Help! Still No Relief on BiPAP – Any Advice?

[sonetti]

Hi everyone,

I recently transitioned from CPAP to BiPAP after I was not seeing much symptom relief on CPAP. It’s been about a month now, and while I’ve gotten flow limitations and leaks under control, I’m still not seeing much symptom relief. My symptoms fluctuate (usually a bad day, followed by a good day, and then another bad day).

Some background: Diagnosed with UARS / mild sleep apnea last year (AHI: 6, RDI: 16, Arousal Index: 37 via PSG). Male, Mid-30s, athletic build/slim. It’s had a big impact on my life, as I’m sure many here can relate.

My breathing is especially irregular during REM, and very positional — worst on my back, better on my side, and best when sleeping prone. 

Here's a link to my SleepHQ as well: https://sleephq.com/public/cbe949b2-3ca3...25d559a15c

Happy to upload OSCAR more data if that's easier. Does anyone have any thoughts on what I can do to stabilize my REM breathing?

Current setup:

• BiPAP + MAD
  
• Mouth tape + Breathe Right strips
  
• Positional therapy (prone seems to be best)
  
• Myofunctional therapy (not sure it's helping)
  
• Good general sleep hygiene (8–9 hrs, regular schedule, AM light)
  
  

Also previously had tonsillectomy, septoplasty, recent RFA turbinate reduction (minimal effect). Allergy tests, MLST to rule out narcolepsy etc, iron, ferritin, and vitamin panels — all clear.

In terms of next steps, I'm also looking into booking a DISE with Vik Veer and possible FME in the US, but I haven't done any CBCT scans yet so not sure if I'll benefit.

Thank you again. This community is a life-saver.

[jdougc]

Please hide the calendar so the device settings show.
Can you post the zoomed in chart as you were awakened those two times?

Any idea as what is happening during the bad nights, arousals?
Are you on any medication that might affect your sleep or breathing?

I found I was more rested with lower pressures.

If your obstructive events have been this well controlled, then lower your IPAP and EPAP down the same amount to maintain the same PS.

Is there a reason your PS is set at 5.0cm?
What is the "Trigger" set at?
Hope you get consistent rest soon.

[RTC75321]

Are we the same person ?

Following along…

[Dormeo]

As I understand it, irregular breathing during REM sleep isn't by itself unusual. At least one study has correlated the irregularities with the bursts of eye movement that occur during REM sleep.

What would be a problem is frequent *arousals* interrupting REM sleep. But to know whether that's a problem for you, you'd need to know when you're having REM sleep.

I do see periods when you have a fair number of arousals in your sleephq flow rate graph, and some other periods that look pretty calm. I looked for a pattern that might be related to REM but didn't myself spot one. Do you know how to identify arousal breathing? It's deeper and messier-looking than asleep breathing.

To pick up on a point made by jdougc, it could be very helpful for you to make notes every day so you can try to figure out what correlates with good days and bad days. Of course, if there are PAP data that fluctuate, you'd want to note those data, but you might also want to note such things as what you ate during the hours before bedtime, when you ate it, ditto for drink (especially caffeinated or alcoholic drinks), bedroom temperature, noise, light, sleep positions -- really anything you can think of that might be relevant. Since you *do* have good days, this kind of note-taking could be very useful for you.

Like jdougc, I wonder why you are using the particular pressure settings you have. You might keep PS at 4.4 and try lowering your range. You might also try keeping your pressure fixed, just to eliminate one possible source of arousals. For example, you might set min EPAP at 7, PS at 4.4, and max IPAP at 11.4. You might also consider turning ramp off.

One final thought: for prone sleeping, you might like the "Falcon" position, named after the guy who popularized it:

https://www. a DME-owned forum .com/wiki/index.php/Sleep_Positions

[sonetti]

@Dormeo and @jdougc

I've uploaded some more screenshots below with the calendar view hidden so you can see my settings and zoomed in on some areas before I was waking up. I've also included a screenshot of my Glasgow Index. Seems like my issue is more in Top Heavy which is why I thought more IPAP might be helpful, but agree a fixed pressure might be better. 

