Optimal Settings on iBreeze BiPAP to reduce FL

[ewriter]

RE: Flow Limits How to Upgrade CPAP to Bilevel
Hi,

I'm seeing a lot of Flow Limits in my setup. I am testing a Revesnt iBreeze BiPAP 25 STA. Have been testing for about six weeks. During the day, if i doze and start snoring, i get a "flutter" sensation in my chest. I also get this when i sleep. It terrifies me; but it has happened in the past. In tha past, the sensation was not very long in duration. Now, it can go on for some minutes or hours. I have had myself thoroughly checked by Cardiology (as in the past, since 2006 several times) and no arrhythmias or structural heart issues were found. Nonetheless, i have dedicated myself to losing weight (I'm 77 kg) and eating a low-carb diet, focused mostly on plants and not bacon (which i ate a lot of before) or saturated fats.

I was using a Respironics System One for about nine years (CPAP, Pressure of 12.5 - 14) and then switched to an Aire10 Autoset for Her (APAP, pressure of 12.5), which i used for about 3.5 years.

Due to panic attacks i was having in 2006 (i didn't realise this is what they were), i was given Propranalol 120 mg and this calmed down all symptoms and the anxiety, until January 2023. At that time, i was down to 20 mg Propranalol (weaned myself down); and the "flutter" and panic attacks came back with a vengeance.

I had a very difficult 2023 and had significant disordered sleep breathing and OSA; but i have since recovered a lot, mainly because of God's grace. I was given Clonazepam in January or February last year, at the hospital, which calmed me down and controlled the panic attacks. But i am having to use sedatives to sleep (some Melatonin, 0.5 mg Clonazepam) and still taking the Propranalol (20-30 mg/day).

I don't like taking sedatives to sleep as natural sleep is the best; and i feel the Propranalol may somehow be causing some of my symptoms (rumbling sensation in the chest, fatigue, and the "flutter" because i think it can induce Bradycardia and my HR during the night tends to be below 50 and often below 60 during the day).

My question is, i am getting a lot of Flow Limitations during therapy, even though my Sleep Tech and i have optimised the settings. Does anyone have any idea what could be causing these? 

I normally try to wear a neck brace; but sometimes i don't (perhaps there's some chin tuck?) and i also use mouth tape and a FFM (Resmed F10).

Note: i am aware of the Respironics recall but i was fortunate in that, in 2013 or so, when i was still using the System One, it began to whine loudly and i saw black specks in the air tube, so i opened the machine and removed all the black insulation, which was dessicating.

The machine seems to be a good machine and an upgrade over the Aire10; but i do feel that it's possible some of the pressure it's giving is being interpreted by my ANS as "backpressure/apnea" and causing my "flutter." The FL are evidence of too much pressure i think? Note: the machine is set for giving additional "breaths" when or if i stop breathing. But, as far as i can tell, my main issue right now (and for some time) is not so OSA but Hyponeas (some of them for this chart's data, for example, were a minute long).

Any help at all interpreting these results is greatly appreciated!

Note: there are several other settings on the machine which i have not used or adjusted (Ti Max, Ti Min, I Trigger, E Trigger, T Max for example) and i don't know what to set them to to improve therapy. 

Thanks!

Paul

[Sleeprider]

What are your settings on the iBreeze. The UA and H events appear obstructive and it appears you need higher EPAP and possibly more pressure support.

[Deborah K.]

You really need to consistently wear your neck brace every night because you are having a large cluster of events that it would be better to avoid.

[ewriter]

Hi Sleeprider,

Thanks for the reply. Before i mention the settings, i want to add that i am using mouth tape (per advice of my sleep therapist) and we have been at this for six weeks. My best results were FL 15 on April 3/4. Recently, FL have been as high as 66 with some hyponeas a minute long. I don't understand why the machine did not "intervene" (i have it set to provide backup breaths, as far as i know).

Note: i have been on PAP since 2011, though i was diagnosed (23 AHI) in 2005. I may have been inadvertently overpressured for 3.5. years, in my 2020 sleep study and followup prescription, due to an error the Sleep Clinic made, before this was discovered by me at my 2022 sleep lab test. This discovery pushed me to optimize my therapy as best as possible on the Aire10 Autoset APAP but, it just seemed too much pressure (12.5) when my AHI in 2020 showed 7. Unfortunately, my sleep Clinic (also a Psychiatrist) did not mention  to me that my AHI had dropped from 23 in 2005 to 7 in 2020 and sent me on my way with another RX of 13. In fact, she said "You don't have sleep apnea. Do you still want the machine." But strangely, when i questioned her on this in 2022, she had no recollection of saying this.

