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Bipap Titration advice needed. - Printable Version

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Bipap Titration advice needed. - amafra - 03-15-2022

Hey buddies, I would like to ask for Bipap start titration settings.

I have been trying to adapt to cpap/bipap for a month with no good results. Maximum consecutive minutes I think as 2h, 12m.
In my sleep study, I was recommended a minimum 13 for CPAP. During the test I woke up and I could not sleep afterwards so they ended up stopping titration at 13 when apneas were reduced but not eliminated. 

I would like suggestions for S and Vauto mode.
Here are my previous experiences, some show good improvement of AHI, the problem used to be high pressure makes me take the mask,  wake after trying it many times during the night even using zolpidem (Ambien 10-15mg) most nights.

Did my best to translate test to english.
Thanks you.

First Sleep test, No CPAP during the test.
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Second, CPAP, used for titration, finished early because I woke up.
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March 6, ASVauto
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March 7, ASV auto
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March 14, Autoset (4-14)[Image: wrcOjXi.png]
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RE: Bipap Titration advice needed. - Sleeprider - 03-16-2022

Starting with the March 14 APAP mode, your pressure was 4-14 with EPR 3 and a ramp time of Auto starting at 4.0. My suggestion is to repeat this test in Autoset mode with minimum pressure 8.0, maximum pressure 14.0 and EPR 3. This will give you a bilevel pressure range starting at 8/5 and maximum 14/11.0. If you tolerate no ramp, then turn off ramp, otherwise use auto ramp at the highest tolerated start pressure. The first chart in APAP is the only one we need showing events, flow rate, pressure, leaks, flow limits. If we need more we will let you know. Your snores, flow limits and obstructive apnea all occurred in clusters, while most of the night had good results. Read the Positional Apnea article for some ideas on how this happens. http://www.apneaboard.com/wiki/index.php/Optimizing_therapy#Positional_Apnea

If we move to Vauto mode, we will use the data from APAP to determine how to set EPAP min, Max pressure and PS settings. You do not appear to need ST mode or ASV. In ASVauto mode, we will try EPAP min 6.0, Max pressure 14.0 and PS 4.0. Again, no ramp.

RE: Bipap Titration advice needed. - amafra - 03-16-2022

Thank you for your advice.

I don't understand why the autoset on day 14 created that pattern jumping to higher pressure at start and moving to lower pressure, then starting it back again. 
Does OSCAR offer any clue why I'm getting the mask off in basically all modes I tried. I can't pass  2 hours. Yesterday I tried Vauto settings MAX Ipap 12, Min Epap 4, PS 5, allowing 4-9 up to 7-12. ignore settings info on OSCAR screenshot, at 6am I changed to S more so it recorded last settings at 6AM on SD card  overwriting previews Vauto settings. After 51 minutes on Vauto, I took the mask off. Figured out in the morning. 

I checked the recommended article, it sheds some light,  it brought up something I remember from a youtube  video that the doctor says bipap is recommended to people that have posture issues, since the chin can be pushed forward and spine posture impacts airflow. I do have Scheuermann’s Kyphosis so posture is something that I need to be aware of and correct all the time.

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RE: Bipap Titration advice needed. - Sleeprider - 03-16-2022

I think your problem is that you are trying to use pressure too low and too much pressure support. I suggested starting at EPAP min 6.0 and PS 4. to start with a maximum pressure to 14, which I'm certain you won't reach. PS 4 will be less likely to result in CA events and the higher EPAP should increase comfort and reduce any obstruction.

RE: Bipap Titration advice needed. - amafra - 03-16-2022

I was trying to use lower possible pressure that allows me to maintain airways open. I will used exact pressure recommended tonight and post the results tomorrow.
Thank you.

RE: Bipap Titration advice needed. - amafra - 03-17-2022

Hey buddies, 
Updating last night results, same mask all night, resmed quattro. I do have F20 airfit (g), airtouch(m) and that mask leaks way more.
Every time I woke up I went to the computer to see data on OSCAR, if apneas or centrals showed up I tried a different mode.OSCAR, if apneas or centrals showed up I tried a different mode. My cpap always likes to hit max ipap allowed, no matter the mode, no matter if it is on stock firmware or custom. 

