[Treatment] RagingBull - Bi-Level Help

[RagingBull]

Background:
Hey everyone, im a 27 yr old guy and i started suspecting sleep apnea or UARS within the past year or so. Always have had trouble with fatigue. My jaw is recessed. My breathing feels a bit restricted by my jaw, and gets worse when i force "good" posture or do a chin tuck.

I cannot sleep on my back or with my mouth open - I will wake up gasping for air if i do. I realize jaw surgery would probably benefit me, but i'd like to try a conservative approach if possible.

I had an at-home sleep study which showed 0 AHI / 3 RDI .  It was a level 2 sleep study (meaning it had EKG and EEG). I only slept 3 hours during it, and unfortunately the EEG cable came unplugged at one point. I'm not sure how much it captured. Anyways, I still decided to buy a used CPAP machine because at that point I was desperate and I still suspected breathing issues.

CPAP didn't provide relief, so i consulted with AXG Sleep Diagnostics and was recommended I try BiPAP for suspected UARS. Trying BiPAP made me feel worse due to central apneas.

I attached some screenshots with labels:
CPAP_fixed: 13.8 / 13.8
BiPAP_fixed: 12.40 / 7.80
BiPAP_VAuto: PS = 4


Now i'm wondering what I should try next. At this point, is it worth trying ASV? Should i stick with BiPAP but change the pressures? One thing to note is that I get aerophagia on pressures greater than 10. I would want to raise the pressure support to counteract that, but I'm worried about more central apneas. Even having an AHI of 5 due to mostly central apneas caused me to feel way worse. 

[OpalRose]

What is the Trigger setting while using the VAuto? The default setting is Medium.
Change it to High or Very High. That should help clean up the CA's.

You may also need to lower the PS a bit, but I would only make one change at a time.

The next time you post a screenshot, leave the Calendar off. This frees up the device statistics on the left side bar.

[RagingBull]

thanks Opal! Just checked, and these are the "other" settings including trigger:

Ti Max - 2.0s
Ti Min - 0.3s
Trigger - Med
Cycle - Med


I'll try setting the trigger to high or very high like you said. Please let me know if there's any more info or screenshots i can provide that might be useful to see.

[CPAPfriend]

I would get another, proper in-lab or at least EEG-inclusive sleep study.

Did you try different CPAP pressures?

Keep trying with bipap but at a lower PS, and the go from there. There's no clear indication for ASV at this point. The bilevel did eliminate your flow limitation, but, as observed, also created central apneas, though not too many, which is not uncommon.

Also, why did you choose those CPAP and bilevel pressures? They seem high unless you have evidence to suggest they're needed.

[RagingBull]

I am considering another sleep study, but I had a prominent sleep specialist (AXG Sleep Diagnostics) look at my sleep data already and suggest UARS. And since I have the machine already I figured I'd try and make it work.

For CPAP, i've tried a range of pressures (from 6 to 14). For BiPAP, I just started on roughly 12 / 8 since that's what the sleep specialist recommended.

One thing I'm confused about though is when people are saying to lower my PS. I'm already on a low PS of 4, and if I lower it to 3 how is that any different from using EPR=3 on a regular CPAP machine? If pressure support is going to stay that low, shouldn't I have just stuck with a CPAP machine? What am i missing?

[Negligee1136]

I think you jumped from PS of 0 to PS of 4 quite quickly. There's some centrals there

Your fixed CPAP wasn't that bad, but it did have a lot of flagged flow limits

What about starting again from for example EPAP 8, and gradually raising PS to see if there is a number that is below 4 that is optimal with no more flow limits and neither centrals?

Also PS of 4 I wouldn't call it low necessarily.

In any case vAuto is a superior machine that also allows smaller increments (instead of EPR 1, 2, 3 you can do things like PS of 3.6 I believe) so I would not regret that choice. It is just a better machine. Believe also the auto adjusting algorithm is more responsive to flow limits and stuff. I don't think that having too good of a machine is much of a concern

[unadvisedfun]

I am in a similar situation ragingbull. UARS patient and switched to bilevel. 

I would recommend setting the trigger sensitivities to high or very high to address the CA events. 

I feel like the aircurve 10 vauto underreports flow limitation. I’ve awoken out of sleep with .10 or .20 limitation events.

I would consider gradually increasing your pressure support to address the flow limitations. Often times UARS patients need more substantial pressure support: The wiki page”Flow Limitation/UARS and BiPAP”
Recommends higher pressure support to address flow limitations.

[RagingBull]

Hey thanks everyone! Im going to try the higher trigger and maybe keep the PS at 4 tonight. But I might need to play around with the PS depending on how it goes and how i feel. Really appreciate all the responses here

[RagingBull]

Hey all, im using a resmed bipap vauto, dreamwear nasal pillows, and last night used these settings : EPAP=10.4,  IPAP=15

I slept for a good amount of time (8.5 hours), and woke up feeling somewhat rested, but as the day went on I began feeling fatigued like usual. Maybe i feel 10% better than usual?

One thing to note is that when i put my mask on at night, my airway/nose feels like it opens significantly. But as the night goes on, and especially when i wake up, i dont notice much pressure or the same "opening" sensation. As if my nose and airway "adjusts" to the pressure and no longer feels the benefit as the night goes on? Not sure if that makes sense, but is that normal?

Anyways, i checked my OSCAR data and notice that im still having erratic breathing moments, although no marked apnea events. Also no flow limitations and very little leaks.

I included 3 screenshots. One is the zoomed out view, and then two zoomed in examples of erratic breathing where im assuming i woke up. Those erratic breathing events happen throughout the night.

Can anyone let me know how my charts look? Should i try changing my settings, and if so, what would you recommend? Thanks!

[Sleeprider]

Everything in these charts looks great. Low AHI, and nearly 25% of events are early as you settle before sleep. The zoomed images of respiration wave show no antecedent respiratory issues, and the arousals seem unrelated to respiratory effort or events. There are respiratory artifacts during the arousals, but they don't originate from respiratory distress of any kind. There is nothing in this therapy that compels a change in settings. That does not diminish how you feel, but I wish mine looked like that.