iBreeze 25 AST Settings (i tried to attach from my phone email but it refused to send i don't know why)

Mode: Auto S/T
Ti: 1.2
F: 17
Auto F ON
I Trigger: Auto
E Trigger: 1
Ti Control: ON
Ti Max: 2.3
Ti Min: 1.6
IPAP Max: 10
EPAP Min: 8.1
PS: 1.4
Rise Time: 300
Vt: OFF
Press ADJ: 2 (greyed out/can't change)
EPAP Max: 10 (greyed out/can't change)
IPAP Min: 4

Mask F10 Resmed FFM

Sometimes i switch to the Nasal Pillows F20 with a chinstrap

Also trying a mouth guard/oral appliance which seems to help; but which is difficult to keep in place and it gives me tinnitus.


Results from last night, based on these settings, are attached (it appears the extra pressure support helped). I will wear the neck brace tonight.

I greatly appreciate your help! I had a terrible year last year and was only getting 90 minutes of sleep (no meds) on my Aire10 Autoset for Her (set to 12.5 APAP Autoset mode) and/or Respironics System One on CPAP @ 14, for all of January, due to being forced awake by the "flutter" (at that point, it wasn't actually palpable). The year got worse before it got better (called the ambulance due to severe panic attacks feeling i might be getting Afib; which only resulted in a Psych evaluation and prescriptions for several antidepressants, which did not help in the least, though i did manage to get more sleep on them (they made me manic or even more severely anxious). Nothing helped except prayer and Clonazepam.

I strongly feel that with the optimal therapy (mask, machine, settings and collateral) that these "palpitations" can be reduced and eliminated (because they were before, in 2013 and in 2006) but i'm not quite there yet.

Note: i feel jetlagged every day and worry about my ability to work and get back to a normal life. I have been temporarily bedridden sometimes, too scared to leave the house. But i generally manage to get out every day for exercise, shopping, restaurants and do chores for my wife, who= was initially very unsupportive and in my face (threatened suicide if i didn't get rid of my panic attacks) but, who has largely changed and is not supporting me a lot. This may be because she has finally discovered she has diabetes.

[Sleeprider]

Are you treating pulmonary or respiratory issues other than obstructive sleep apnea. You are using a PS of only 1.2 which is not really enough to overcome the flow limits, and you have really created some unusual respiratory timing issues that the low PS cannot contain. Did you use EPR on the Airsense 10 Autoset? Unfortunately Oscar is not properly reporting your respiratory statistics or settings, so we have to rely on the charts to really interpret your respiration. It may help to see a zoomed image of 2-3 minutes in length that shows the flow rate waves in detail. If you have a graph of the mask pressure, include that with flow rate. If you have a copy of a sleep test, redact personal information and post. It would really help to know why these unconventional settings are being used.

[ewriter]

Hi Sleeprider,

I will get the zoomed-in image to you later today.

I'm not treating other issues, as far as i know. My Cardiac workups don't show any arrhythmia or abnormalities; but i do get a "flutter" sensation (more like the feeling of a water pipe shaking in a modulated rhythm; i was convinced it was fibrillation for a long time; but now i am not sure. It has been happening for many years and was controlled i guess by 80-120 mg Propranalol but when i cut the dose down to 20 mg it resurfaced). So in that sense, yes, i am treating this issue specifically but i know for a fact that my apneas/hypopneas are definitely causing it, or aggravating it.

The settings i am using on this machine. I can't say much except that i am working with a CPAP tech (not a Respiratory Therapist) to set the machine peoperly. He gives me some settings to try and i have been trying them; so far we are slowly making progress.

When i used the AirSense10 i wasn't told there was any difference between AutoSet For Her and AutoSet mode and i just used the machine on the AutoSet For Her for a long time (not sure how long maybe six months or a year or even 3.5 years) before switching to AutoSet mode. I set EPR to 3 but i think initially it was zero.

The last sleep test i had was a baseline test and showed AHI of 14. Desats were minimal with the lowest being 87% for about 90 seconds. I was advised to continue using the APAP at a pressure of 9, which i did. But i continued to have "flutter" which forced me awake every night, for the next six months that i used it before switching to the BiPAP.

I'm not sure why you mentioned PS of 1.2 as it is 1.4?

Also, regarding "you have really created some unusual respiratory timing issues that the low PS cannot contain" i don't know what to say as i am following the advice of my sleep tech. However, he doesn't know everything about this machine although he is using the same machine to treat his apneas (i don't know what his AHI is, though).

Will get you the sleep report and data this evening (i am in Singapore currently).

