[Treatment] Help Please - Hypopneas remain with BIPAP

[Newby]

Hi all,

62 year old female, 5'4", 140 lb.   No other (known) issues.
Diagnosed with sleep apnea after an at home test about 18 months ago.
Tried CPAP for 3 months with significant treatment emergent CAs, primarily when supine.
Technician advised sleeping on side and sent me off to sleep lab.

PSG showed 2 CAs and 1 OA plus 75 Hypopneas (AHI 23.8).  All sleep was on side.
Titration showed an even split between CAs and Hypopneas when supine (AHI 44.5) and primarily Hypopneas when non-supine (AHI 19.2).
Ended up with BiPAP and recommendation for side sleep position.

Currently sleep only on side.  Have been using BiPAP in A/T mode since mid October.    Backup rate = 8, Ti = .3-1.5, rise time = min, triggers medium.
Started with IPAP 14, EPAP 10 and technician adjusted weekly until we got to 13/8 and AHI approximately 7.
Technician is now happy but I am not (retired Engineer).   Oscar shows me way more than he looks at.

I have two concerns:    

First one is that I sometimes appear to have a strange breathing rhythm, often taking double breaths.
Also, the hypopneas appear to happen in conjunction with central events.    The backup kicks in for a few breaths but the tidal volume still drops.  I am not sure if I am interpreting this correctly.

I am attaching a full night overview from a typical night plus two zoomed in views, first with double breathing and second just prior to a hypopnea.

Any suggestions on how/what to adjust would be appreciated.   I plan to make slow adjustments.

Thanks for your help!


           

[Newby]

I am now almost one year using a BIPAP.   The best I can get to is 7-8 AHI.  I am hoping for some advice on what to adjust next.
Background in the post below from February.

• 62 year old female, 5'4", 130 lb, no other known issues
  
• ResMed AirCurve 10 ST-A
  
• PAP Mode: BiLevel-S/T
  
• EPAP 9.0 IPAP 13.0
  

Here's what I have tried:

• Tried using the machine is CPAP mode (no timed mode).    No change in AHI but Apneas instead of Hypopneas.   Returned to BIPAP after 7 weeks.
  
• Adjusted the BIPAP parameters (based on info found here) to Ti = .3-2.0, Trigger and Cycle medium, Rise time = 300ms.   This made it much more comfortable.
  
• Tried cervical collar since sometimes the events are grouped - no change.   I do sleep 100% on my side.
  
• Eliminated ramp-up time - this actually made AHI worse as I got multiple clustered events at the beginning of the night.
  
• Adjusted EPAP to 10 - this made things substantially worse.
  

The charts posted below are from a night where I wore a cervical collar.

Questions:

• Is it possible to tell whether these are Central or Obstructive events based on the wave pattern?    It seems like the timed mode always kicks in before an event is flagged.
  
• Any thoughts on the double breathing? or on the breathing pattern in general?
  
• Suggestions on what to adjust next?
  

Thanks for your assistance!



                  

Full night                          Regular breathing              Cluster of Events

[staceyburke]

It looks like positional apnea from grouped H events. I know you tried a collar but maybe it was not well fitting. The main size is the height of the collar. The correct height is the distance from the chin to your sternum and tight enough that your chin can NOT slip down.

[Jay51]

What you label as "double breathing" may be you and the back up rate of 8 not syncing all the time perfectly.  

Your median respiratory rate is around 15.  Even though your tidal volume is a little bit low around 350 or so, you have a decent minute ventilation because your respiratory rate is good at 15.  

It is just a matter of getting the timing better IMO.   You can change the back up rate a little bit if you want to.  Possibly try 9 and 10, etc.  Even 7 if you want just to see how that affects your respiratory rate, tidal volume, and "double breathing" as you put it.  You can also tweak Ti, Cycle, Trigger, Rise Time, etc.  It may take some time to get things as smooth as you would personally like.  Lots of settings can be good in that when everything is just right, it is great therapy.  But it takes more time to test every little setting to see if a change to that particular setting can help or hinder your therapy.  

The ST(A) can effectively treat CA's with its back up rate capabilities.  

I agree with Stacey's assessment as well.

[Phaleronic]

Welcome to the forum Newby

With your large number of hyopneas and your low ipap pressure setting you please need to open the machine up to allow it to add enough pressure to know them down, keep ti trigger timing as you have it (as it's comfortable) but raise ipap to 17cm please.

This is the basic titration protocol for ST:

• Set IPAP at 8 cm H2
O
• Set EPAP at 4 cm H2
O
• Set Rate at 8-10 BPM or 2 BPM below the patient’s spontaneous rate
• Set I-Time at 1.5 seconds or patient comfort
• Set Rise time at 2 or 3 patient comfort