Titration Assistance Needed (Kiwii)

[kiwii]

I have been at 6-13, ps 3 for 4 nights.

I will be seeing a new doctor in 2 weeks. My settings are being pulled up from the 4-10, ps 4, which was the original doctor's response to "taking the edge off the aerophagia" occurring at 5-20, ps 4 (history: earlier charts; seeing new doctor). At the lower setting, it felt as if there was not enough readily available air. Btw, SleepyHead revealed that the worst aerophagia was occurring at the initial erroneous setting of 5-20, ps 5.

I feel pretty good now and this morning I even have some energy for the first time in years. However I can see on the graphs (or think I see) that the minimum EPAP is set much lower than what I actually use. Also it seems to be defined by the PS (Max IPAP - PS = Min EPAP) rather than the setting.

How do the min EPAP and PS look at the current settings? Is this something that needs adjustment? I would very much like to be dialed in to something reasonable before seeing the new doctor. I do feel better at these settings, but somehow suspect that the charts are screaming for refinement. Your help is much appreciated!

Last night's chart (woke early but stayed in bed):


The previous 3 nights (NOTE: 9/26 was the last night of needing to roll over to turn off the machine):

[Sleeprider]

KiWii, a simple rule for VPAP titration is that EPAP is used for treating OA, and pressure support treats hypopnea, flow limitations and inspiratory snores. You are doing pretty good, but could use more EPAP pressure to reduce the OA. There are a couple ways to approach this.

One option is to increase EPAP min and allow IPAP max to also increase, leaving PS the same. This would eventually move EPAP into an effective pressure to eliminate most or all of the OA events. The risk is that pressure could rise high enough to cause aerophagia again. It appears you have adapted to the therapy and no longer have a high risk of aerophagia as you did originally. So using this option, your settings could change to EPAP min 8.0, PS 3.0, and IPAP max 14.0.

Another option to consider is to still increase EPAP, but reduce PS. This will keep IPAP pressures lower while treating OA. The risk here is potentially a decrease in comfort and increase in H events. Using this option, you would again increase EPAP min to 8.0 and decrease PS to 20. IPAP max could remain at 13.

Both options give you an EPAP maximum of 11.0 cm, but have different IPAP pressures at maximum pressure.

[kiwii]

Here are the charts since changing to 14/8, ps 3, and eager to here thoughts/opinions. I'm thinking to leave it at these settings for a bit (unless advised there is some reason not to).

Not the best of sleep due to pillow problems, but I'm working to get that resolved. There seems to have been an increase of CA's, although I wonder if some of that could be from the poor sleep positions...? Currently using a bolster pillow while researching buckwheat pillow suppliers.

There has also been a return of aerophagia, as evidenced by some flatulence and abdominal distension. I'm willing to deal with it for now (it's not painful like it was before) and see how things settle out, unless there is some pressing reason to make another change.

10/2 - first night being aware of mask leaks - I was actually awake right after that, and I suspect the group of events around 3am was while awake:



10/1:



09/30 - First night of changes; first night of bolster pillow (delightful! Too bad the following nights on bolster sucked; just couldn't find a good position):

[Walla Walla]

Are you using a Cervical Collar?

[Sleeprider]

Are you using a Cervical Collar?

Hey, that was my question!

[kiwii]

Lol! Great minds think alike, apparently.  

No, no cervical collar. But the bolster pillow puts my neck more in alignment than it has ever been before.

[Corvette817]

Just fyi, I had bought a cervical collar online but it was much too big and too hard (described as small size and medium density).  I may rip it apart and remodel it. 
But I saw a childs travel pillow (small, soft, cheap, washable) at a dollar store.  The first night I used it, the AHI was 0 (!!!).  Not to be repeated, alas, but a lesson to not underestimate the impact of sleep positions and/or chin-tucking.  

Keep at it, you'll get there.  

   

[Walla Walla]

I know the Cervical Collar made a big difference for me. The clusters you see of OA's indicate positional blocking of the airway.
If your concerned about fitting size most drug stores carry them. Just go to one and try them on before buying.

[kiwii]

Are you guys side-sleepers? I am, and I do think I'm prone to tucking my chin down. hmmm.

Walla: I'll need to order one from Amazon to get sizing options. I haven't had any luck in the local stores.

Corvette817: That's a great idea to modify the collar that doesn't fit!! I may give that a try tonight, assuming I don't find one that works while I'm out shopping today.