Thanks!
ps (1) do you think it would help if i set everything to Auto on the machine, and allowed it to do the titration automatically?
(2) I did use Auto BiPAP mode on the old Respironics but had terrible sleep with it; and the APAP mode on the Aire10 seemed to be causing more issues than it was
resolving the last time i used it (i could attach a chart from my last Aire10 usage if that would help?)

Paul

[Sleeprider]

Your PS is far to low to have any effect in S or ST mode. We use pressure support on an ST to overcome flow limitation, hypopnea, and to supplement inspiratory tidal volume and stimulate a breath in the event of a central apnea.  Yours can do none of that, and whoever set it has no understanding of the device.  I'm going to recommend some fairly radical changes to your settings, but I'm trying to gather enough information to do that intelligently.  Nothing about your settings is currently correct from respiration rate to pressures and other settings, we're starting over.

A basic ST titration protocol is below. It's pretty obvious you were never titrated  according to a protocol like this.  Note the starting PS is 4.0.

[ewriter]

Hi Sleeprider,

I have attached a zoomed-in version of the Flow Rate and also the Mask Pressure. These are for April 18 and we have made some increases to PS since then (now at 1.7). 

I seem to be very sensitive to pressure changes mid-stream, so I think my PAP tech is slowly adjusting the PS upwards.

Current settings:

IPAP Max: 10
EPAP Min: 8.1
PS 1.7
Rise Time: 300
I Trigger: Auto
Auto F: ON
Breathing rate: 17
E Trigger: 1
Ti Control: ON
Ti Max: 2.3
Ti Min: 1.6
Vt: OFF
All other settings are "greyed out"

I want to make it clear that i have had the "flutter" (it used to be a mild "buzzing" and then became a "rolling sensation" like a pipe vibrating rhythmically), which 120 mg of Propranalol completely subdued) extensively investigated over a 27 year period; but my doctor and Cardiologists in several countries have not found anything more than a benign condition they cannot describe or detect (even on a 14-day Holter about a year ago). The only thing that really works is a lot of beta blocker; but as i am now 59 and there are side effects of chronic long-term use of beta blockers, i started tapering the 120 mg/day dose given in the UK when i came back to Canada (can't remember when i started the taper) until, in 2018/2019 i was down to 80 mg/day and doing great (i was never woken up from sleep by a "flutter") and then, all the way down to 20 mg/day in 2023. I am currently on 20-30 mg a day but switched (for the second time in a year) back to Bystolic because Bystolic is less toxic, and more targeted to heart issues; i am taking slightly more than 10 mg (apparently, a strong dose).

I greatly appreciate any help and i will go through your email again in detail. I have a sleep tech who makes house visits and helps me to titrate the machine; but this is a long process and at the moment, i think it's getting close to two months. I do feel more rested during the day, not so jetlagged (on the Bystolic) and do not suffer from the disabling panic attacks linked to the "flutter" that i suffered last year; but i do believe, at the moment, medication and PAP are needed to see the most progress.

[ewriter]

Hi Sleeprider,

I forgot to attach the Sleep report. I had one done about a year ago and insisted on having a baseline in-house study done; so i was only on a small dose of Clonazepam (i think maybe 0.5 mg) for this study and the Propranalol.

[ewriter]

Hi SleepRider,

The final two pages of my latest Sleep Study.

From what i can see, they felt that my results were good. I wasn't satisfied, however, as i continued to use the Aire10 in APAP mode and was continually woken up by "flutter" or a racing heart or bounding beat, etc. and i felt the machine itself might be causing me issues (hence the change to a BiPAP). I made several more calls to the sleep Lab (via Zoom) but the sleep doctor was not that helpful. He suggested increasing the pressure as high as 20, staying on APAP or switching to CPAP; but he didn't give me any other prescription except for a pressure of 9 cm. 

Please Note: i have been very functional and travelled to and lived and worked in four countries since 2001, lived and worked in Toronto for ten years, and drove for Uber for 3 years plus, including passengers, and SKIP the Dishes and Doordash, clocking an average of 120-200 km /day city driving. I find it very hard to believe that my sleep apnea is that severe (and so do my doctors and Cardiologists, etc).

However, the anxiety attacks i get when i think (or someone suggests) i have a horrible disease can become very disabling if i allow them. By God's grace, i have recovered a lot but, please don't make flippant remarks or suggest i have severe disease, as this can set off a bad panic attack.

I will discuss your feedback with my sleep tech. He is doing his best, working with me for free, essentially, and doing home visits, to help me to titrate my pressure and settings, when my Canadian DME did very little and my sleep doctor was not helpful at all.