Abletree's Therapy Thread

[SarcasticDave94]

On a BPAP, PS is pressure support. It's the same as your APAP's EPR but that is not limited to Max of 3, and it adds to your pressure where EPR reduces. A BPAP PS will represent the difference between EPAP the exhale pressure setting and IPAP the inhale pressure setting.

If you get a BPAP, it'll make more sense when you see and feel it in action. If the BPAP is your goal, you need to tell them why you feel you need it. If this isn't comfortable or you believe therapy should be better, tell them. Don't let it up to the doc and others to guess why you want BPAP. Give them reasons why you want this. Be polite yet assertive.

[Abletree]

Yes! This is exactly the direction I am trying to go - although I don't understand the ins & outs of the technical aspects as well as you do - I definitely have had struggles with expiratory pressure since the 1st moment & ever since - also other pressure issues. 

The bipap PS positive pressure you describe sounds like it might be the answer

I will re-read your description again as I advocate with my provider in the days ahead

Thank you

[SarcasticDave94]

You're welcome. Just consider this to see if it'll help. Take pen and paper, note down every negative aspect of your APAP and Apnea. If you're still fatigued, if your PAP disrupts sleep, uncomfortable pressure delivery, how it delivers therapy, and so on.

I'm not referring to PAP therapy being a nuisance or anything like that, but aspects you believe the BPAP will or should fix for you. It's not required to be anything other than you believe BPAP will fix this, that, the other. Let the doc link it to medical reasons, you base your comments on what you think, feel, and believe.

[Abletree]

Gotcha - Thanks again! I'm on it

[Geer1]

Regarding your comments about not understanding the technical aspects that needs to be your first step so here is an explanation. PAP treatment in obstructive/restrictive cases like this is very simple in nature and winging it guess and check style is not effective.

The most basic CPAP treatment is done with a single fixed pressure, EPAP. This pressure provides outward force on your airways preventing them from collapsing. The goal of titration is to find the minimum EPAP that holds airways open most of the time. This is how PAP treatment originated and it treats the majority of obstructive cases and is the reason that almost all focus during titration is purely on pressure.

APAP expands on this by giving the machine the ability to adjust EPAP since the pressure required to maintain an open airway depends on the individual, sleep position and sleep stage. APAP machines record your sleep data, interpret issues such as apnea, hypopnea, flow limitation and snore and then they reactively increases pressure if any these events occur in the hopes that the increased pressure will make them go away (which is true in the majority of cases but not all cases).

At some point they realized that increasing the pressure during inhalation and then dropping the pressure during exhalation can make treatment more comfortable for some patients. This idea was taken from mechanical ventilation techniques which use two pressures (EPAP, IPAP) and the difference (PS) between them to provide ventilation for people with insufficient breathing capability. IPAP = EPAP + PS. Bilevels use this same terminology but in basic CPAP/APAP machines they limit PS to under 3 cm to prevent significant ventilatory assistance and Resmed has decided to call this EPR and for some reason use the formula EPAP = set pressure - EPR.

PS on a bilevel is not limited and is used to provide ventilatory assistance to a patient that has weak spontaneous breathing capability. Historically mainstream medical has only considered higher PS and a bilevel necessary in cases where a patient has known health issues affecting their spontaneous breathing ability such as mild COPD, obesity hypoventilation syndrome and many sleep doctors/techs still treat patients this way.

What mainstream medical is starting to realize and what some members on forums like this have found is that EPR and PS can have therapeutic effects in some cases and in rare cases can be the difference between adequate treatment and not. For example one of things forums like this have become to focus on is treating flow limitations with EPR/PS as it appears to be more effective then pressure. As a mechanical engineer I can say this makes some mechanical sense since not all obstructions or restrictions will improve with pressure and the higher EPR/PS effectively helps pump air through these obstructions/restrictions.

So to recap. Goal 1 is to find the minimum pressure (EPAP) or APAP range that effectively reduces airway collapse (apnea/hypopnea/restriction) to the best of the machines capability. Keeping this pressure low as possible is usually preferable as higher pressures can create their own issues (aerophagia etc). Then if treatment is not adequate because a collapsing airway is not the issue (or because higher pressure does not prevent the airway from collapsing) then you can try increasing EPR/PS to provide ventilatory assistance to see if that helps with symptoms.

In your case low pressure and EPR of 3 has stopped all apnea, hypopnea and almost all flow limitation (as Resmed records it anyways). Your flow rate graph is fairly uniform without obvious signs of obvious obstruction or restriction (which would show up as low amplitude or decreasing flow rates) and everything looks fairly good. I think it is pretty safe to say that 99% of doctors would believe you are treated adequately at these settings. The only potential argument of symptoms remaining due to breathing issues is to say you have UARS, that you have narrow airways that do not improve with higher pressures, that your body is working too hard to breath through these narrow airways and that this hard work and the odd RERA associated with it is disturbing your sleep and causing your symptoms. That would mean your symptoms are being caused by this minor remaining restriction and not the apnea/hypopnea that were noted on sleep study and that have already been resolved. 

