[Treatment] Having several Unclassified Apneas....

[meatheadmd]

Hey there,

Have suspicion that I have UARS given I was previously on CPAP for a year without any real success (titrated pressures all the way to 15 cmH2O with EPR of 3, still with several unmarked arousals and feeling crappy with good sleep hygiene).

Now on BiPAP-S with 17/12 per Lankylefty's recommendations after doing an AXG Sleep Diagnostics call (I know how you all feel about him, but wanted to hear your perspectives too). Previously tried 14/10, 15/11, and 16/11 before with moderate improvement in data but not perfect. On the previous BiPAP settings (14/10, 15/11, and 16/11) I was having significant leaking from mouth breathing even though I was mouth taping. I was also getting a few post-arousal central apneas on 14/10 and 15/11 so I turned up trigger sensitivity to high then very high and it got rid of the central apneas (though I think these were more due to breathing after being aroused from not being on correct pressure). However, adjusting trigger made my aerophagia worse so I tried to fix aerophagia by adjusting rise time last night . I think this may be why I had so many unclassified apneas. Currently at a rise time of 600 ms. I want to go back to Easy Breathe as it feels much more natural but it seems to make my aerophagia worse. 

Can you all tell me what these unclassified apneas are from? What my rise time should be? Also what my trigger setting should be? Seems like when I adjust one parameter it just makes the other worse. Tried to attach screenshots from all pressure settings but limited to 3 attachments. Ill post more in comments

Thank you!

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Attached more screenshots...

[Sleeprider]

The UA are obstructive positional apnea. Fix your pillow avoid chin-tuck or get a soft cervical collar.

[Sleeprider]

I replied before on my phone, so didn't get into much detail. Is there a reason you're not using Vauto mode? Your results were better with 15/11 pressure, so I don't understand why you increased IPAP and and PS. I would honestly go back to Vauto mode, EPAP min 10, IPAP max 18, and PS 4, with whatever trigger sensitivity you need to resolve most of the centrals. I'm all into Lanky, but I'm far more cognizant of individual variation in response to the changes, and he still hasn't gotten to trigger sensitivity as a therapy option. I think I deserve a raise.

[meatheadmd]

Thanks for the recommendation, I will trial VAuto mode. I increased PS and my pressures per Lankys prescription. He stated that VAutos algorithm is too slow and inadequate in responding to flow limitations. What are your thoughts on that?

[Sleeprider]

Depends on the cause of the flow limits. The Vauto does not change PS on a breath by breath basis like ASV, so I'm not sure what the response expectation is. we try to set PS high enough to resolve flow limits proactively, while using the pressure range across an effective range for obstructive apnea. In S-mode, your device may not be registering PS correctly, and of course there is no pressure response. Since I have only seen your results in S-mode, I have no opinion because I don't see any variation in flow limits.

[meatheadmd]

Attached is what last nights data looked like on the settings you suggested @Sleeprider:

VAuto
IPAP 14 
EPAP 10 
PS 4 
Trigger Very high
Mask: Bleep eclipse with mouth taping

Looks somewhat improved (and feel relatively rested today though I am writing this just after waking up, I will see how I feel in the afternoon) but still having many arousals not marked by the machine. I am trying to get this leak rate under control but it is hard because it is due to mouth leaking/cheek puffing/air going into my mouth. I am using a bleep eclipse with great mask seal as well as mouth taping. I've tried the "push tongue into roof of mouth" trick to reduce this but it is hard to maintain that position through the night. 

What would you all suggest from here?

Also been having this irregular flattening of flow rate during REM that is not being marked as a flow limitation by the machine.

[Old Codger]

Overall, what is the main thing you’re trying to achieve? Most of your data results in the 15/10 and 14/10 show very good AHI results between 1 and 2. Until you get the leak fully under control, going up and down on your pressures is not going to be very helpful at really dialing in on a specific setting, because if the blower can’t be dialed in without fluctuations in leak, then you’re always compensating for something that is a moving variable.

[Sleeprider]

I don't see a need for changes from your last results, other than keep working on the leaks. Try to remember to minimize the monthly calendar for screenshots.