New to BiPAP, hoping for titration assistance? (Probable UARS)

[Easing5319]

After years of struggling with CPAP/APAP, I have finally managed to get a prescription for a BiPAP (Resmed Aircurve 10 VAuto).  I'm hopeful this may be better for treating what I suspect to be UARS.  Was diagnosed with OSA at 29.7 AHI in sleep study, but no matter what CPAP/APAP settings I used I couldn't get rid of the fatigue and brain fog/ADHD-like symptoms.

Heres a normalish night on APAP with lots of flow limitations:
   

And here's my first night on Auto BiPAP using doctor's settings:

   

   

Obviously there are a lot of CA's which the machine flags even though I'm wide awake and trying to fall asleep.  My insomnia last night was terrible, taking forever to fall asleep and then waking up wide awake after only 5hrs ... but that's a separate issue...

I think its a good sign that my flow limitations are much less already using PS of 4.  I am struggling to make sense of all of the different VAuto settings available, and I have tried to read the articles about it on here and my brain fog is so bad that I can't focus, understand or retain the vast majority of it.  I tried reading others' threads here and having the same problem.  I feel basically non-functional today, unfortunately, but I'm guessing thats at least as much due to the lack of sleep as it is due to any issues with the machine.

I guess my question is, should I adjust machine settings at all to start dialing this in or give it longer to get a better baseline of how I'm responding to the new machine/settings?

[PeaceLoveAndPizza]

It did help with the flow limitations, but at the expense of CA’s. 

I suggest using EPAP min 8, IPAP max 18, PS 4, trigger very high.

Post a chart after a few nights using those settings. We can dial it in further from there.

[Sleeprider]

There are two things going on. The CA events come from not be accustomed to bilevel pressure (PS 4). Your 95% flow limit is now 0.0, down from 0.26 which is great progress. The second thing is the OA events you are getting are clustered, and you may want to review positional apnea as a possibility. Even with CPAP we saw your flow limitation events were clustered, but with flow limitation, the pressure rose and prevented the apnea. Without flow limits on bilevel, the machine is not getting the prior warning to the apnea. So a higher minimum EPAP pressure as suggested by PLAP is exactly what you need. Finally, the CA events can be minimized with higher trigger sensitivity. All that does is lower the threshold of expiratory flow needed to trigger IPAP. The onset of IPAP works as a stimulus to breathe and generally avoids the CA that might otherwise occur. I usually recommend increasing trigger sensitivity to high, then move to very-high if it is still needed. With that caveat, I agree with the old kitty.

Your friend, the dog at the bar.

[PeaceLoveAndPizza]

Fair play. I agree with everything you said. 

The “old kitty”? Hmmm. I wish I could take offence, but it is an apropos description.

[Easing5319]

Thanks for the input, i appreciate the advice.

I tried the new settings last night.... aerophagia was noticeably worse unfortunately and I actually somehow had more OA's this time, as well as more flow limits (not crazy high, but still at 0.23). I didn't realise setting the minimum pressure at 8 meant it would use 12 IPAP?  It seemed a lot stronger than usual... I also had a couple hours of large mask leaks.  

I think I'm going to set back to 6 minimum because it was quite uncomfortable last night with the aerophagia, and i think overall the strong air was disturbing my sleep.  One good thing is I dont feel too bad today in terms of fatigue/brain fog (one of the better days i've had in the last couple weeks), so thats definitely a positive and a sign that the higher pressure is likely helpful, but it does seem like going from minimum 8 on APAP to minimum 8 on VAuto is quite uncomfortable for me so far.  I woke up quite a lot throughout the morning also...

I know i'm probably tinkering too much since its such early days with the machine, so hopefully I will resist the urge to mess with it again tomorrow and give it a week or so this time.

Thanks

[Sleeprider]

I missed that you have moved to the aircurve 10, so apologies to the kitty. I think EPAP min 6.0 is fine and cap EPAP max to prevent pressure from rising above your pressure threshold for aerophagia.

[Easing5319]

Thanks to those who have provided input on my situation so far.  I've attached my last 3 nights of data for review.

As you can see, there's a considerable amount of variability in results...  This variability in apneas/AHI has continued to happen since I set the machine up.  However, I want to say that my brain fog/fatigue is at least somewhat better so far... Maybe a bit early to be making that call, but, I think it seems to be trending in a mildly better direction.

I dont feel amazing by any stretch, but compared to what's normal for me, this seems like at least a moderate improvement.  So I'm thankful for that.  I'm hopeful maybe I can continue to tweak settings a bit to continue to improve things further.

Still dealing with a decent amount of aerophagia, as well as the apnea clusters as you can see in the results.  I'm wondering if maybe i should increase PS?  Unfortunately cant really do much about mask leaks, as I'm limited to using Resmed AirTouch F20 due to skin reaction from the silicone of basically all other masks...

All input is welcomed, thank you!

[Sleeprider]

Check your sleeping situation and avoid tall firm pillows or multiple pillows that elevate your head causing your neck to bend. This kind of airway obstruction is what we call "positional apnea". Your results are excellent and consistent at 10/6 pressure until you get into a position where even 18/14 pressure does not prevent the blockage. Note how flow limits, pressure and events all coincide with just a few episodes in a night. This does not require an increase in pressure, although I think you should be at EPAP min of 8.0 based on your median pressure results. Read the Positional Apnea optimization wiki. https://www.apneaboard.com/wiki/index.ph...onal_Apnea

[gainerfull]

Time to invest in a soft cervical collar for that positional apnea you're experiencing.

[Easing5319]

Thank you.  I have my suspicions that the 18cm pressure spikes are happening when I'm on my back, but, I'm not 100% sure. 

I have also experimented with a cervical collar in the past.  I think I struggled with it primarily due to the fact that it encourages me to nasal breathe while sleeping, which is actually terrible for me (in my experience).  Any time I nasal breathe through the night, I feel absolutely awful.... even though I can get my AHI down quite low when nasal breathing, there is something about it that very clearly and significantly exacerbates my symptoms.  I'm guessing that's probably related to my suspected UARS...

Is there any reason to believe that it may be possible to find settings for the BiPAP that would allow me enough symptom relief to use the cervical collar and a nasal mask ?  Even now, with the BiPAP + FFM, i find i need to force myself to fall asleep mouth breathing in order to improve my chances of feeling better the next day.  A couple of nights I fell asleep nasal breathing in the last week or two with the FFM and felt very bad in the morning...  Very frustrating problem as I would love to just nasal breathe if possible.