[Treatment] Waking up on BiPap [adjustment assistance needed]

[rowanbustaman]

Hi,
 
I am very new to this forum. Would like some feedback on whether there is headway to my BiPAP therapy and ways to improve it. I have been using BiPAP for a month.
 
Sleep study report shows AHI 10-15 during non-rem and AHI 40-45 during rem sleep.
 
My machine setup is:
BiPAP: Philips Respironics DreamStation Auto BiPAP
Pressure settings: PAP Mode: Auto Bi-Level (Variable PS) 
                          Min EPAP 4.0
                          Max IPAP 15.0
                          PS 2.0-8.0 (cmH2O)
Additional Settings: Smart-Ramp on
                            Ramp-Time set at 0.20
                            Ramp-Start set at 4.0
                            Bi-Flex set at 2
                            
Before going to bed, the machine displays IPAP 6 and EPAP 4. 
 
I wake up after 4-5 hours due to the pressure change. IPAP was increased to 12 and EPAP is at 4. After which, there was difficulty getting back to sleep while trying to accommodate to the increased IPAP. I noticed after exhalation that I did not want to continue inhalation again and thus stop breathing for a few seconds. After getting out of breath, I'd inhale again. 
 
There were nights that I was puzzled about what was happening and could it be Central Apnea. So, I tried sitting up straight for about 30 minutes with the BiPAP. Oddly, I was still having the same inhale-exhale-stop, end up out of breath and begin breathing again situation. 
 
I showed the SD card data to my machine vendor, and asked if their machine settings were tunable to improve my AHI. They suggested there was Central Apnea and recommendation was to continue usage for the next 6 months and monitor if the situation improves.

Would any kind member please review my situation and offer their insights? Much help would be greatly appreciated.

Regards,
Rowan

[OpalRose]

Something doesn’t seem quite right with your settings, mabye epap is too low. I’m no expert on bipap settings...just bumping your thread so you can receive advice.

[Walla Walla]

Just my opinion but I'd set both the minimum and maximum Pressure Support to 2cm and try to reduce those CA events. I'd also increase your EPAP pressure to 6cm so you can breath easy. 4cm is too low for most people.

[Sleeprider]

You are experiencing a number of flow limitations and hypopnea, and this is what is driving your machine to increase pressure support. Unfortunately, when pressure support exceeds 5-cm you have too many CA events. I think we can probably help here without cutting pressure support quite as drastically as suggested by Walla.

OA is very low, so the EPAP minimum of 4.0 is acceptable, however there might be some benefit to increasing this to 4.5. You need pressure support to treat the hypopnea and flow limitations, so I think EPAP min needs to be 3.0 and EPAP max needs to be 5.0. If this continues to produce excessive CA we can cut the PS max down to 4.5, 4.0 in 0.5 cm increments. The IPAP max setting won't make any difference because your EPAP never moves off the minimum and if that continues to be the case, IPAP won't exceed 9.0 anyway.

What is your current BiFlex setting?

[rowanbustaman]

Hi all and thanks for your time and replies.

@Sleeprider:
My current BiFlex is turned on and set to level 2. This machine also does not give me EPAP max setting and EPAP min permissible lowest setting is 4.

The pressure settings I found to be adjustable are EPAP min, IPAP Max, PS min and PS max. There is also comfort settings which are Smart-Ramp, Ramp-Start and Bi-Flex.

Since EPAP max is not adjustable on my end, should I proceed by setting EPAP min to 4.5-5 and monitor again for excessive CA amount?

Thanks all,
Rowan

[Walla Walla]

Sleeprider meant to say Pressure Support minimum of 3cm and maximum pressure support of 5cm. Also setting the Minimum EPAP of 4.5-5cm.

[Sleeprider]

What he said ^^ Sorry I was unclear.

A slight increase in EPAP min to stabilize the airway, 4.5-5.0
Increase PS min to 3.0 for hypopnea and flow limits
Decrease PS max to 5.0 to avoid CA events
EPAP max to 9.0 mostly because you don't need any more than that, and probably won't even go above 6.0. Resultant max IPAP will be 14.0.

[rowanbustaman]

Hi all,

Thanks for the settings recommendation. 

I will update the settings on my machine, and also post the results after 1-2 nights of use.

You all have been of tremendous help.

Regards,
Rowan

[rowanbustaman]

Hi all,

I am now sleeping soundly throughout the night while using the BiPAP with the new settings.

EPAP min: 5.0
PS min to 3.0
PS max to 4.5-5.0

On the other hand, my AHI still over 5 on most days. And I know that AHI is still an important factor even though my sleep was uninterrupted. 

A new Event Flag (Vibratory Snore) also appeared in the SleepyHead report.

I am unsure of what to do next, would you all recommend what the best course of action should be?

Thanks in advance,
Rowan

[Sleeprider]

Rowan, things have improved. The events are still heavily biased toward central apnea, and that may mean we should further reduce PS max to 4.0.

I'd like to get a zoomed in view of the flow rate, and it doesn't need to be where events are occurring. We're looking for a 2-minute period where the flow wave is clearly visible. The reason to look at this is to understand why the machine is averaging your inspiration time as relatively long compared to expiration time. I presume that is an error by the machine, which is common, and to see if decreasing the rise time might help. Also, what is your BiFlex level set to?