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cpap and apap not effictive
Here are 3 closeups from different points. When you say breathing waveform do you mean the flowrate chart, or the insp and exp rate charts?




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Charts are interesting, and perplexing. Once again, we see Respironics does not properly time the inspiration, expiration time, but counts the zero flow period at the end of exhale as the beginning of inhale. You're normal in that regard. The oscillations during the breathing pauses are unusual because I understand this machine uses a pressure pulse to determine CA from OA, not forced oscillation technique (FOT), but that looks a lot like the Resmed FOT. In spite of the oscillation, the events are not ended with recovery breathing, and are of short duration, and it looks like this goes on much of the night, even when events are not recorded. It might be worth ruling out other sources for this. The respiratory vibrations in the charts could be physical movement. So, are you aware of any issues with RLS? Also, you have high tidal volume with a low respiratory rate, and extended exhalation that has a long period of zero flow. Have you been tested using a spirometer to evaluate restriction and obstruction?

As far as your discussions with the doctor on bilevel, he is wrong that Flex is like bilevel...EPR is like bilevel. CFlex is pressure relief that is proportional to your exhalation flow. So when expiratory flow is low, the pressure relief is nearly non-existent. With flex, the IPAP pressure is restored before the end of exhalation. As you can see on the charts, you have a very brief exhale, that is extended by a period of near zero flow, so your airway is open during this time as flex pressure increases to IPAP, which I think aggravates your aerophagia. Bilevel is based on pressure support where the patient is titrated to find a minimum EPAP that resolves OA, then pressure support is used to resolve hypopnea, flow limitations and tidal volume. It's very different. Upon detecting exhale, the machine drops pressure to EPAP, and pressure stays low until spontaneous inhalation is detected, then pressure rises to IPAP. The difference should have obvious implications for those that have a problem with air ingestion.

I don't know that bilevel or a Resmed CPAP with EPR would resolve all your problems, but the key points are this:
1. Your pressure is high and a bilevel machine is indicated when pressures exceed 14 CM and the patient is not responding to CPAP.
2. You have aerophagia, and bilevel is known to provide better resolution of OSA while providing relief for aerophasia by providing real pressure reduction during exhale.
3. You have no indications of OSA in spite of the events being flagged by your machine. Without flow limitation and snores, these events are very questionable...(only PSG could really identify what's going on).
4. You and your doctor have tried many different solutions using your current machine without success. It might be time to try something different. Leaving you inadequately treated and fatigued and uncomfortable should not be an option; and the next logical step is bilevel.

Note bilevel is still a OSA solution,and is frequently prescribed for patients that do not tolerate, or are unsuccessful in spite of compliance with CPAP. I'll be honest, I don't have a better solution with your current machine, as you seem to have tried most of the alternatives with pressure and flex that are available with it. I think the diagnostics suggested above may be worth looking into, and a discussion of real bilevel, as in an auto bilevel. Assuming the exhale wierdness in your graphs is not related to a pulmonary disease (spirometry check), or movement (RLS), then real EPAP pressure relief may smooth that out.

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Thank you so much for your insight. I really appreciate it very much (as does my wife who wanted to thank you for giving me some hope that there still may be a solution).

Is there a particular bi level machine that you would recommend I ask for?

I do have RLS btw.

Thanks, Ed
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Oh - I suspect I know what the snore events are. I have sooooo much air that I burp like a wookie many times per night (and am constantly passing air too). The burps can last for several seconds and have a high volume of air.

I spoke with me DME and left a message for my doc to see if I can get the bilevel - the DME said they would most likely provide the Dreamstation Auto Bipap. Given they are slower to respond is there a different system that might be better? The aircurve v10 auto?

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I have both the Philips Respironics Auto BiPAP and Resmed Aircurve 10 Auto. I think the Resmed follows your breathing more and keeps the EPAP pressure low until you spontaneously initiate the next breath. I want to emphasize that there are no guarantees, but you do meet the insurance criteria for intolerance of CPAP and authorization for bilevel. The intention of my comment is to help you lay that out with your doctor, and hopefully find something that works better. I wish Robysue was more active on this forum as she has similar issues, and also went to bilevel. Another member, JVinNE had very bad aerophagia along with central apnea, and used a bilevel ASV which worked.

Bilevel seems to be an effective solution for many people in real life, and a search on the subject on this forum might help you get some perspective. https://www.google.com/search?q=aerophag...8&oe=utf-8
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Looking at the graphs again, the oscillations may well be related to RLS (thanks for confirming). Another possibility is that those are micro ingestion of air. It makes sense that your lower esophageal sphincter is failing to hold back pressure during the quiet zero-flow period, and this is the root cause of aerophagia. If so, this gives me more confidence that low EPAP pressure may be a significant help. People with this problem often do well with EPAP pressure as low as 6.0 cm, and IPAP pressures of 10. Time will tell. Hope you get the upgrade and we get to experiment a bit.
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While I am working out the new machine options, would an apap setting of 6-10 and cflex 3 basically simulate a bi level with 3cm less epap? I know it isn't exactly the same and a broader range will likely be better with bi-level. I do tend to do better with c flex rather than a flex or c flex plus.

I tried running 12.5-18 last night and didn't do very well, even after setting c flex to 3 in the middle of the night. I basically need to stay below 13-14 or I really get bad aerophagia.

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With the CPAP, you will probably trade some OA for comfort. Setting a Philips APAP to 6-10 with Flex at 3 won't simulate a bilevel at all, but it may relieve the aerophagia. What it does to your events is unknown to me. My guess is the machine will increase to 10 and stay there. Give it a try. It's easy to change back to your discomfort settings.
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A couple of thoughts. I think the oscillations between breaths are a reflection of heart rhythm. Next I would like to see a post of a "normal" clip of your respiration for comparison . It seems to me that your breaths in the posted close ups are somewhat flattened on the top as is characteristic of obstructive hypopnea. The waveforms are not typical and suggest to me a kind of hybrid of periodic breathing and obstructive hypopnea. I would like to see some more discussion. Please post additional snapshots of brief sections of your waveforms.

Apnea Board Member RobySue has posted a Beginners Guide to Sleepyhead Software here:  http://www.apneaboard.com/wiki/index.php...SleepyHead

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Here is a capture from early in the same night as the other screenshots.


I've used up my 512kb for attachments so this is a onedrive link. Takes a moment to open/display.
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