VAuto (23:20 - 00:45 AM) - EPAP 4-12, PS 4
[Image: W0Wh5yG.png]

Bipap - S mode ( 02:00 - 03:55 AM) - EPAP 8, IPAP 12, PS 4  Central Apneas, according to the polysomnography test I don't have CA.
[Image: TqIK0T0.png]

Due to the fact of OSCAR report central apnea, I decided to run ASVauto as well.
ASVAuto (04:35 - 06:05AM) - Min EPAP 6, Max EAP 12, PSmin 2, PSmax 7 (if SD card is not erased OSCAR gets confused on the settings and does not save it correctly with same night different settings.)
[Image: VPKgpv3.png]

RE: Bipap Titration advice needed. - Crimson Nape - 03-17-2022

#1: Quit screwing with the settings during the night!  You are doing nothing more than chasing numbers and not getting a handle on your therapy. Develop a game plan, set the CPAP, and give it time for you to acclimate to the settings.  You were advised to set the minimum pressure to 6, the maximum pressure to 14, a PS of 4, and make sure the ramp is off.   Use these settings for at least a week.

#2: The S mode does not report Flow Limits.  In order to get this parameter to report, set the CPAP to Auto and use a sudo-S mode setting.  Set the Max pressure to match the equation, IPAP+PS=Max Pressure.  That way, the pressure can't go anywhere.  I don't recommend using this currently, because we don't know what actual pressure to use.  Stick with the pressures listed in #1 to see the direction you need to go.

#3: You have too many large leaks.  You need to find a mask that will work for you.  Look into the F&P masks.  They have a very well-designed seal.  Also, read the [Link] - Wiki Mask Primer Article.

- Red

RE: Bipap Titration advice needed. - Sleeprider - 03-17-2022

You have extended periods of very good, smooth therapy, with clusters of high events and uneven respiration. The VPAP auto test had high leaks. I don't think it is a good idea to interrupt your night to change modes and would rather see you stick with a single therapy option for at least a full night. My impression is you have either positional apnea (chin-tucking) or some other disruption to your sleep that causes the periods of high AHI and variable breathing. Look to the periods of good therapy for the answer to what works well. Even on ASV it was minimal pressure support and EPAP moving down from 10 to 8 cm. BiPAP S demonstrates 12/8 pressure is effective if you deal with the clusters of apnea that look positional. Similarly, the VPAP Auto test shows 12/8 is your sweet-spot. My suggestion is to try Vauto mode with EPAP min 8.0, Max pressure 12.0, PS 4. This will result in fixed pressure but with Easybreathe, and will let us evaluate this pressure without variable pressure. I'm pretty certain your pillow is a problem or you may need to stabilize your airway with a soft cervical collar.

RE: Bipap Titration advice needed. - amafra - 03-17-2022

Thank you buddies. 
I will keep the first recommended settings for a week. I don't understand why I have so much leak, I may need to look for a pillow mask. I'm using it very tight, if it's set loose or median, leeks happen below the mouth when I move my chin towards the chest even when awake.

You are correct I was trying to chase lower numbers believing that it will give me a better night's sleep. My cpap sleep study technician said I should use a minimum 13,  I woke up  when titration gets to 13 and could not sleep anymore. Yesterday the doctor asked for bipap titration. 
It is my 3rd polysomnography this year, first doctor asked just to detect apnea, second to titrate cpap and now titrate bipap.

I will set the Vauto to Epap 8, Max Ipap 12, PS 4 and post the results.
Appreciate Crimson Nape and Sleeprider inputs.

Not sure if the graph helps. It is in Portuguese but some words are similar.

Micro Desp = Micro Awakening
Apn. Cen = Central Apnea
Apn. Obs = Obstructive Apnea
Apn. Mis = Mixed Apnea
Hipopnea = Hypopnea
Supino = Supine
Direita = Right
Freq. Card = Heart Rate

[Image: YTRDsVF.jpg]

RE: Bipap Titration advice needed. - Sleeprider - 03-17-2022

Notice that your PSG also suggests clustering of obstructive apnea. This is looking like a pattern to me. http://www.apneaboard.com/wiki/index.php/Soft_Cervical_Collar

You are actually pretty close to my settings in Vauto of EPAP min 9.0, IPAP max 18 and PS 4. The pattern of your apnea is completely consistent with what we call positional apnea or chin-tucking. The frequency of OA is reduced at higher pressure, but nothing will open up an airway closed due to obstruction from bending, twisting etc. It is like you move to a certain position and choke yourself. If there was a way to record your sleep with a night vision camera, you would probably see the physical position or bend in your neck that triggers this.