In these sort of UARS cases using a bilevel with mildly higher PS might help resolve symptoms. Most doctors would consider this controversial as treating UARS with higher PS is not really proven medically and there are not good enough tests to diagnose who it will help and who it won't. On these forums we have seen examples of it working but I would say we see just as many examples of it not working to resolve symptoms patients think might be related to breathing but imo ultimately are not. I fall into this last category myself, tried a bilevel unsuccessfully and still struggle from unknown sleep issues (except bruxism is known but hard to treat). What I have noticed is that higher PS helps in cases where there is obvious flow limitation or signs of restriction in flow rate data but rarely helps in cases where these issues are not present (like yours). For that reason I think a bilevel and higher PS would be a longshot to work for you but if you get desperate it is about the only thing that could potentially help (if this is breathing related).

[Abletree]

Wow - How very generous of you to take your time to walk me through this. I truly appreciate your help & insight.

I feel as if I am fighting brain fog that is slowing down my ability to readily absorb technical concepts. This isn't something I am used to. It is a bit frustrating, as I am normally pretty good at these kinds of things.

I believe my poor sleep has impaired my mental and physical ability in many ways - which is why I am motivated and determined to find some improvement. I've been struggling with oppressive daytime fatigue for about 4 years now.. My sleep behaviors - flipping, jumping and flailing - have been awful. Less than 6 hours of restless sleep with very little deep sleep

I was unaware of how bad things were. I was just pushing myself at all ends. I'm very active in my daily tasks and I have intense job duties. Then, I was misdiagnosed last August with cardiomegaly and congestive heart failure. After extensive 2nd and 3rd opinions and testing from the University of Michigan and Cleveland Clinic, I have a clean cardiac bill-of-health. I was simply misdiagnosed. I exercise vigorously every day, eat smart, quality foods and I have strong endurance. I have excellent cholesterol levels without medication. I'm probably about 40 pounds overweight - trying to lose

One of the good things that happened as a result of my misdiagnosis was obtaining a sleep study. I am finally aware that I have clinical issues and I am really looking forward to solving my plague of endless fatigue. BTW - I also see an endocrinologist regularly who follows all my labs & keeps me in good control of my hypothyroidism

On Day 1 of trying a cpap/apap at the sleep lab, expiratory pressure was a physical challenge for me. My original settings of 8-16 seemed to address most of the SA issues quite well from what I could tell - except for continued restlessness, mask on/off, headaches & lots of burping. * The highest pressure my apap went to was 9.6. After my sleep lab follow-up, my provider changed my device to cpap at a straight 10 setting. This greatly worsened my headaches & aerophagia to a point of all-day nausea. I actually stopped using the device for one night. I simply could not tolerate it

The sleep lab changed my device back to apap at a lower setting 7-12. EPR is still at 3. Since then, I am back to where I was before. It is tolerable, but I am still burping and getting headaches. I still wake up several times during the night and find myself taking the mask on and off - subconsciously and consciously. 

This seems odd, because I actually look forward to the ritual of putting the mask on. I like  the feel of my nose pillows and headgear. It kind of feels like tucking myself in - a feeling of security. I like the sound, the rhythm and the air. I also like thinking that I will be getting better sleep. I'm even happy if it is a placebo effect! My point is, I am not oppositional in my attitude to this therapy, quite the opposite

On the technical aspect, I remain confused about the difference between EPR and bipap. I seem to recall in other explanations I have read, that EPR somehow reduces pressure, while bipap adds pressure. I'm kind of freaked out at the notion of adding pressure since I already feel like I'm being blown up like a balloon

Obviously, I need to re-read your explanation and read some more. I've been sooooo busy with a whirlwind life - I have been speed-reading with brain fog! It is hard for me to find the time to read without distraction and have focused time to think

I'm seeing this a a long-haul journey with steps forward and steps back, but over time incremental and giant leaps forward will add up. I'm not impatient about this. I'm looking forward to unearthing the layers. I'm convinced there is more involved than SA in my case. I think I have some additional sleep disorders, or borderline issues that need identification and intervention. Even my own simple sleep hygiene practices need some tweaking

