might sleep similarly to those people "on paper", but are missing whatever it is that knocks those people out enough for it not to matter. 

Exactly.

There's how you breath, and how your autonomic processes breathing restriction (FL).

By definition, someone with UARS has hair trigger sensitivity. The typical OSA person, I would venture, does not.
Caveats: I'm just a patient, with no medical training. And my first experience with xPAP was fairly recent. So I'm somewhere along the path of a steep learning curve.
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RE: Treating UARS with CPAP and bilevel
(02-25-2020, 05:11 PM)slowriter Wrote:
(02-25-2020, 04:28 PM)jomama Wrote: ... Which makes me think that it's a matter of "sensitivity," for myself and many others, who might sleep similarly to those people "on paper", but are missing whatever it is that knocks those people out enough for it not to matter. 

Exactly.

There's how you breath, and how your autonomic processes breathing restriction (FL).

By definition, someone with UARS has hair trigger sensitivity. The typical OSA person, I would venture, does not.

BTW, the first link I posted here goes into the science on this. 

Key point to recognize is for some people, even RERAs aren't enough to diagnose and treat their SBD issues. You can have fragmented sleep even without arousals.
Caveats: I'm just a patient, with no medical training. And my first experience with xPAP was fairly recent. So I'm somewhere along the path of a steep learning curve.
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