BiPap Newbie - struggling

[McMartin]

Hello, I am new to trying a PAP device.  My first few nights have not gone well.

Ordinary (without a PAP device), I fall asleep fast, and I usually do hit an early incident of apnea right away, but usually manage to fall asleep anyway through it or right after that. Then, I usually sleep for a long time after that, albeit with frequent (according to a sleep study both central & obstructive) apnea events through the night (these usually do not wake me to consciousness).
 
On the new CPAP (technically a BiPAP), that immediate initial apnea event causes the device to trigger more air, which wakes me.  It also makes the apnea incident worse, and I end up fully stopping breathing or snorting or whatever.  So, I close my eyes and try again.  At which point, I go into a repeat cycle of this pattern, maybe a dozen laps in a short period.  So, after an hour, I have done maybe a dozen laps of drifting off, stopping breathing, and then having the device wake me up.  At which point, I am exhausted and miserable.  Last night I had to stop after an hour or so of this.  My heart was racing and my chest was starting to feel weird.  I felt like I was being given a cardiac stress test.
 
Based on my limited understanding of the device, here’s my layperson’s guess at what might be happening: as I am nearing sleep, my breathing gets very shallow (or stops entirely) for a moment, the device at that moment is doing one of two things: either making it hard to exhale or making it hard to inhale, which makes the apnea moment worse (if not causes it), I start to suffocate and wake up.  Next, the device switches modes, and blasts me in the face with air, which ensure I stay awake.  Repeat and repeat.
 

Device: ResMed AirCurve 10 ASV (aka Bi-Level, BiPaP)
 
Settings:

• Mode: ASV
  
• EPAP: 5.0
  
• Min PS: 5.0
  
• Max PS: 10.0
  
• Ramp: off
  
• Humidity: 4
  

I will reach out to the support and doctor, but that will take a while.  Looking for other insight sooner. Thanks.

[Jay51]

Welcome to ApneaBoard.  I feel your pain.  The same scenario you are describing happened to me around 75 times with the ST(A).  I failed compliance on it and got moved to a ventilator (by failing a capnography test).  It took me a very long time to fall asleep and stay asleep.  During my PSG, RT said I stopped breathing just before I fell asleep.  

Fast forward to today:  I can fall asleep and stay asleep just fine.  A trick my RT came up with was to lower the pressure as low as it could be set (so I could at least tolerate it and fall asleep and get some success).  Then slowly raise pressure until it was therapeutic.  Can your epap go down to 4?  Can you lower the min PS and max PS as low as it can go?  It may help in your situation.  

There have been a few times also, when the exact thing happens that you are describing happens to me.  I just fall asleep.  A rare few times I can hear the air being pumped into my stomach just as I am nodding off.  

I have an S9 adapt ASV also.  It took awhile to fall asleep with it also.  I have used it for naps.  Epap was from 7 to 10 and PS was 3 min and 10 max I think.  I had to learn to let the machine win.  A ventilator always wins.  At first, it felt like it was attacking me, but it was really keeping me breathing (doing the breathing that I was missing for me). 

It takes patience, practice, and time, but I am very grateful for getting past this particular learning curve.  In the past, my sympathetic nervous system would kick in every time and wake me up.  Somehow, now, my parasympathetic nervous system is in control and I simply fall asleep and stay asleep.  Takes practice I have found to make this switch.  It took an attitude change also.  I hated the ST (A) because I thought it was trying to torture me. Seriously.  But finally, I learned how this all worked and the miracle happened.

[Rich66]

Finding what works for you take a lot of manipulation to get it dialed in. Most people find setting the mode to ASVauto to be helpful. And doctors and DME's seem to like setting these things to maximum pressures. They hope the machine will solve everything. If, as you say, you're getting blasted with air, adjust the pressures down, and then try to find what works for you.
If you don't know how to set them, reply back. I use ASVauto and the graphs I use are:
Event Flags
Flow Rate
Pressure
Leaks
Mask Pressure

Also, you'll see a vertical green line that moves around a lot. I find that helpful to determine exact pressures at an exact point on the graphs.
And in case you're not aware, you can directly set EPAP pressures, and you can directly set PS Pressures. The IPAP pressures are a result of adding EPAP to PS pressures. Can give more on that if you need it.

