Liz's CPAP therapy

[Lizcpap]

I need some help refining my CPAP therapy.  I suspect possible UARS and positional apnea.  I've attached charts from a couple of recent nights.  Any suggestions of where to start? Thanks!

[BoxcarPete]

Why is your pressure so low? It looks like you are significantly under-titrated. You list a full face mask in your profile, have you tried a nasal-only mask yet?

Many people with UARS get some benefit from bilevel therapy. This is available to you on your machine through the pressure support setting. Try increasing it to at least 3 with your current EPAP range.

[Lizcpap]

Thanks for your response.  I need to use a full face mask due to having allergies.

[Deborah K.]

I suggest you move your PS (Pressure support) setting to 4.  It does look like you have positional apnea too.  There are a variety of things you can do to solve this.  I think the easiest and most comfortable solution is to buy a child-sized pillow that has the front raised, causing your head to tip back a little  This is what I use, and it solves positional apnea perfectly.  The pillow I have is no longer made, but some on Amazon would probably do the same thing.  Here are a couple:

https://www.amazon.com/Hcore-Adjustable-...r=8-9&th=1

https://www.amazon.com/MLILY-Adjustable-...r=8-5&th=1

Both of these have three layers, so you can make the pillow even thinner if that works better.  Amazon is a good place to buy from as they are great about returns.

Others prefer to wear a soft cervical collar.  I did that for a while but like the pillow much better.  Some use chin straps, but most find they don't work well, if at all.

[Lizcpap]

Thank you, Deborah K.  Does the pressure support come from reduction in EPAP or a rise in IPAP?

[Sleeprider]

With pressure support, inspiration pressure rises. With the CPAP EPR, pressure is reduced to EPAP. Right now you're using Vauto mode with pressure from 4.2 to 5.4. I recommend EPAP min 5.0 Max pressure 12.0, PS 4.0. This will result in a pressure range of 9.0/5.0 to 12.0/8.0 (IPAP/EPAP), and should resolve the flow limits and a lot of the obstruction. If clusters of obstructive events continue, you will need to mitigate the positional apnea. https://www.apneaboard.com/wiki/index.ph...onal_Apnea

[Lizcpap]

Thank you, Sleeprider, this is great advice.  I've had a prior history of aerophagia at relatively low pressures, so I'm going to increase pressures slowly.  When adding pressure support, do I need to adjust the IPAP too, or does it happen automatically?

[OpalRose]

Liz,
When using a VAuto BiLevel, (PS) Pressure Support is added to EPAP.  
(PS + EPAP = IPAP)

I was just going to recommend the same settings as Sleeprider.

Set your PS at 4 (This is a good starting point, but may be lowered or raised in small increments depending on apnea events).  

Set EPAP to 5.  Set max IPAP to 12

From the Clinicians Manual:
Bilevel pressures:
The AirCurve 10 device assists spontaneous breathing by cycling between two pressures in response to the patient flow or a preset fixed time.

The inspiratory positive airway pressure (IPAP, or the sum of EPAP and the pressure support level) assists inspiration.

The lower expiratory positive airway pressure (EPAP) facilitates exhalation comfort while providing a splint to maintain an open upper airway.

The difference of the two pressures—pressure support (PS) level—contributes to patient comfort.

VAuto mode:
In VAuto mode, the AutoSet algorithm automatically adjusts pressure in response to flow limitation, snore and obstructive apneas.

Min EPAP, Max IPAP and pressure support in VAuto mode:
Pressure support allows you to set the difference between inspiratory and expiratory pressure and is fixed throughout the night.

Min EPAP and Max IPAP settings allow you to restrict the delivered pressure ranges in which the AutoSet algorithm can operate.

The EPAP and IPAP will vary across the session according to the patient’s needs. It responds to snoring, apneas and flow limitation of the patient’s flow curve.

Min EPAP and Max IPAP can be adjusted to limit the upper and lower delivered pressure limits.

Hope I didn't confuse you.     Order the Clinicians Manual for more detailed instruction.  
https://www.apneaboard.com/adjust-cpap-p...tup-manual

https://www.apneaboard.com/wiki/index.ph...re_Support

https://www.apneaboard.com/wiki/index.ph...ure_(BPAP)

[Sleeprider]

Your Vauto will provide the set pressure support, provided there is enough margin between EPAP and maximum pressure. If you set EPAP at 6.0 and maximum pressure 10 with PS 4.0 you will get fixed pressure with PS 4.0 because the pressure cannot rise. If the maximum pressure is only set to 9.0, the machine will provide 9.0/6.0 because max pressure is lower than PS. At EPAP 6.0, max pressure 11.0, PS 4.0 your machine will range from 10/6 to 11/7, a difference of 1-cm.

Here is what is important for you to know. We control obstructive events with a higher EPAP or fixed pressure, and use pressure support to relieve flow limits and hypopnea. Because you do not tolerate higher IPAP pressures, the use of bilevel pressure results in lower EPAP and more obstructive events. As a result, we don't have many options available to us until you resolve the positional apnea.

[Lizcpap]

Thanks Sleeprider and Opalrose!  I'm working on making pressure changes in .2 increments at a time, due to history of aerophagia.