Help! My bipap experience has gone off the rails!

[Sleeprider]

In bilevel (BPAP) therapy, the EPAP must support the airway to prevent obstructive apnea. Your EPAP pressure is too low. You are using a fixed IPAP of 9.0 and EPAP of 3.0 which results in a pressure support of 6.0. Your respiration rate, minute vent and tidal volume are all normal, so the only issue at hand is your excessive obstructive apnea.

I will propose two ways for you to address this. First you can switch your machine to Vauto mode and let it do the titration automatically, or second, you can manually do the titration in VPAP S mode. For Vauto, I recommend putting the machine in Vauto mode at EPAP min 4.0, PS 6.0 and IPAP max 14.0 This will provide an auto-pressure range of 10/4 to 14/8. Somewhere in there I suspect you will find efficacy. Other than pressure, stabilizing your airway with positional therapy, such as a soft cervical collar may be a viable alternative, however your EPAP pressure is very low and I was actually unaware that our Aircurve 10 Vauto could produce an EPAP of 3.0. I thought the minimum was 4.0, so I learned something.

If you prefer fixed pressures, start at 10/4, then if OA are present, add 1-cm to EPAP and IPAP in VPAP-S mode. Stop adding pressure when AHI reaches the lowest point or CA becomes an issue.

[wubisnotanabbreviation]

Thanks for the suggestions.  I was running my EPAP at 4.0 until that last night, when I felt that I had little left to lose, so I went all the way down.  I didn't realize 3.0 was possible either.

In my initial diagnosis, CA was the main concern.  The OAs show up from time to time - I think I have some allergies that are flaring up at the moment.  So I think I'll try the S option starting with 10/4 and see where this takes me.

[Sleeprider]

Please understand the basic titration protocols that apply here.  If your problem is obstructive, increase EPAP, and for hypopnea or flow limits increase pressure support (IPAP relative to EPAP), but for CA events decrease pressure support (decrease IPAP closer to EPAP).  If you are having central events, the solution is to keep your EPAP at 4, but decrease IPAP.  Your pressure support is currently 6-cm (10 - 4 = 6), and with EPAP at 3, PS may have been 7.0 cm.  What I am suggesting is to begin reducing IPAP in steps to reduce CA, and if you have centrals, your pressure support should probably be less than 4.0 cm.  Try using a pressure of 4.0 EPAP and 8.0 IPAP. Let's see if that resolves the problem. If you actually have mixed or central apnea, the appropriate therapy is ASV, if you can't get results with your current equipment; however your high pressure support of 6.0 is probably causing the centrals to be much worse.

See the VPAP-S protocol below and follow the decision matrix.

[wubisnotanabbreviation]

Thanks for the clear explanation.  I tried 10/4 last night, which was OK at first, but I found myself really struggling when I woke up after a few hours of sleep - the usual cycle.  I decided to just jump to 10/5, which felt somewhat better.  I'm going to give this a night or two so I can see if acclimation helps the situation.  If not, I'll work on pressures as you advised.

I haven't looked at my data from last night yet, but I did get a ridiculously low AHI - I reminded myself that if I just stay awake all night, I'm pretty sure to score a 0.  The real test is that I feel more rested today than I have for some time.  I think you may have gotten me moving back toward the right track.

Thanks for your time and patience!

[Sleeprider]

At 10/5 you were at PS 5. Whatever EPAP resolves OA is fine, but I think your pressure support should be 4 or less.

[wubisnotanabbreviation]

Thanks.  I'll go to 10/6 and see what the data show, posting with questions as they arise.