Optimal Settings on iBreeze BiPAP to reduce FL

[ewriter]

Hi Sleeprider,

Yes, you were absolutely right. I will make sure to listen in the future! I will post the Resvent data here later; i just installed the software.

My main goal, believe it or not, for PAP therapy, has been (for the past 20 months, anyway -- and I only realised that this was the goal a few weeks ago!) to reduce the narrowing i get in my airway, which definitely causes the "flutter." This is the case, even though i have been using PAP therapy since 2011. I could never discover what was causing the "buzzing/fluttering" in my chest; and none of the 30 doctors and seven or eight Cardiologists in four countries could find out what was causing it, either (to date all my Cardiac workups are very good and i have no trouble running on a treadmill for 30 minutes at an incline of 4 or more).

Here's my main issue: severe anxiety and fear, which overwhelms me when this "flutter" sensation starts. I only get this when i am attempting to nap, or trying to fall asleep in bed and still awake, and my heart rate is slowly approaching the 40s. I also get it when i am waking up, and my heart rate is starting to move to the 50s and 60s. As far as i can tell, i have had Bradycardia for some time; but my doctors and Cardiologists don't seem to care. They also don't seem to be bothered by the fact that the Propranalol i was prescribed in 2006 in the UK (likely for severe anxiety and panic attacks over the "flutter," which abruptly wakes me out of my sleep) is probably the cause of the Brady.

I have tapered the Propranalol down to 30 mg a day but i don't like it's side effects; it makes me always feel jetlagged and fatigued even at 10 mg. And it can cause arrhythmia, Brady and even heart block in some individuals (this on top of any issues caused by inadequate PAP therapy).

The long story short (27 years) is that i probably had sleep apnea when i was a teenager or as early as at least 1997; but i did not know it and, even when diagnosed in 2005 (AHI 23) i was absolutely petrified of wearing a mask "for the rest of my life" and refused to buy a CPAP machine. Note that this was in 2005; and the Propranalol was prescribed in 2006. However, because i moved between the UK and Canada between 2001 and 2008 (when i moved to Singapore), nobody -- especially me -- connected the dots that my refusal to get a CPAP literally was the cause of my panic attacks in 2006 and the subsequent prescription of Propranalol (and any issues it may have caused).

I am grateful for the BiPAP as the therapy does appear to be helping. When i first used CPAP in 2011, my recovery was remarkable and i became fully functional and extremely busy, until in Canada, i was driving for Uber, Doordash and SKIP up to 200 km a day in the City, and driving people as well, and having no issues sleeping with my Respironics System One (later an Aire10 AutoSet For Her), and then everything broke down in 2023 January, probably because i had tapered the Propranalol down, at that point, to 20 mg a day. I was doing fine and then, suddenly, the "flutter" started coming back (only once or twice a week and not severe). 

The "flutter" was waking me up in January 2023 after only 90 minutes of sleep, and i could not return to sleep. This went on for a month; and my doctor prescribed antidepressants, which only made things much, much worse (i am not on these anymore but do take 0.5 mg Clonazepam every night). 

I am looking to God to heal me and i believe He is doing that; but i also need to do everything i can to achieve the best results and, i want to thank you for your help. I am hopeful that with appropriate pressure (and perhaps I will need to switch to S mode soon) and no complicated interruptions in flow (caused by unnecessary trigger or backup rate or other settings), i will fully recover my sanity and functionality and no longer be forced to manage my PAP therapy so much, that i find it very difficult to focus on anything else.

I really don't know what is going on with me: when i was leaning on the bed today, i may have almost started to nap (not sure) and i got a bad "flutter" which really feels like a "block" from the top of my heart to the bottom (but i am guessing; and my Cardiologists cannot find anything even on a 2 week Holter and two Echoes about a year ago).

Thanks and looking forward to your reply.

Paul

[ewriter]

Hi Sleeprider,

I think i might have to answer your question "Are you treating pulmonary or respiratory issues other than obstructive sleep apnea." in the positive but it's unclear. I am still experiencing the "flutter" sensation; it's there when i wake up, in spite of having AHI=0 and setting the pressure to 11/7.

Last night, i had quite a few hyponeas (AHI of 0.0 but HI of 5.6) and i am not sure why. I was using mouth tape. Perhaps it is the sedatives? Last night i took 10mg slow-release Melatonin (i have run out of Dayvigo and Zopiclone) and 25 mg of Hydroxyzine, plus 10 mg Propranalol (i normally take 20 - 30 mg at night but i have been trying to cut down. In 2006 i was prescribed 120 mg, probably for anxiety).

Do you have any suggestions?

I have attached the data from Oscar and the iMatrix report PDF (i imported the data into iMatrix; but i can't seem to take a screenshot and i don't know how to export or print the data. Any ideas?) though i am not sure where to go in the menu to get the data you might be interested in.

