High Hypopneas with PR DS BIPAP ASV ?

[mmannari99]

Attached are screenshots of Oscar Daily. The therapy setting pressures are not right, but the graphs look correct.
I'm set at EPAP min/max 4/4.5, Ps min/max 0/3. MaxP 8. I have difficulty tolerating pressures much higher than this.

I still get lots of Hypopneas. Are my current settings contributing to this?

   

   

   

[Gideon]

No, your settings are not causing it, they are just not adequately treating it.

You need a higher PS to treat those and your Flow Limitations,  I would suggest a PS of 4 or a PS min of 4 and a PS max of 6 and sufficient IPAP Max (10) to allow it.

[mmannari99]

Thanks, I’ll try that.

[Sleeprider]

I agree with Fred, but let's talk about what is going on. Your PS is set from zero to five cm and the machine is giving you nearly 2-3-cm on every breath. It would help a lot if you took a standard screenshot using the View menu and choose Take Snapshot F12, rather than using the File/Report function. Much better information from the screenshot of daily details as outlined in Fred's and my signature links.

Back to my point, in the image below we see the blue mask pressure graph has a couple white notches in the bottom. Those are brief times your EPAP rises to 4.5. The top of the blue graph hangs around 6.0, suggesting that most of the time you get 2-cm of PS. We never see a time when the height of the blue is less than 6-cm. We know from titrating bilevel users, that pressure support can resolve hypopnea, so the zero to 4 is not working. I'm thinking that setting the minimum PS to 3.0, and PS max to 6 as suggested by Fred, with Pmax to 10 is better. It is the minimum PS that will resolve the H events, and setting it higher should reduce hypopnea and give more consistent therapy. I can still see moving PS max a bit higher, but this should help. Why do you feel uncomfortable with higher pressure?

[ajack]

I saw in another post that the bipap is an ASV. I think bonjour and sleeprider  think it is the normal bpap. While both are right,that  with normal bpap. After the OA are cleared, the PS is raised for the H. One reason is to minimise CA.

With the ASV it is different, the min epap is raised for both OA and H. Is there a reason why you aren't using the script you had on the old one?

There are also other settings. I would suggest you download the Philips titration protocol reference guide and start with the default settings, if you aren't using your script. I'm on a phone, so I can't get to my links for the guide, it's hard enough just trying to read posts.

[Sleeprider]

Here is the Philips BiPAP SV Titration protocol.  I disagree it is much help here since settings are so much lower than the protocol recommends and mmannari99 claims not to tolerate the higher pressures.  I'm going to drop the Resmed ASV titration protocol as well since it is more helpful.  I don't disagree with Ajack, but am considering the input to higher pressures already discussed.

[ajack]

Mmanari said in the other post that he was on ASV and this is a machine swap. There is a DME. that isn't trusted and I understand that you can use another in the US. He would have his script and I assume he was using it on the old machine. It's possible other settings Like rise etc. have been changed and could explained n the discomfort. I thought it would be a good idea to use default settings, probably even factory reset. Then move the pressure from there. It seems strange there would be a pressure problem, causing him not to use his old script.

The Philips one in my post is a good titration advice for their ASV. I will post the link, it should be ok.

http://incenter.medical.philips.com/docl...%3D9792335

[mmannari99]

To Sleeprider and Ajack and Bonjour:
First, thanks for offering to help, it is much appreciated.
I will organize the Oscar charts and use the F12 Screenshot as Sleeprider suggests for any future posts.

My original Rx when I first got the DS BIPAP ASV was EPAP min/max 9/15, Ps min/max 0/15, MaxP 30.
The high pressure spikes, often up to 25, largely due to ffm mask leaks were so noisy they constantly woke me and my wife up.
When I switched to a nasal cushion mask, leaks went down, but I still got woke up from large pressure spikes to 20 or more.
Probably does not help I am a vey light sleeper.

I made initial changes to the low pressures on my own (EPAP min/max 4/6, Ps min/max 0/2, MaxP 8), when I got no help from my doc or home care provider.
It eliminated the large noisy pressure spikes that were frequently waking me up, but as I've posted, I was still getting high numbers of Hypops and a moderate number of CAAs, and still did not feel I was getting better quality sleep.

I will say after 1 night with the higher pressure settings suggested by Bonjour, (EPAP min/max 4/6, Ps min/max 4/6, MaxP 10) I slept much better for the first half of the night, (bad 2nd half of night for non-machine reasons) and Hypops were reduced but still high at an index of 5/hr. Unfortunately, with the average pressure at around 10 for the whole night the noise from the mask (average total leak was 26.8 L/m) was hard for me to fall asleep to and kept my wife awake when she would come back to bed. 


It may just be normal venting, but it continues to be hard to adapt to. Perhaps my deviated septum and enlarged turbinates contribute to my discomfort with pressures at around 10 and higher. Also, the PR DS ASV just seems to be noisier and report higher mask leakage than the ResMed AirCurve 10 ASV, with the same mask and same pressure settings. I had one night on the ResMed with a leak rate of 1.2L/m, and averaged 8L/m for the 2 weeks I had it. With the DS ASV, I cant get below 20L/m. I know that's still considered "good" but the venting is simply noisy to both of us.

I'll post another Oscar screenshot of last night with the higher pressures, should any of you folks still be willing to review it.

NOTE--> The pressure settings reported by OSCAR at the top in the left panel, and in the "machine settings"  are NOT CORRECT !! But they appear to be accurate in the middle of the left panel under "statistics" and in the graphs.

Again, thanks.

   

[mmannari99]

After viewing the Oscar charts I attached to my previous post in more detail, the pressures in the stats panel and the graphs are NOT correct. 
I've attached a screenshot of an Encore Pro 2 Daily report for the same night. I believe the pressures it reports are accurate.
Again, my DS BIPAP ASV was set last night at EPAP min/max 4/6, Ps min/max 4/6 and Ps Max 10.

Not to look a gift horse in the mouth, but might the Oscar software folks, (when they get time), take a look at these pressure errors for the DS BIPAP ASV?

Regards.
Mark

   

[Sleeprider]

As best I can tell the Encore graphs are showing similar information to OSCAR. EPAP is stuck at a 90% of 4.7, and IPAP is pegged at 10 nearly all the time. Conclusions are unchanged that your PS does not have enough range to resolve inadequate respiratory volume, and perhaps that EPAP is too low. We need to better understand how to make you comfortable with higher pressure and pressure support.