Optimal Settings on iBreeze BiPAP to reduce FL

[ewriter]

Hi Sleeprider,

As far as i know, the protocol my CPAP supplier is using follows the one you provided and we did start at PS of 4. But i was having a lot of problems, felt the pressure was far too high and that the high pressure caused my "flutter" and that was ALSO because (later on) i began getting a lot of bloating, which also seems to induce "flutter".

Note: it's possible i was overpressured for several years because i was using BOTH a Respironics System One at 12.5 to 14 cm for nine years, then did a sleep lab test (in 2020) where they found i was at AHI 7.0. Unfortunately, they did NOT tell me the pressure should be reduced and i was given a new prescription for 13 cm, with my new Aire10 AutoSet For Her. On APAP mode, i set the machine to a range from 4 - 12.5 cm (because 12.5 or thereabouts was the IPAP for my Respironics) and used that range for awhile, eventually moving to a range of 6/13 for the next 3.5 years. During those years, i did NOT wake up with "flutter" and severe anxiety and i was doing well and had a full and active life.

Today, i think what happened is that the APAP did not overpressure me (because it's APAP) but, because i had reduced my Propranalol down from 120 mg prescribed in the UK in 2006 (probably for anxiety -- remember, i had been diagnosed with mild/moderate sleep apnea in Canada in 2005 but had refused to get a machine. I did not connect the dots between not getting a machine, and waking up suddenly with "flutter" and severe anxiety in 2006. And many doctors i saw ALSO did not make the connection (one Cardiologist in the UK suggested i see a Psychiatrist).

I did well on the 120 mg Propranalol WITHOUT CPAP between 2005 - 2011, when i started getting severe, "narcolepsy-like" symptoms. I finally gave in, got tested a second time for sleep apnea by a Specialist ENT, and bought my Respironics System One (i also pulled out all the insulation after awhile as the machine began to whine).

I am getting more sleep and the BiPAP therapy is helping. We are slowly raising the PS (which as far as i know is added to EPAP) to allow me to comfortably breathe on this machine, while not inducing "flutter" by sudden changes of pressure, too much pressure in my abdomen, or allowing air to leak too much into my stomach; this might explain the low PS.

I'm not sure i understand your comment. The BiPAP AST is a different machine from the Resmed Aire10 and has many more options including Trigger sensitivity and breath length; what would you suggest? 

I value your feedback and input very much.

Thanks!

Paul

[Sleeprider]

You have a respiration backup rate of 17 BPM set on your machine. Your titration and diagnostic data do not include a backup rate. The mode needs to be changed to "S" for bilevel without the timed backup rate. The 17 BPM rate is too high, and it should be set at your normal breathing rate minus 3 bpm. Since the Oscar summary data is not accurate, I need to see a typical 3-minute zoom of the flow rate to give you an idea; however, you should not be in ST mode. Your therapist is doing it wrong.

You may want to download the Resvent Imatrix software from the Private Files forum. Oscar is not doing the job. https://www.apneaboard.com/forums/Forum-...-and-Links

[ewriter]

Hi Sleeprider,

I agree with your assessment that my PS is too low. I have read the following article:

Clinical Guidelines for the Manual Titration of Positive Airway Pressure in Patients with Obstructive Sleep Apnea | Journal of Clinical Sleep Medicine (aasm.org)

While this article appears to be specific to CPAP, it isn't and it also discusses BiPAP; the initial PS is supposed to be 4.0.

Here is the specific content:

