Please help with Bipap settings after heart surgery

[bluemom51]

Hi everyone - I have not posted in a few years.  In 2017, I was switched to a ResMed V10 Bipap with settings of 9-18 and a ps of 5.  I could not tolerate the 5, and settled on a ps of 2.  I did ok in 2018 - did not feel great, but the events were usually no more than 5-7 with occasional centrals.  In mid-2019, I had my aortic valve replaced through the TAVR procedure (highly recommend).  After that, everything seems very uncomfortable.  I struggle to fall asleep, and the charts look like a mess.  I am exhausted during the day, and usually take a nap.  Sleep feels like torture now, instead of restful. 

The sleep study done in 2017 was when I had a failing valve, and now that my heart is working properly, I would assume some adjustments need to be made.  I have tried to adjust the pressures up and down, and tried adjusting the trigger, etc, but nothing seems to improve. I would so appreciate any suggestions - the only thing that seems apparent to me is that the mask is leaking pretty bad.  I use a Nasal FX, but I do have other masks I could try.

I am in poor health - very overweight, on heavy steroids for autoimmune stuff, bad RLS & PLMD (nothing works for it), and a messed up hip that causes pain 24/7 (makes it difficult to find comfortable sleep position).  I just don't have the energy to go through another sleep study and deal with the sleep doctor again. I have been very depressed about everything for about a year and a half, and am forcing myself to address the sleep issues.  Hoping that it will help me with moving more, etc.

The members of this group seem to know (and care about) the details of the sleep experience, rather than "well you are near 5 - you are good" mentality.  She refuses to look at the Oscar charts or any of the data, and has never asked how I actually "feel" each day....Thank you for any suggestions - I will be happy to try them, and adjust as necessary.  I have some trouble with posting the charts, and tried to follow the instructions.  Please let me know what I need to change, and if you need a different view, and I will try to post them.


       

[staceyburke]

It looks like you have positional apnea. Have you started sleeping on your back or gotten new pillows or increased the number of pillows?

Positional apnea is when you cut off your own airway by the position you sleep. They call it chin tucking when the chin drops to your Sternum. If a simple charge of sleeping position or pillows do not help many have found real help with a collar. 

Please read the link at the bottom of the post to collars. It shows people without and the same people with using a collar. It is dramatic the change it brings.

[bluemom51]

Thank you - I start on my right side and seem to end up on my back.  I have extra weight in my neck and face from the steroids so it's possible for sure.  And yes, I do sleep more on my back now because I have less hip pain in that position.

[sheepless]

others will likely have more nuanced suggestions. my first thought is ps 2 isnt handling the flow limitations (they're not so high as persistent & they raise pressure, which may contribute to not tolerating it) so I'd start by incrementally raising ps. in addition to needing a soft cervical collar for the oa clusters, you may also need to increase min epap. for ca, raise trigger to high. one change a time for at least 2 nights each (unless a change really blows things up). pap wont help rls/plm, which will likely plague your sleep & mess with optimizing cpap settings until/unless you find some relief from it. I find my resmed apap, vauto & asv all raise pressure during plm episodes (causing leaks, aerophagia, arousals & awakenings) so I restrict my vauto max ipap to the sum of epap & ps. this results in more or less constant epap & ipap which is less disturbing.

[bluemom51]

Thank you - seems very logical. I can increase the trigger setting.  I have tried increasing the PS from 2 several times.  It always resulted in increased events.  Since I have always been a little confused by bipap settings, could you (or anyone) suggest a possible starting range for the settings.  Right now I have them about 9-18.  I don't know what to try.  And then I can try raising the PS slowly.  Thanks

[Sleepster]

a ps of 5.  I could not tolerate the 5, and settled on a ps of 2. 

What was it about the PS of 5 that you couldn't tolerate? Did it elevate your CA index?

The thing that jumps out about your charts is that you are leaking way too much. Have you ever tried a full face mask?

[staceyburke]

The way the VAUTO handles pressure support (ps) and the autoset handles exhale pressure support  (EPR).

The VAUTO example
Min = 9
Max =20
PS = 5

Your inhale pressure is 14 (min + PS)
Exhale is 9 your min number
Your max 20 it will not go that high - it goes up enough to try to eliminate the obstruction. 

Autoset example
Min 9
Max 20
EPR 3 (only can be set 1, 2 or 3

Your inhale is 9 (your min number)
Exhale 6 (the min - EPR)
Max 20 same as VAUTO

I hope that helps you understand how PS works on the VAUTO

[sheepless]

would someone post the vauto titration protocol here? I'm having trouble locating it.

good idea to start fresh. more than one way to do this. one is to follow the protocol that hopefully someone else can provide. another is to temporarily change to cpap mode with a single setting that you vary until you determine the setting that best titrates out your obstructive apnea. then, in vauto mode set your min epap to that value. from there you can experiment with ps &/or max ipap settings.

i cant speak to how your other health conditions may bear on your current therapy issues but they could be an important factor that you'd be wise to take up with your providers.

[SarcasticDave94]

Here's the titration protocol page for the ResMed S and VAuto.

[attachment=32324]

[sheepless]

thanks Dave. that's all I found too. it'll do but I thought there must be one for vauto mode. apparently not.

if it were me, I'd try the cpap mode route to limit variables to one, especially since you seem sensitive to ps. 4 cmw will likely be too low leaving you feel air starved but the idea is to start low and incrementally work your way up until obstructives are as low as possible. if ca increases, back the pressure off increment by increment to fine tune for least oa and least ca. this is pretty much how they do titration in the sleep lab except they make pressure changes within about 5 - 20 minutes of the last setting. you might adjust more than once a night if it's awful but at some point it's best to try a setting for a couple nights to see if/how you adapt. post some oscar charts along the way. once you find your 'optimum' pressure for oa, we can see about ps and max ipap.