[Pressure] BiPap air pressure question

[AmbitiousCut0]

Hi all,

I'm posting in regards to my brother who has had untreated OSA for years. We finally bought a bipap machine after receiving our titration results/prescription.

He hasn't used it yet and I have a couple concerns. When we went to the cpap store we got a comfortable mask but it would not get a good seal when we tested it (too much facial hair and pressure) his prescription is 25 inhale/10 exhale, basically max inhale.

He said the pressure was way too uncomfortable for him and didn't want to use it so the 2000 dollar machine is just sitting in the corner for about a week. We really wanna start using it during the day so he can hopefully get a good night's rest for once in his life.

I was reading about how we could adjust the pressure settings through the clinical menu and I wanted to try that out to see if I can get his AHI below 5 but have a comfortable sleep by keeping the pressure lower.

Things to consider is that he is a mouth breather (using full face mask), his AHI is 69, has a very deviated septum so basically can only breathe through one nostril, and from one of his MRI scans shows that he's missing a sinus.

He also has terrible insurance and I think they might have prescribed him too much inhale pressure. The sleep study didn't even have the right size mask for him. I plan to monitor him to lower it but wanted to start at a lower pressure because I read on this subreddit that there's a condition called "venous return" which "negatively lowers your blood pressure in a drastic way" me knowing nothing in the medical field this scares me for him to try such a high pressure.

I've read posts and seen videos saying if I can read the results from the SD card I can adjust it myself accordingly. His insurance doesn't have any sleep doctors and his primary care provider doesn't know about sleep at all. Should I go with the prescription or try lower pressures at first? I was thinking of starting him at 10 or something and working up if needed but I'm also unsure what to set the exhale to since it's a bipap machine and has 2 separate settings (airsense 10 vauto) Also was wondering if I could use it as an apap or if it wouldn't be recommended.

I made this same post on reddit and was recommended to post here since more people know about BiPaps here. Also I am familiar with the ramp up function but that wasn't exactly the solution I was looking for.

P.S. is it necessary to use the built in humidifier? (Live in Southern Califronia so not very humid here.)

[cmpman1974]

25/10 is some serious pressure!   Even at 20, I had major issues controlling any leaks.  How on earth does someone get a 25/10 prescribed level, but at the same time you said insurance had no sleep docs. I'm confused there. Who set this? Who would offer a recommended pressure and perform the polysomnogram if not a qualified facility/medical doctor?

[AmbitiousCut0]

25/10 is some serious pressure!   Even at 20, I had major issues controlling any leaks.  How on earth does someone get a 25/10 prescribed level, but at the same time you said insurance had no sleep docs.  I'm confused there.  Who set this?  Who would offer a recommended pressure and perform the polysomnogram if not a qualified facility/medical doctor?

Yup that's exactly what I was thinking, I believe the reason why was because we had asked the sleep study to expedite the prescription because my brother had gone through leg surgery and was at the point where he couldn't fall asleep until after a few days of being sleep deprived. I'm thinking they just BSed something and gave it the okay. There are sleep doctors that review the sleep study but there isn't a specialist he can go sit down and talk to one on one that's in his insurance network, so it would just be another sleep study essentially which is too small of a sample size with suboptimal testing conditions imo.

I wanna start him off at low pressure to reduce leaking, get some data, measure his AHI, see how he tolerates sleeping with the mask on, and go from there. My only issue is since it's a bipap with 2 separate pressures I'm not sure if the inhale/exhale should match but I was thinking of starting anywhere from 7-10 pressure and perhaps ramping it up to 15 to see if helps to provide a more comfortable experience although I have a feeling wouldn't be enough because he has severe OSA but I'd like him to just get used to the machine. 

Any thoughts would be appreciated.

[OpalRose]

Do you have a copy of the sleep study? If you do, post it here.

With an AHI of 69, it would be helpful to know the breakdown of that number.
How many were Obstructives and/or Centrals? Or was it more Hypopnea? All of that can determine the settings.

I too would hesitate to start someone on such a high pressure.

[Gideon]

Now try these settings the post your results.
What you quoted was a PS of 15 which is most likely wrong and I suspect a misunderstanding on your part.  
Try this

Mode=  Auto
Min EPAP=10
Max IPAP=25
PS=4

Please post the Daily pic from OSCAR so we can actually see what is going on.

[Sleeprider]

Gideon took the words right out of my mouth. No one could use EPAP 10, IPAP 25 (PS 15).