I noticed something: if i calm down during the "flutter" and modulate my breathing, this ends the "flutter" very quickly (less than 10 seconds). So i am hopeful that making some fine-tuning and adjusting my breathing patterns when asleep using the BiPAP, i will be able to smooth out the "flutter" and get rid of it (i believe this happened before; but i was on 80 mg/day of Propranalol and that might have masked this "flutter."

According to all my cardiac workups so far, the "flutter" is either not real or benign and caused primarily by anxiety. I think it's also apneas/hyponeas that induce it; and my anxiety in response to it, makes it worse (and also increases my blood pressure, which was 154/90 this morning but normal last night).

I did make one change since i implemented your suggested PS (11 and 7) which was to extend the Rise Time to 400 from 300; but i didn't change anything else. Perhaps i should try 12/8 ? Then put that in S mode?

Please can you make time for a reply i really need help with this!

I have attached a Zoomed-in view of one of the longer Hyponeas (some of them 60 seconds), together with the Oscar data from the previous night when AHI = 0.0.

Thanks!

Paul

[ewriter]

Hi Sleeprider,

Though i tried your settings in Auto S/T mode, and also switched to S mode with PS of 7/11, i was woken by significant "flutter" (perhaps and apparently a heart rate of 145). This was with a Rise Time of 500 and Backup Breath of 5.

I don't know what to do. I don't know what to do.

Based on the following article (https://pubmed.ncbi.nlm.nih.gov/16149210/ ), the stimulation to breathe naturally comes from the reduction in CO2 to specific levels. My question is how does any CPAP machine measure this O2 saturation level? Do they have sensors?

Here's the part: "When PaCO2 falls below the threshold required to stimulate breathing, the central drive to respiratory muscles and air inflow ceases and central apnea ensues. Apnea, hypoxia, CO2 retention and arousals provoke elevated sympathetic activity, increased afterload and elevated left ventricular transmural pressure, and promote the progression of heart failure."

I am going through great difficulty at night trying to rest and get quality sleep, after buying this new machine. I have been using mouth tape, a neck brace and nasal tubes (short straws) to keep my airway as patent as possible (i have somewhat of a deviated septum on the left).

I have tried the S mode alone for one night (PS of 4 as you suggested and using 12/8; therapy results were similar to the Auto S/T but i had maybe double the AHI (1.7 vs < 0.5). So i am not certain about using the S mode alone, at 12/8. Do you think,  over the long term, the AHI will drop and my "flutter" will resolve (it appears to be directly related to apneas and hyponeas, and seems to start even when my heart rate drops to the 40s).

In order to try and improve things, i have weaned myself down to about 10 mg Propranalol, as it was dropping my heart rate into the 40s (i am only 59) and it seems that the "palpitations" i am getting are related to this induced lowered heart rate; that's why, once my heart rate starts rising above 55 or so in the morning, all the "flutters" stop completely.

I really welcome your informed assistance and knowledge. Is there any information you can give, further?

Thanks!

Paul

[Sleeprider]

There are no sensors for PaCO2 or any CO2 on any CPAP. We can manipulate CO2 by using enhanced expiratory rebreathing space (EERS), which is simply providing a small space or extra tubing for accumulation of expired air, that is then re-breathed on the next inhale. We have a Wiki for that.

I see the events being marks as flow limitation as obstructive apnea, and it is clustered, or positional.

[ewriter]

Hi Sleeprider,

I followed your suggestions and increased PS to 4 and EPAP to 12 (at one point, i tried 8/12 but got so many clustered apneas and hyponeas, i switched down to 7/11 and i am gradually trying to move up).

However, the "flutter" symptoms i mentioned have not disappeared even when AHI is zero; they only seem to be significantly affected when i increase the dose of beta blocker (Propranalol). Doctors cannot help.

I'm using the Resvent iBreeze 25 ST/A in Auto/ST mode but i also tried S mode and this did not help.

Do you have any further suggestions?

Thanks!

Paul
ps i don't know what is happening and doctors can't help. I am beginning to wonder if my issues don't have anything to do with PAP therapy per se and could be caused by the Propranalol. I was originally prescribed 120 mg a day in 2006 and, due to the fact i lived and worked in four countries, i did not change the dose for a long time. In 2019 for example, i had weaned myself down to 80 mg/day. Cutting down seems to make things worse. I don't know if it is because i was cutting down the beta blocker; or because i have an issue that needs sufficient beta blocker to control symptoms; or because i was having a rebound effect from stopping the beta blocker; or because the PAP therapy was not quite adequate; or because the beta blocker was interfering with the PAP therapy.

[Sleeprider]

I can't explain the "flutter" and it may be unrelated to your positive pressure therapy, as your experimentation with different settings seems to confirm. At this point you should be focused on the most comfortable options for you, and I think getting PS to 4.0 was a pretty big step in the right direction.

[ewriter]

Turns out the neck brace was causing some cardiac issues including high blood pressure (eg 150/90) nd high heart rate (eg 140).