Based on this review, the Task Force developed these recommendations for conducting CPAP and BPAP titrations. Major recommendations are as follows: (1) All potential PAP titration candidates should receive adequate PAP education, hands-on demonstration, careful mask fitting, and acclimatization prior to titration. (2) CPAP (IPAP and/or EPAP for patients on BPAP) should be increased until the following obstructive respiratory events are eliminated (no specific order) or the recommended maximum CPAP (IPAP for patients on BPAP) is reached: apneas, hypopneas, respiratory effort-related arousals (RERAs), and snoring. (3) The recommended minimum starting CPAP should be 4 cm H2O for pediatric and adult patients, and the recommended minimum starting IPAP and EPAP should be 8 cm H2O and 4 cm H2O, respectively, for pediatric and adult patients on BPAP. (4) The recommended maximum CPAP should be 15 cm H2O (or recommended maximum IPAP of 20 cm H2O if on BPAP) for patients <12 years, and 20 cm H2O (or recommended maximum IPAP of 30 cm H2O if on BPAP) for patients ≥12 years. (5) The recommended minimum IPAP-EPAP differential is 4 cm H2O and the recommended maximum IPAP-EPAP differential is 10 cm H2O (6) CPAP (IPAP and/or EPAP for patients on BPAP depending on the type of event) should be increased by at least 1 cm H2O with an interval no shorter than 5 min, with the goal of eliminating obstructive respiratory events. (7) CPAP (IPAP and EPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 1 obstructive apnea is observed for patients <12 years, or if at least 2 obstructive apneas are observed for patients ≥12 years. (8) CPAP (IPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 1 hypopnea is observed for patients <12 years, or if at least 3 hypopneas are observed for patients ≥12 years. (9) CPAP (IPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 3 RERAs are observed for patients <12 years, or if at least 5 RERAs are observed for patients ≥12 years. (10) CPAP (IPAP for patients on BPAP) may be increased from any CPAP (or IPAP) level if at least 1 min of loud or unambiguous snoring is observed for patients <12 years, or if at least 3 min of loud or unambiguous snoring are observed for patients ≥12 years. (11) The titration algorithm for split-night CPAP or BPAP titration studies should be identical to that of full-night CPAP or BPAP titration studies, respectively. (12) If the patient is uncomfortable or intolerant of high pressures on CPAP, the patient may be tried on BPAP. If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the patient may be switched to BPAP. (13) The pressure of CPAP or BPAP selected for patient use following the titration study should reflect control of the patient's obstructive respiration by a low (preferably <5 per hour) respiratory disturbance index (RDI) at the selected pressure, a minimum sea level SpO2 above 90% at the pressure, and with a leak within acceptable parameters at the pressure. (14) An optimal titration reduces RDI <5 for at least a 15-min duration and should include supine REM sleep at the selected pressure that is not continually interrupted by spontaneous arousals or awakenings. (15) A good titration reduces RDI ≤10 or by 50% if the baseline RDI <15 and should include supine REM sleep that is not continually interrupted by spontaneous arousals or awakenings at the selected pressure. (16) An adequate titration does not reduce the RDI ≤10 but reduces the RDI by 75% from baseline (especially in severe OSA patients), or one in which the titration grading criteria for optimal or good are met with the exception that supine REM sleep did not occur at the selected pressure. (17) An unacceptable titration is one that does not meet any one of the above grades. (18) A repeat PAP titration study should be considered if the initial titration does not achieve a grade of optimal or good and, if it is a split-night PSG study, it fails to meet AASM criteria (i.e., titration duration should be >3 hr).

My sleep technician who sold me the machine here in Singapore has been extremely helpful and has gone completely out of his way to support my efforts to get my apnea and it's sequalae under control. I believe back in March we started at pressures of 4/8 based on my Sleep Study, which said i needed pressure of 9 (later, the doctor said i could use any mode, APAP or CPAP, as long as i didn't go above 20 cm. However, he has not really been that helpful and didn't care what type of mask i used, for example, nor that i have to take sedatives to even get to sleep).

I have been dealing with the consequences of sleep apnea (both treated and untreated) since 2011 when i purchased my first CPAP machine after resisting for six years after my first Titration study, however, it's very likely that i started getting issues from sleep apnea, together with stuffy nose, severe allergies to dust mites and mould, and a deviated septum, plus a narrow airway and a big tongue, since 1997. This is when i was first woken up abruptly from sleep, could not sleep through the night for many months; and when i woke up, sometimes my legs would be shaking or shivering for "no reason." Because i enjoyed drinking alcohol (two bottles of wine a week sometimes, plus some beers and/or several glasses of spirits or mixers) and did not know i had sleep apnea until 2005, i suffered for many years with the effects of undiagnosed and untreated sleep apnea (like hundreds of millions if not billions of human beings). Doctors couldn't help me much at all, even though i have seen 30+ doctors and Cardiologists, ENTs, Psychiatrists and Sleep Clinic doctors in four countries (I move around a lot due to my work as a software Technical Writer).

My conclusion (only recently arrived at) is that i have a form of UARS which is easily treated if i had a strong enough oral appliance to prevent my soft palate from collapsing when i enter REM. I am currently using a neck brace, used to use a chinstrap, nasal spray, and Propranalol (the latter helps to control blood pressure spikes from severe apneas); however, i am on my third machine since 2011 and i am extremely disturbed by the return of a "heart flutter" (subclinical and does not show up on even a 14-day holter) that i have confirmed personally is caused directly by my soft palate falling closed, even when i am sitting upright and begin to doze.

