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Flow Limitations, For Her, UARS, etc. - WakeTired - 02-28-2019
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Thanks in advance for everyone's assistance and insights. Great to have such a supportive community!
I'm a diagnosed UARS SDB sufferer with flow limitations. My Stanford trained doctor prescribed the Airsense for Her because of algorithmic rapid response to flow limitations, which isn't available on the bi-pap machines.
Most nights, I have zero events and the machine seems to respond immediately to flow limitations. I have yet to wake up or feel rested.
Background: over many years, I've unsuccessfully used bi-pap (as high as 21/17), cpap, apap, and oral appliances, as well as had some pretty nasty surgeries (which shouldn't be the focus of this post). When I increased pressures, I had aerophagia and centrals. I tend to sleep soundly for the first few hours each night, but then typically wake up after 5-6 hours and have a hard time falling back to sleep. Suffering from SDB for the past 20+ years has created a high activation level which is thought to make the flow limitations even more disruptive to my sleep.
I've posted data take over 2 days. Please let me know if additional details and/or data would be helpful.
I welcome your suggestions, questions, and wisdom.
RE: Flow Limitations, For Her, UARS, etc. - Sleeprider - 02-28-2019
First of all, welcome to the Apnea Board. Your AHI is fine, but you have chronic flow limitation. Your settings are currently at 8 to 15 pressure with EPR 3, and many UARS sufferers do achieve good results with these settings. The fact that you are already on EPR 3, means the pressure support capabilities of your machine are maxed out, and the next step is a true bilevel like the Aircurve 10 Vauto. I wish I had a better recommendation for you, but if you want to resolve the flow limitations and RERA, you will need the bilevel. Increasing pressure is not likely to yield the results and comfort you seek. What you need is low EPAP pressure and enough pressure support to mitigate flow limits.
We have worked with many individuals with UARS and many can resolve or significantly improve their results with the Airsense 10 Autoset and the For Her variant. It appears you need more pressure support than the 3-cm you are getting. In bilevel terms, your current pressure is EPAP min 5.0, PS 3.0 and maximum pressure 15.0 providing a range of 8/5 to 15/12. The PS 3 is a hard limit on any Airsense 10 CPAP, so further improvement on flow limitation would only be possible with a bilevel. Higher pressure will trigger increased adverse symptoms of aerophagia. This article in the Apnea Board Wiki describes using bilevel to treat UARS http://www.apneaboard.com/wiki/index.php?title=Upper_airway_resistance_syndrome_(UARS)
The Aircurve 10 Vauto is available from Supplier #2 for $799, and that is the lowest price I am aware of other than used machines through Craigslist. What does your doctor say about bilevel? He clearly setup your current machine at the maximum pressure support available, so he knows what he is doing.
RE: Flow Limitations, For Her, UARS, etc. - WakeTired - 03-01-2019
Sleeprider -
Thank you for your thoughtful and detailed reply.
In response to your question, my doctor's concern on the bi-pap is it will trigger aerophagia and the 'for her' response option isn't available on bi-pap, thus causing the bi-pap machine to go to a higher pressure than required to treat the flow limitation with resulting miserable aerophagia pain. (I added the word 'miserable' for effect
)My previous physician, Stanford's CG, was always concerned that using pressure support greater than 4 cmH20 would trigger centrals. Perhaps machines perform better now.
If I were to use the Aircurve 10 Vauto, is there any collective wisdom on where to start with machine settings? Would it be appropriate to do another titration study or could we simply take my prior history and look to a PS of say 6 (or another setting) using an EPAP min of 5 and IPAP max of 15 - effectively making the settings 15/9 to 11/5?
Again, I greatly appreciate the wealth of knowledge in this forum.
Thanks!
RE: Flow Limitations, For Her, UARS, etc. - Sleeprider - 03-01-2019
Let me address the concerns of aerophagia first. The use of pressure support is what stabilizes and augments inspiratory effort, and in the presence of an upper airway restriction, results in a normal breath. The flow limitation subsides, volume increases, and the time of inspiration may be shorter. Aerophagia is different for anyone affected, and the pressure that opens your lower esophageal sphincter (LES) is an individual matter. We have had members that could not tolerate even low pressure of 5-cm, and others that were able to tolerate fairly high pressures before the "gate" opened. We have also found that low EPAP pressure allows the LES to recover and remain closed compared to constant positive pressure. So using a low EPAP with enough pressure support to overcome upper airway resistance, often does not result in ingested air. Your EPAP pressure needs appear to be very low. EPAP is what prevents obstructive events, and at your current minimum EPAP pressure of 5.0 with the Airsense 10, you only had one OA event. We can postulate that you may tolerate EPAP pressures between 4.0 and 6.0 and have zero events. We would add pressure support to that low EPAP pressure range. We also know that your APAP increases IPAP pressure to nearly 11.0. What we are proposing is to try PS of 4.0 which would be 8.0/4.0 pressure, and with the Vauto, the maximum pressure would be 10.0/6.0 (IPP/?EPAP).