I would start with: ASVauto
: EPAP Min 4.0
: EPAP max 8.0
: PS Min 2.0
: PS Max 10.0

[Sleeprider]

Are you treating mainly obstructive apnea or central? The ASV is designed to manage both types, and your settings probably need to take that into consideration. It would have helped a lot to see a chart. From your description, you are experiencing a cluster of apnea immediately after falling asleep. This is not unusual, but it also sounds obstructive as your ASV should have picked up any central events. The ASV will flag all apnea as UA (unknown apnea), but normally we assume those to be obstructinve, and in your case, the cluster is probably due to positional apnea. https://www.apneaboard.com/wiki/index.ph...onal_Apnea If this is the case, it might resolve with lower or less-firm pillows and changes to your sleep position to prevent chin-tucking.

I'm going to assume for now you don't have predominately central apnea. For that situation, obstructive events are prevented through higher EPAP to hold your airway patent during expiration. If you zoom into your flow rate chart and see that ahead of any apnea you expire (less than zero flow) and the apnea occurs while the machine tries to supply PS breaths, that is a confirmation of what I'm saying. My suggestion is that your change your settings to ASVauto mode so EPAP can rise on obstruction, and set EPAP min 6.0, EPAP max 12.0, PS min 3.0, PS max 8.0.

In the event you actually suffer from central or complex apnea, I mostly agree with Rich, but you will need a spread of at least 5-cm on minimum and maximum PS, so in
ASVauto mode: EPAP min 4.0, EPAP max 8.0, PS min 3.0. PS max 10.0. Post a chart and we can get it sorted out pretty quickly.

[McMartin]

Jay51.  Thanks for the inspirational story.  I have heard enough of these to keep me motivated to get this done.  I have also heard stories of how long it can take to get there, so i will stick it out.

---

Rich66.  Thanks.  I think changing the mode & settings is a little out of my comfort zone at this stage, without bringing in my doc.  But I will definitely bring these to the conversation.

These are helpful replies, because I live in a rural place, so it takes a while to get support appointments, and the support isn't always that great.  So it helps to be an educated consumer ready to ask follow up questions.

[McMartin]

Sleeprider. Thank you.  This is helpful. See also reply to Rich66 above.

I do have both central and positional apnea.  Apparently they take turns.  Falling asleep on the device was a big challenge in my sleep study, but once there, I allegedly settled in and did not need a high number of support.

I do not have any reports.  What is the best way to get those?  FYI: I have low cell service, so the device does not get cell signal to do its recording.

Also, thanks for talking about the phase where I am about to fall asleep. My gut feeling (based on about 100 reps of observation) is that this is critical: right at that moment, I am not getting enough oxygen, and the device is making it worse. It is (I believe) literally restricting airflow, either on the inhale or exhale, at the exact wrong moment.  So, I am trying to breath through a closed tube.

[Sleeprider]

McMartin, If you have a laptop comuter or Mac, you can download the free OSCAR software (the name is the link). Your Aircurve 10 ASV has, or can be provisioned with a SD card of 4.0 to 32.0 GB size formatted to FAT32.  You can import the data from your machine to OSCAR and  use the tutorials in my signature to organize the charts and attach graphic images to your posts.  Examples of charts with ASV can be found in the Soft Cervical Collar wiki here. This article pertains to you because this is probably why you are having the apnea right after falling asleep.  https://www.apneaboard.com/wiki/index.ph...out_Collar

Let's discuss your settings:
Mode: ASV
EPAP: 5.0
Min PS: 5.0
Max PS: 10.0
Ramp: off
Humidity: 4

If you are experiencing obstruction, it may be because EPAP min it too low. If your airway is closed, no amount of pressure support will open it and you will feel suffocated. I mentioned earlier this may be positional, and/or a need for higher EPAP pressure.  You are using ASV mode, which means your machine is unable to respond appropriately to obstruction by increasing EPAP.  My suggested settings were ASVauto mode with EPAP min 6.0 and EPAP max 12.0. This would give your machine a fighting chance to properly titrate your pressure to treat obstructive events.  I also suggested a lower PS min of 3.0. This setting is important because it won't "cause" more CA events due to over-ventilation like your current minimum pressure of 5.0.  I increased the span between minimum and maximum PS to ensure you would have enough reserve to cause a breath in any central event.   Your current settings are not working, and I am offering to help you sort that out.  The graphic below shows the recommended titration protocol for ASV. Take a look, and you will see my suggestions address all the possibilities.  If you do not know how to access the clinical settings, follow this link. https://www.apneaboard.com/resmed-airsen...setup-info