Do you think there is any hope of my setting my new BiPAP correctly so that i can achieve the optimal pressure to keep my airway patent, without the pressure going above the level that causes so much aerophagia that my stomach presses against my Vagus nerve and my heart (especially when i am on my left side) and induces the "flutter"? If i do sleep on my left, with or without PAP, within my first sleep cycle i will eventually be forced awake. Sometimes, i won't have any "flutter". But if i again go back to sleep on my left side or my back, with or without CPAP, i get the "flutter" and it is no longer once a week or a few moments long; it appears to be occurring every night and sometimes subtly during the day; and it can go on for several hours. The strange thing is, if i wake up with it, and i "tap" my chest once, it stops (does this make sense from a Cardiac standpoint).

My current Cardiologists (i have seen two in Canada, one is a Specialist; and one in Singapore just a week or two ago) don't believe my condition is anything more than severe anxiety and "palpitations" and they, along with my family doctor, are extremely dismissive. They don't mind pushing more beta blockers on me (which could actually be making me worse, especially as i have been on Propranalol for 16 years and was started at 120 mg, tapering down to 30-40 mg a day now) but refuse to believe that my apneas could have anything to do with the "flutter" (in fact, my Canadian family doctor has stated that there is no evidence that they are linked).

So, again, i believe there is a very good chance that i can recover fully from this "flutter" which did subside completely, for many years, in the past, even with very poor PAP compliance and a significantly leaking mask (sometimes i would be off CPAP, feeling no need for it, for MONTHS); but i need to find the best pressure to patent my airway; or else i must find an alternative (e.g. iNAP or oral appliance) which can save me from further damage.

I have insurance to cover some costs; but the issue there is that i can't buy any new devices unless they're approved by the insurer and, i must wait five years between purchases. This obviously is inadequate when a solution is needed asap.

Any feedback you can provide is greatly appreciated.

Thanks!

Paul

[ewriter]

Hi Sleeprider,

Thanks so much!

I will change the backup rate to 15 - 3 based on your advice (my own test sitting down for the past hour) and switch to "S" mode (we tried S mode for about a month but as i was still having "flutter" i believe this is why we switched to Auto ST mode). I will also change the mode to S and see how things go, for tonight.

I will send you the Zoomed-in 3-minute flow rate tomorrow if possible.

I am still having panic attacks relating to the "flutter" especially (as with this morning) when i am trying Bystolic (switching from Propranalol), and i reduced the dose and got what felt like an irregular heartbeat (my Cardiologist knows about this).

[Sleeprider]

These changes will make a significant difference. If you increase the backup rate from 12 BPM based on the "feel:, go one step at a time to 13, then 14 bpm. Post a chart so we can track what this does for events. As I said before, without these changes, using ST was counter-productive.

[ewriter]

Hi SleepRider,

On this machine, there is no "Backup Rate" in S mode; only in Auto S/T. How do I apply the suggested backup rate setting by switching to "S" mode?

"The 17 BPM rate is too high, and it should be set at your normal breathing rate minus 3 bpm." In my case, resting awake breathing rate is 15 (so the setting should be 12); however, i have no idea what it is exactly, when i am deep asleep.

Attached are last night's results for Auto/ST. With such a low AHI, are these good results or not? (i did not make any changes yet). I am confused, because my sleep tech would probably say these are good results. However, i still woke at around 5 am and i think i was having "low level flutter." What i don't know for 100% certainty is whether or not the Bystolic (beta blocker) has "induced" the "flutter" because of Bradycardia (my sleeping/REM heartrate usually drops into the low 40s and that's when it get this "flutter" just as i fall into REM, or when i am resting and not sleeping, and my heart rate falls below 50s).

After i woke up, unfortunately, i tried to sleep on my left side without the PAP and fell asleep, waking up with what felt like an irregular beat, which is still frightening me after 16 months (i didn't have it at all last January but it might be related to the Bystolic; i might not get it when i am on the Propranalol, even without PAP). I have been getting "low level flutter" or some kind of muscle vibration (i don't know if it's Cardiac because multiple tests at my Cardiologists have ruled this out completely), normally when i fall asleep on my left side. It also happens when i fall asleep on my right side and on my back but it did not happen in the past. Again, it "might" be related to my tapering of Propranalol too much between 2006 - 2023 (from 120 mg down to 20 mg/day) and i am hesitant to increase the dose because i have been taking Propranalol for 16 years now and my doctors here (it was prescribed in the UK in 2006, likely for panic attacks relating to my complaints about a "chest vibration" or "flutter") are not sure i should even be on it (my blood pressure during the day is very good in general and it only spikes when i have apneas, as i have checked when i am getting the "flutter" and it is usually a bit high e.g. 153/87). With the current settings, the "flutter" appears to be subsiding and the blood pressure is getting better but it's a very slow process.