Data is from last night, I feel absolutely terrible today (brain fog etc). I'm honestly really desperate for help guys

According to O2 ring, it seems like I'm having hundreds of pulse changes each night → not sure how much to read into this given accuracy but has anybody else seen this before? / What is normal?

Re medication - doc thought I might have PLMS so put me on Gabapentin 600mg but that didn't really make a difference. I've also taken an SSRI for anxiety for long-term (low dose), I know this affects REM sleep but the fact I've been on it for 10 years and given symptoms only appeared only appeared last year makes me question how strong the link is. I also periodically take Benadryl and melatonin (3mg) as it helps me raise my arousal threshold somewhat.

[Deborah K.]

Folks could help you better if you set your charts up differently.  Press the fn key to copy your chart.  That will give us most of what we need to see.  Ensure that we can read to the very bottom of the flow limits.  

[jdougc]

Your movement tracks your flow limitations quite a bit.
In the zoomed in chart, your movement followed the missed flow limitation.
I think it is normal to move after an respiratory event, even if it is to short or small to be counted.

[Dormeo]

Heart rate variability during sleep is normal. More here:

https://www.ahajournals.org/doi/10.1161/....91.7.1918

Also, your O2 levels look good.

As you may know, gabapentin can have sleepiness and tiredness as a side-effect. You might discuss with your doctor the value of continuing it. If you discontinue it, get guidance from your doctor about tapering off.

The zoomed-in view shows arousal breathing.

Does the movement graph reflect all movement or just turning over?

Any thoughts about changing your settings? Keeping track of variables?

[sim62]

I think that Dormeo gave you a good advice. Just want to explain why, and how complex the issue can be. Below are my non-expert thoughts based on what I have read and my experience. 

Your graphs are similar to mine, but my AHI is usually in the range of 0.7-1.2. The characteristic feature is short-term respiratory arrests without or with mild airway obstruction (like that on your graph 06:00:25 - 06:00:35). Breathing pauses lasting up to 10 seconds (as on your graph after 06:01:55) are not registered by my device as incidents. My pauses are usually slightly longer than yours (this may be why my registered AHI is higher) but they still do not lead to a measurable desaturation. Sometimes my CPAP device reports short-time obstructive apnea incidents but they are always minority or may not happen overnight at all. As I said, short-time respiratory arrests have little effect on the measured spO2 index. However, it is possible that in people with increased sensitivity, even a small desaturation can lead to sleep disturbance. 

What causes respiratory arrest? I am inclined to think that in my case it is not an isolated problem of the nervous system, but rather a reflex phenomenon. The number of incidents decreases in the most comfortable position. This may be related to my spine problems (osteochondrosis), although in everyday life I do not feel any symptoms. Another issue is reflux. I read that it can manifest itself as vegetative dystonia, even if a person does not experience typical symptoms like epigastric burning. Next, if the bedroom is cool and my arm or leg is uncovered, I can wake up shivering, with the muscles of my entire body tense and shaking. In this state, reflexive breath holding is quite possible. I am trying to say that ANY discomfort [even if you would not feel or realize it when awake!] can trigger reflective breathing incidents when asleep. 

Breathing incidents are usually considered to be the cause of sleep disorder. However, it is possible that sleep and respiratory problems are just different consequences of general discomfort. If any part of your body is at discomfort, it will send the signals to CNS. The reaction of CNS will denend on its capability to treat these signals properly. As far as there is no threat to your health and life, your breathing center should ensure continuous breathing, and the respective centers of your brain should not receive signals that would make you awake. A dysfunction can break that balance. 

If you have the obstructive apnea, you need to do something to clear your airway. After that, besides assisted ventilation (BIPAP, ASV), an option is to ensure maximum comfort during sleep. This may be not easy: a wedge pillow reduces reflux and allows for less nasal congestion (UARS) but makes the position less comfortable for spine. The properties of the mattress and pillow (softness/hardness, elasticity/viscosity, pillow height and form) are very important to me. If your intestines or bladder are distended or irritated by food you ate before going to bed, you may have sleep problems too. Thus you need to keep food hygiene. When I was younger (I am 63) I did not have to think about such things, now I have to. Thinking about something does not always mean doing it properly.  Your situation may be different, I just wanted to point on things that are frequently overlooked in discussions and literature (AFAIK).