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Started BiPaP treatment, makes things worse. Struggling with the settings. - Printable Version

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Started BiPaP treatment, makes things worse. Struggling with the settings. - ldinks - 02-03-2021

Hi everyone.

I'll keep this as short as I can.
  • Use the "Dreamstation bipap autosv dsx900h11" for UARS, with a heated humidifier.
  • No "Good Days" on it, two days with the most flow limitations also came with immense brain fog and worse symptoms.
  • Headache/nausea today, teeth/nose hurt, mask too tight though as it's been too loose until 2 nights ago and I've overcompensated. Not worried.
  • Often have a blocked nose on a night or when waking up. Cleaning, diets, fasting, etc doesn't fix the issue.
  • I have a full-face mask. It's the F30i medium with medium nasal pillows.
I originally had 0 EPAP Min, 0 Pressure Support Min, no humidifier on.

I currently have 6 EPAP Min, 4 Pressure Support Min, humidifier set to 1. 

I've attached two images, one for OSCAR data last night, and one for a small overview of every night so far I've manually written up.

Settings so far:

Optistart Off
Max Pressure 30
EPAP Max 10
EPAP Min 6
PS Max 10
PS Min 4
Bpm auto

Tube Type 15 H
Tube Lock off
Mask type off
Mask lock off
Check Mask Fit off

Humidification A
Humidifier 1
Smart Ramp - On
Smart Time - 0.3
Ramp Start 4.0
Flex - Biflex
Flex - 3

What should I be changing my settings to?

Thanks!


RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - Sleeprider - 02-03-2021

I'd like to see some charts of areas you think are a problem for UARS with the respiratory flow rate, Mask pressure, tidal volume, minute vent and respiration rate. I think that is the Advanced View in Oscar under the view menu.


RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - ldinks - 02-03-2021

I've attached the data you've asked for, I think. I did an overview, and then 1 at FL and 1 at H events.


RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - Sleeprider - 02-03-2021

Your charts show severe flow limitation for the period, with pressure support ranging from 6 to nearly 10 cm. Breaths are marked as triggered rather than spontaneous, and have a strongly "RERA-like" appearance, particularly at 05:55. This does look obstructive but inspiratory flow is very limited in spite of what should be plenty of pressure support. Before using the ASV, did you have positional clusters of apnea?


RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - ldinks - 02-03-2021

I apologise, but I don't really know what you mean.

What's the significance of events being triggered rather than spontaneous?

What can I do about inspiratory flow being limited even with pressure support? What does this mean for my treatment?

My country doesn't support UARS and I wasn't allowed a sleep study. I had a at-home WatchPAT sleep study that showed low ADI but high RDI numbers. So there is no "before using the ASV" information that I can give you unfortunately.

If it helps, my positional RDI/AHI stats from my watchpat are:

Supine: RDI (8.2), AHI (1.7), ODI (1.4)
Left: RDI (13.2), AHI(0), ODI (2.2)
Prone/Right: N/A or 0.


RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - Sleeprider - 02-03-2021

Most people without central apnea, spontaneously breathe at a rate of 12 to 18 breaths per minute. There is naturally some variation. The respiration rate here looks to be about 10 BPM, which is below your median 12 bpm. The BiPAP SV on auto breath rate has detected that this is below your normal respiration rate, and is automatically switching to IPAP, which is a triggered breath. The machine is simply trying to maintain your respiration rate and volume during a period where your breathing has become shallow and slow. We can see the EPAP pressure is rising near the end of these charts at 05:56 and we can see the EPAP pressure continues to rise to near 10 cm, until 06:25 when it rapidly starts to fall back to the 6.0 minimum by 06:35. The curious thing is, your machine is acting like the maximum pressure is 16.0, so as EPAP rises, the pressure support is dropping back to 6.0.

The appearance of the is severe flow limitation resembles the flow limitation I have seen in other members with positional apnea clusters (chin-tucking). http://www.apneaboard.com/wiki/index.php/Optimizing_therapy#Positional_Apnea It is clearly a problem when it is a problem, but then by 06:40 your pressures are back to the minimum and you seem to be breathing normally. We see clusters like this through the night at 02:15, 03:30-04:15 and 05:56-06:30. I think you should try using a soft cervical collar and see if the problem resolves. It's not definite that this is the problem, but it sure looks possible. The other mystery is why your machine is not reaching the maximum pressures allowed by settings. I tend to attribute it to being a Philips, but it is not as responsive as I'm accustomed to seeing in the Resmed ASV. Yours is not the only one. I see this repeatedly in Philips BiPAP Auto SV machines. Notice, I don't define positional apnrea as sleeping supine. It can happen in any position, and I have seen a lot of it in people that sleep on their side in a fetal position when they tuck the chin downward.


RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - ldinks - 02-03-2021

Thanks a lot for clarifying everything, Sleeprider.

If I understand correctly - are you saying that I normally breathe too slowly, so the machine is bringing me to the more typical breathing speed? Or is that only when I'm chin-tucking (or whatever the cause is)?

Chin-tucking makes sense. When I look forwards and breathe naturally and relaxed, I do find it a little harder to breathe, and if I look down I can't breathe at all (unless I stop being fully relaxed / breathing with natural level of effort).

If a collar fixes some of the flow limitations, what's the next step? Or shall I wait and deal with that when I get there?

I'll try sleeping without a pillow in the meantime too, see if that prevents tucking as much.


RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - Sleeprider - 02-03-2021

I think the machine is supplying breaths when you fall to about 10 BPM, and that may be related to chin tucking, or it may be due to central apnea induced by the high pressure support. I'd like to try some different things, and don't know what you've tried before. First, I think you should understand and screen for chin-tucking as described in the positional apnea article I linked. Let's get a zoomed look at your normal breathing like around 01:30 or 16:30. This just doesn't look like the treatment of UARS to me. Have you felt any better since starting to use ASV?

In theory, you don't need a backup rate. Turn the backup rate BPM to OFF and let's see. I'd like to see PS min 4.0, PS max 5.0 if you can get that.


RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - ldinks - 02-03-2021

I got the machine a week ago. I had it on default settings, posted at "settings so far" in the original post, other than EPAP min being 4 and PS minimum being 0, not using the humidifier, and the mask being loose.

4 days ago I set the humidifier on and to 1. 2 days ago I changed EPAP to 6 and made the mask tight. Last night I changed PS min to 4.

That's my entire story! I'll try PS Max 5.0 and BPM off tonight, thank you.

When you say it doesn't look like the treatment of UARS, do you mean that I'm not treating it properly, I don't seem to have UARS, or there's something else going on?

The first night with my machine (on only 4 hours sleep), one night in the middle, and this morning, I woke up easily and was energised/motivated more than usual through the day, somewhat. Nights with more flow limitations (typically) have led to horrible days and the rest were just normal, maybe a bit less motivated and more distracted and sleepy but not "horrible" (brainfog, headaches, etc).

I've attached some data from both times for you, they're slightly different.

Thanks for the patience and for helping me work this out. I'm quite lost as you can probably tell!


RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - Sleeprider - 02-03-2021

The normal breathing periods we picked out look really good. I have no idea why the machine is pacing your breathing, but I think in your case, we should either turn off the BPM or set it to about 9, which is 3 below your normal median. Both of the above graphs have normal inspiration wave shape, and I'm just becoming more convinced that you occasionally have higher levels of obstruction due to chin-tucking where your airway becomes more obstructed due to head/neck position.