Since I believe this is a long-haul journey, I want to make sure I end up with the best machine possible - one that has the ability to adjust to the discoveries that lie ahead. My insurance initially approved the apap. I am now in a trial period. I need to demonstrate "failure" to obtain approval for a bipap. I am not trying to get into a bipap just for the fun of it, but I don't want to end up with an apap for the next 4 years if I can benefit from a bipap

Coincidentally, my current struggles with my apap are real. My sleep lab doc actually suggested another sleep study with titration for a bipap if the current setting of 7-12 apap doesn't improve things. They were also quite interested in my dream verbalization and night terrors. Those seem to be improving, but the interrupted sleep, headaches & aerophagia remain

I'm also interested in more information on my borderline low o2 numbers in my original study. As time goes by, I'd like to end up with a versatile bipap, a home recordable oximeter and something like the Muse S EEG brain wave monitor that I believe also captures heart rate. I'm fascinated by the emerging biometric monitoring devices that can make intelligent self-care a continuous process

My wife has a continuous blood glucose monitor and he real-time data has made all the difference in the world for her!

Look at me - I don't even understand the basics and I am after all these gizmos! It won't happen overnight though. Right now, I am grateful to have you, the board & my sleep lab provider helping me get set up with the proper foundation


Thanks again - I will re-read and read some more

Abletree

[Gideon]

EPR vs PS. The simplest way is to ignore them and deal with only the pressures involved. There are two pressures, inhale (IPAP) and exhale (EPAP). It is the difference in these pressures that matters.
The low pressure is always the exhale. And EPR or PS simply defines the difference in pressures. Yes the math is different, but the result is the same. No matter what your machine is I look at both the EPAP ad IPAP pressures and evaluate what I want them to be and recommend settings based on that.

[Geer1]

In short EPR (on CPAP/APAP) and PS (bilevel) are the exact same and equal to IPAP - EPAP. They are just named differently because EPR is handcuffed and Resmed thinks "Expiratory Pressure Relief" is a good advertising/selling point.

There are only two significant factors to obstructive/restrictive PAP treatment. EPAP to try and hold airway open and EPR/PS for trying to force air through partial obstruction/restriction. You don't need high EPAP because you don't have obvious obstructions. You also don't appear to have partial obstructions so don't need higher EPAP or PS to treat them.

The only thing you may potentially have are constant levels of restriction due to say narrow airway structure, if this is the case (there is a low possibility) then the only thing that will help is slightly higher PS from a bilevel (4 or at most 5 PS compared to your current 3 EPR).

The sleep behaviours is something you have commented on a few times and it has caught my eye before. You don't have apnea that would explain such a behaviour and for the most part your breathing looks pretty good on OSCAR data. If these movements/behaviours are still occurring on CPAP then I would think they are unrelated to breathing and trying to figure out more about them might be your best bet. Getting a night vision camera and recording some of it might help understand what is going on (periodic limb movement, rem sleep behaviour disorder etc).

[mper6794]

Hi,
- very nice Geer's and other’s PAP therapy explanations above;
_ Albetree: long story; hope you will succeed! Follow it with very much interest. It might be we progress together;
_ in my modest opinion, your waveforms suggest to me you may have problems to run smooth through REM stages (likely with too many arousal/awakenings and truncations/interruptions - stuff nose, the culprit? -  and just anteceded by bad dreams and nightmares), maybe just like me (my only remaining therapy drawbacks, after some 2.8 years), and maybe like ten/?hundredths of another cases in this Forum;
_ I am very curious on your Doctor will end up with concerning the bad dreams and some of your acting outs. I keep being bothered with such things, which I am associating with remaining non-flagged minor respiratory efforts/highly sensitive nervous system, very sure during REM stages; 
_ Should these remaining issues during REM be true, what would be the solution? Well, I really still don' know! Meanwhile I took 0.4 mg of Clonazepam, which help a great deal with my overall sleep ( I also have RLS/PLMS);
_ Just to share: I am now completing some two years on BIPAP with everything virtually zero, so to say AHI, flagged RERA's, flow limitations, both maximum and p95%, tailored pressures (following up Resmed Protocol: https://document.resmed.com/en-us/docume...er_eng.pdf ) and mask, using soft collar, no mouth breathing, etc, …… and yet, having problems to go smoothly through REM stages (either with too much arousals/awakenings or with interruptions of them after some 10, 15 minutes, - as seen/re-calibrated during recent PSG);
_ Recent ENT appointment and CTomography showed some polyps/cists (no direct signal syntoms on  my day to day). He has left open going or not for a surgery to remove those. Just to test, four days ago I started using fluticasone, even without any dectable  syntoms (other than eventual effects on respiration, see this article: https://www.scielo.br/j/bjorl/a/BN6tbBLr...b/?lang=en), to see what happens with arousals/awakenings during REM; I will let you know….

All the best and good luck