Your brother might be able to use nasal pillows. They are much easier to seal, and more comfortable. As long as he keeps his mouth shut and tongue on the roof of his mouth to exclude the air pressure, he will really like it. I use the Resmed Airfit P10 nasal pillows, and Gideon has a magnificent beard and also uses the nasal pillows.

[AmbitiousCut0]

Do you have a copy of the sleep study?  If you do, post it here.  

With an AHI of 69, it would be helpful to know the breakdown of that number.  
How many were Obstructives and/or Centrals?  Or was it more Hypopnea?  All of that can determine the settings.  

I too would hesitate to start someone on such a high pressure.

Had to merge a few screenshots from a word document since I wasn't sure what exactly to show let me know if it's too small. This includes both the polysomnograph and titration tests. (2 nights) He told me he wasn't comfortable in the mask they provided so he wasn't able to sleep much. He likes the full face one we bought with the BiPap. During the test he woke up with "full air pressure being blasted" so his cheeks were constantly puffed up. He had told the tech to lower the pressure twice, and after they did he eventually fell asleep. They started him off with a nose piece and later changed to full face mask to help with his breathing.

Now try these settings the post your results.
What you quoted was a PS of 15 which is most likely wrong and I suspect a misunderstanding on your part.  
Try this

Mode=  Auto
Min EPAP=10
Max IPAP=25
PS=4

Please post the Daily pic from OSCAR so we can actually see what is going on.

We haven't began using it but I will try those settings and get back to you when I have the data, my brother is pretty anxious when it comes to the air pressure, so I'd like for him to wear it during the day to get used to it and also you're right I'm not exactly sure what I meant by PS 15 I've been researching and reading the user manual.

Gideon took the words right out of my mouth. No one could use EPAP 10, IPAP 25 (PS 15).  

Your brother might be able to use nasal pillows. They are much easier to seal, and more comfortable. As long as he keeps his mouth shut and tongue on the roof of his mouth to exclude the air pressure, he will really like it.  I use the Resmed Airfit P10 nasal pillows, and Gideon has a magnificent beard and also uses the nasal pillows.

I think in the sleep study they started him off with a nasal pillow and tried breathing through his nose, and later he said he couldn't breathe through his mouth (his words) so they switched him to a full face mask. I've read that there are chin straps you can use with nasal pillows to keep the mouth shut but I'm not comfortable going that route, on top of that I've read that for extra high pressures full face mask is recommended...his beard isn't too thick so trimming it could help with the seal. I think he's alright with the full face mask it's just the pressure is too high for him.

Thank you all for the replies I'll make sure to keep you updated.

[Sleeprider]

The titration test recommended EPAP min 10, IPAP max 25 and PS 6.0. The titration test actually failed to demonstrate efficacy due to patient not sleeping. Looking at the hypnogram, it appears there was considerable central apnea onset with therapy in the first half of the titration, however later in the night CPAP titration (equal IPAP/EPAP) seems to have been helpful, but patient was awake most of this period. After falling back to sleep AHI remained high and was mostly obstructive.

I think it's going to take some trial and error to get decent results, and I'm pretty certain that he is going to need a soft cervical collar as his apnea does not respond to pressure alone. http://www.apneaboard.com/wiki/index.php...cal_Collar We will recognize the pattern of clustered apnea if present once he gets started. I don't think the titration portion of his sleep study gives us good guidance on pressure, especially since there was only a brief period where PS 5 or 6 was attempted at about 12:30 AM and efficacy was poor. Nothing there is persuasive to me to use the settings recommended in the report, so I'm going to confirm the ones suggested by Gideon will provide the best starting point:
Mode= Auto
Min EPAP=10
Max IPAP=25
PS=4

Please encourage your brother to join the forum and work with us first-hand. His feeling unwell and leaving the titration early may have been aerophagia (air in the stomach) from the high pressures. I think he is best served by interacting here directly.

[AmbitiousCut0]

Thank you for taking a look at the results. I'm pretty new to this so I'm not sure how adequate of a job they did but I had my suspicions and doubts. I assumed most of his apnea was obstructive rather than central so I may try doing the SCC if these settings don't seem to help him. I'll go ahead and review this with him and ask him to make an account on here to continue communicating with you guys I really appreciate all the feedback and suggestions.

[Sleeprider]

Ambitious, I think the frequent sleep disturbance could be sufficient to explain the centrals, but we're not really going to know until he is in therapy at home and able to put in some hours in a more comfortable environment. If we can sort out the positional, central and obstructive issues, then he will win the night.