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[Treatment] help with starting settings and titration for UARS - Printable Version

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help with starting settings and titration for UARS - GoldMaster - 06-08-2019

Hi! I have tried CPAP, APAP, and a dental appliance that I am still healing from minor TMJ. I have not experienced much improvement in treating UARS. My Ahi is 0 but my RDI is 12 and RERA's 10.  The block is coming from my Lingual Tonsils they are enlarged.

I now own a brand new Resmed Aircurve 10 VAUTO.  Can someone please give me a good start setting? I will post OSCAR screenshots for proper titration after a few nights of sleep.  

Thank you


RE: help with starting settings and titration for UARS - bonjour - 06-08-2019

Starting with a VAuto
AHI = 0 so No OSA so start with low pressure, but allow to go high. Pressure support, titration guides start at PS=4 so that is a good start.  It will be better for RERAs and Flow limitations than your previous machines. so

Mode: VPAPauto
min EPAP: 4
MaxIPAP: 20
PS: 4

This is intended for 1 night, then re-evaluate with daily charts.


RE: help with starting settings and titration for UARS - GoldMaster - 06-08-2019

Thanks.  What is Ti Max, Ti min, trigger, and cycle. Do I need to adjust these? Oh and on my first sleep study my Ahi was 5 and the new one it was 0. So let's say 2.5


RE: help with starting settings and titration for UARS - bonjour - 06-08-2019

(06-08-2019, 03:26 PM)GoldMaster Wrote: Thanks.  What is Ti Max, Ti min, trigger, and cycle. Do I need to adjust these?  Oh and on my first sleep study my Ahi was 5 and the new one it was 0. So let's say 2.5

Things that you don't normally need to worry about.  They tweak the breath timing.

Additional comfort features and synchrony settings can help to customize therapy to meet each patient’s unique needs. (Available in VAuto, S, iVAPs and ST. )* 

TiControl for patient-device synchrony 
TiControl allows you to manage your patient’s inspiratory time according to their disease state. For challenging respiratory conditions, TiControl allows you to manage the time a patient spends in the inspiratory phase of their breath cycle. 

Ti Max lets you set a maximum inspiratory time, to reduce the risk of intrinsic PEEP and missed patient effort. For example, Ti Max can be helpful for patients with obstructive disease, ensuring a limited time is spent in inspiration and allowing a longer time spent in the exhaling phase. Ti Min ensures adequate time for gas exchange without having to increase the pressure setting. 
Ti Min may be helpful for patients with restrictive lung disease. 
Rise Time sets the time taken for the device to reach IPAP. The greater the rise time value, the longer it takes for pressure to increase from EPAP to IPAP. Patients with a high ventilatory demand may prefer a shorter rise time, while patients who are slow breathers may prefer a longer rise time. Note: A prolonged rise time inhibits fast pressurization, therefore, rise time should not be set longer than Ti Min or the patient’s normal inspiratory time. 

Trigger & Cycle Sensitivity Settings for better patient comfort 
To achieve patient–ventilator synchronization, you can customize the beginning and end of each inspiration with ResMed’s adjustable Trigger & Cycle technology. Recognizing that each patient is different, ResMed provides five levels of Trigger & Cycle sensitivity to help you tailor and fine-tune triggering and cycling values to different patient conditions. 
• The Trigger sensitivity setting helps care providers customize the sensitivity level of the device to better recognize patients with decreased inspiratory efforts. 
• The Cycle sensitivity helps the care provider ensure appropriate breath termination for every patient, promoting patient-device synchrony.

https://www.resmed.com/us/dam/documents/products/titration/s9-vpap-tx/user-guide/1013904_Sleep_Lab_Titration_Guide_amer_eng.pdf
is where I pulled these from, there is more detail there (pg 42)


RE: help with starting settings and titration for UARS - GoldMaster - 06-10-2019

Chart I was only able to get 3 hours sleep. Please let me know what adjustments to make.  I normally get 6 hours with no machine.


RE: help with starting settings and titration for UARS - bonjour - 06-10-2019

The numbers look good, why didn't you retry after you woke up? Why do you think you only got 3 hours of sleep?


RE: help with starting settings and titration for UARS - GoldMaster - 06-10-2019

People with UARS are very sensitive I hear.  When I first used the machine I find it hard to breathe.

Maybe the range is too wide and caused me to wake up?  Can we tighten up the range?


RE: help with starting settings and titration for UARS - Sleeprider - 06-10-2019

Based on your posted results with pressure of EPAP min 4.0, PS 4.0 and Pmax 20, your pressures stay low and you have insignificant AHI. Your pressure only ranges up to a max IPAP of 10. According to the data, and charts you have very little flow limitation, which is the first thing we would look at with UARS.

I think we need to have a closer look at some of the data, especially where we don't see the pressure support being used. If you can zoom into the flow rate graphs at 02:49 to 02:41, that is an area of flow limitation and pressure changes. Your sleep looks disrupted after 03:00 and you may have been awake. If you have the time, I'd like to get another shot of a time when you think you were definitely asleep. You have the best possible machine for UARS and we can work with its capabilities to get you as comfortable as possible. One of the things I'm thinking about in increasing Ti Min to 0.80 to ensure you get more time at IPAP during those periods where the mask pressure and flow looks a bit ragged.


RE: help with starting settings and titration for UARS - alshayed - 06-10-2019

(06-10-2019, 10:54 AM)GoldMaster Wrote: People with UARS are very sensitive I hear.  When I first used the machine I find it hard to breathe.

Maybe the range is too wide and caused me to wake up?  Can we tighten up the range?

I'm not one of the experts here but am trying to tame my OSA/UARS and have comments based on what I'm going through.

First off I don't think you're at a point where limiting the max pressure is going to do a lot. I think you really just need another night or two to acclimate before making more changes. It does look like when the pressure started changing you might have had a position change, some snoring, and then a low level persistent leak. It could have been the leak that woke you up, I know I'm really sensitive to leaks and almost any will wake me to some level. Try tweaking your mask fit and see if you can prevent them.

At the overall level I don't think there's enough going on that anyone will advise changing your pressure support. If you look at some ~2 minute sections and evaluate your flow rate for flow limitations that don't register on the flow limit graph you might find some evidence to increase PS, but perhaps not. See http://www.apneaboard.com/wiki/index.php?title=Flow_Limitation/UARS_and_BiPAP for some guidance, and also http://www.apneaboard.com/wiki/index.php?title=Flow_Limitation and http://www.apneaboard.com/wiki/index.php?title=Beginner%27s_Guide_to_SleepyHead#Flow_Limitations.


RE: help with starting settings and titration for UARS - bonjour - 06-10-2019

Yes the ranges are wide but Your Pressures are stable, For all practical purposes you were at a fixed pressure of 4.1, so it wasn't pressure.  If you are that sensitive to pressure, don't fly, don't drive over mountains, and when a weather front is coming in drive to avoid it noting the above.  

Better
Provide several random 2 min segments and print those charts One around 1:30 your only significant event a flow limitation and the cause of a small pressure increase.  We will see if there is something in the wave form, but I see nothing here.