I don't want to sound critical; but i think the Titration settings you provided are for individuals who have conditions that I don't have? or who have central apneas (I have had some CAs in the past but for months now i have not had any):

- neuromuscular/restrictive disorders
- COPD
- Obesity hypoventilation

Note: I was not prescribed a specific CPAP as you can see in my sleep report. I bought this machine to replace the Aire10, which is only about 4 years old, because i felt a "backup rate" and/or a more sophisticated machine with Triggers and breath control might help me (but, then again, it might be overkill). As far as i know do not suffer from COPD or any other pulmonary or lung condition. My results on the BiPAP titration so far are very good in terms of AHI (for the past two weeks or so, less than 1 and sometimes zero, with <1.0 residual hyponeas and i think RERAS are also <1.0. It is these hyponeas and RERAS which we are trying to eliminate, as i appear to have become sensitized to them.

I am concerned that going to a much higher PS will create havoc, since i am now used to a PS < 2.0. When i tried the settings you suggested, while awake, i felt the pressure was definitely high.

I am confused, because you have suggested using a Backup Rate; but there is no Backup Rate setting in "S" mode.

Please can you clarify?

I have attached some additional charts in the hope you can help me gain improvements and eliminate the "flutter," which as far as i know is driven not by apneas or centrals but by hyponeas (or something that the machine cannot or does not add to the data card, or perhaps isn't designed to detect).

I will attach a couple more charts in a followup post, from previous settings, where there were many flow limitations (such as for April 18) as i can only attach 3 charts at a time in a single message here.

Thanks,

Paul

[ewriter]

Hi Sleeprider,

Attached are some charts for significant FL on April 18. I have zoomed in some of them.

I will download the software for iBreeze, as Oscar doesn't provide complete data.

Thanks!

Paul

[Sleeprider]

If you switch to S-mode there will be no backup rate, only straight bilevel pressures with spontaneous triggering. ST mode of course uses a timed trigger in the event you fail to spontaneously inhale at the pace set by the BPM. For example at 12 BPM, that is every 5-seconds, but at 17 BPM it is every 3.5 seconds. What I have been trying to tell you is that with PS set to only about 1-cm, neither pressure support nor timing has any effect. You are on CPAP.

Based on your chart, the hypopnea at 15:36:20 was obstructive and caused by RERA. Following that event your breath rate was 12 BPM showing your backup rate of 17 is patently incorrect if it was to be used with effective pressure support. There are many flow limited breaths in this segment in addition to the hypopnea showing you NEED more pressure support. The other chart is zoomed in too far to be useful, but again looks obstructive. Your charts show you don't need a timed trigger, and using BiPAP S will provide good therapy.

Using my suggested settings is your choice, but if your choice is not to use them, please don't waste my time.

[ewriter]

Hi Sleeprider,

I'm still a bit confused as this machine has both an ST mode and an Auto S/T mode. Which one are you referring to? Only the Auto S/T mode has the Backup Rate setting; not the ST mode.

I am going to assume you mean the Auto S/T mode and change the Backup Rate to 12 for tonight. Because i am getting such good AHI results at the moment, i won't change anything else. However, i am considering changing the PS as you suggested; but going from 1.7 straight to 4.0 is probably a bad idea (i was on 4.0 before).

As far as i know, PS is added to EPAP to get IPAP and since my EPAP is 8.1 right now, that would mean my Min. IPAP become 12.1 (I THINK) which would be intolerable (my Aire10 which i used for 3.5 years was set to AutoSet for Her for most of that time (my DME said it didn't matter whether "AutoSet Standard or AutoSet For Her" was used; but i think it does matter. Anyway, i used EPR of 3 and APAP of 6/13 meaning that (i think) my typical IPAP was 10. My latest Sleep Study says 9 is my optimal setting; but the sleep doctor (who wasn't that helpful after the Titration) suggested i could go as low as 7.

Thanks

Paul









Which

[Sleeprider]

I'm not familiar with how the iBreeze modes function, but you do not need a backup rate, but you can certainly use bilevel with higher PS. It's probably easier if you just use the ST mode or if there is such a thing as S mode, that one. If your Autoset was in the range of 6 to 13 pressure, then your pressure range was 6/4 (IPAP/EPAP) to 13/10. A pressure of 12/8 is not that high, and is below the maximum pressure of your Autoset, but if it is intolerable, then try 11/7.