Just this small extra pressure support, along with controls for trigger and cycle sensitivity, and inspiration time control can probably resolve your inspiratory flow limitation, and limit the time IPAP is applied. You have zero central apnea events at 3-cm of pressure support, and I seriously doubt 4-cm is going to remarkably change that. Pressure support is a titration or trial and error process, so if you need addition pressure support above 4-cm, than you would monitor your results and choose to reduce the pressure, or discover it is just fine. A certain number of individuals do indeed develop central apnea in response to pressure support, but the sensitivity is a highly individual response. The fact you have no CA at your current settings, means you can likely tolerate considerably more pressure support than you are currently getting. The mechanism for CA at higher pressure support is the removal of CO2 from your system which can affect respiratory drive (hypocapnea). There is a solution for that called Enhanced Expiratory Rebreathing Space (EERS). I wrote this article your physician might be interested in http://www.apneaboard.com/wiki/index.php?title=Enhanced_Expiratory_Rebreathing_Space_(EERS) I doubt very much you will have a problem.
In summary, a Vauto bilevel machine can more effectively treat your UARS at lower pressures than you currently use, and can limit your exposure to higher IPAP pressure by setting the pressure properly and using the Ti Max (maximum time of inspiration) control. There is nothing to suggest you have a sensitivity to pressure support that would increase CA events.
RE: Flow Limitations, For Her, UARS, etc. - WakeTired - 03-01-2019
Sleeprider:
Wonderful insights! Thank you. Looks like the V10 and I have a future together!
Where can I find guidelines for setting controls for trigger and cycle sensitivity, as well as inspiration time control?
WakeTired
RE: Flow Limitations, For Her, UARS, etc. - Sleeprider - 03-01-2019
Start with the defaults for medium sensitivity for trigger and cycle and defaults for TiMin and Ti Max (0.3-1.8 seconds). We can make decisions after you have started on what is more comfortable or prevents aerophagia. I'm certain you are going to find the Vauto comfortable and effective.
RE: Flow Limitations, For Her, UARS, etc. - WakeTired - 03-02-2019
I just found my old Philips Bi-PAP auto M-series in my used CPAP appliance graveyard.
Would this machine be suitable to use in the interim as I work through the insurance challenges to obtain the V10?
I have a hunch the ResMed V10 has a more responsive algorithm, especially for flow limitation and breath by breath response.
In the past, I never realized beneficial results with the M-series. We ran really high pressures to overcome the FLs.
Just a thought.
RE: Flow Limitations, For Her, UARS, etc. - Sleeprider - 03-02-2019
The M-Series is a very good machine, but it is hard to get any data unless you are equipped with the smartcard reader. The same settings would apply and feel free to give it a try. You are not treating apnea, so "more response" is not necessarily a good thing. We are just hoping to apply more pressure support. The M-series will do that, however it has a PS min and PS max setting. I would set them equal at 4.0 for the time being since you won't be looking at the data. It's not a bad idea to go by how your feel rather than the data anyway.
RE: Flow Limitations, For Her, UARS, etc. - WakeTired - 03-02-2019
Thanks again Sleeprider.
Please forgive me for so many questions...
In auto-Bi-PAP on the M-Series, I can't find a PS Min setting. There's PS MAX, which I set to 4. I also set EPAP MIN to 4 and IPAP MAX to 10
When I start using the machine it appears to set PS MIN to 2 since the pressure is 6/4.
Since I can't figure out how to set PS Min to 4, one option is to use straight Bi-PAP at 8/4, 9/5/ or 10/6 and hope for the best.
Is there another setting option where I can set PS MIN that I missed?
Thanks in advance,
WakeTired
RE: Flow Limitations, For Her, UARS, etc. - Sleeprider - 03-02-2019
Don't worry about the range. I guess the variable pressure support began with the System One series. My error for the legacy machine.