[Treatment] Struggling to treat UARS with BIPAP

[Humancyclone7]

Here is my data from last night using VAuto (PS=5, minEPAP=5, maxIPAP=15) with trigger set to very high.
For some reason I started hyperventilating (probably due to trigger change) shortly after starting the therapy, so I only fell asleep at 3am. As expected, maxing out the trigger sensitivity eliminated the CA events (only one event lasting 13s), but I did not feel rested and my Fitbit still indicated fragmented sleep. There were lots and lots of stretches where my breathing looked flow limited (see example).

To answer SingleH:

• In S mode, CAs are prevalent even at low PS if trigger is kept at medium e.g. IPAP=12,EPAP=8 gives around 5 CA/hr.
  

• I've tried tongue retainers and, like MADs and iNAP, I can't tolerate them.
  
• I'm not sure what to make of the CO2 comment. My experience keeps pointing to symptoms of hyperventilation/overbreathing i.e. hypocapnia. I did some research into Buteyko breathing and it asserts that most us, especially with anxiety (which I definitely have), are actually overbeathing and the resulting hypocapnia causes a number of serious health consequences, namely; a reduced ability for oxygen to unbind from haemoglobin and become available to cells (the Bohr effect), vasoconstriction of arteries and capillaries (especially to the brain), bronchoconstriction and nervous system overactivity (low CO2 raises pH causing hypocalcemia). You can read more about it here: https://www.normalbreathing.com/co2/
  I have been using a Frolov device (hypoxia and hypercapnia training) for the past few days and I feel much better after each session i.e. calmer, more energy, breathing is more slow and even, so this suggests to me that my body is lacking in CO2. Unfortunately it hasn't improved my sleep as advertised (yet).
  

• I suppose there might be microscopic levels of mould or other irritants in my room. Without buying an air purifier, is there any way to know? If there were irritants in the air though, surely I should have experienced nasal congestion during the day by now, or found relief when using a nasal steroid before bed, no?
  
• In S mode I do use EasyBreathe. Having it disabled feels like an airbag is going off in my face. I have heard that maxing out the rise time can reduce CO2 washout, so perhaps I could try that in the future.
  
• Yes, there is an iVAPS mode on my device, though I haven't tried it yet. The settings available are: Target Pt Rate, Target Va, EPAP, minPS, maxPS, Ti Max, Ti Min, Trigger and Cycle.
  

Sorry it's taking so long to respond, I'm getting by on little to no sleep these days due to the PAP therapy, I have to keep taking breaks to recover.

[Humancyclone7]

I have tried 17.5/8 on S mode a few times. One time with trigger set to medium which unsurprisingly gave a ridiculous amount of CA events, the other time with trigger set to very high which bought it down to 0.88 CA/hr however my sleep was extremely fragmented (compared to sleeping without PAP). Flow limitations, in general, were greatly reduced, so I'm not sure why I slept so badly.

One theory I have, over than leaks, is overventilation. As outlined in the previous post, I think hypocapnia has the potential to cause arousals/put the body into a state of stress and we can certainly expect hypocapnia at high PS. What I'm concerned about is that things like backup rate and trigger sensitivity do nothing to address this, and only address the lack of respiratory drive hypocapnia causes — by forcing a breathe it aborts a CA event, but it does not address the lack of CO2, in fact, I would imagine that backup rate/trigger actually exacerbate the problem by forcing you to overbreathe.

SingleH, you mentioned that I could treat my TECSA by slowly increasing PS in 0.2 increments until I could tolerate PS=9.5 i.e. waiting until my chemoreceptors adapt to the low CO2 levels. For the same reason as above, wouldn't this also be unhealthy? My respiratory drive may have adapted to the low CO2 levels, but my body would still be in a state of hypocapnia, won't it? And by making my breathing more sensitive to CO2, won't it mess with my daytime breathing i.e. encourage me to hyperventilate?

It seems to me that the treatment for TESCA should focus on retaining CO2/lowering washout e.g. EERS, rather than trying to adapt to unnaturally low CO2 levels.

[ewriter]

Hi,

I have been helped by the information Sleeprider gave and SingleH. However, i think SingleH would have a different setting from yourself and myself because she has other issues (from what she posted); so her needs will be different. However, i used her Backup Rate information to cut my Backup Rate from 17 to 6 because she is comfortable using 6; and when i actually checked my resting breathing, it is 8-9 BPM and SleepRider said that if i was going to even use Backup Rate (he said i don't need it and i agree, as i do get AHI zero often) then it should actually match my rate. Unfortunately, for about two months, my sleep tech had set the machine to 17 BPM Backup Rate, as that was what the machine indicated; but it's definitely too many BPM as i could feel the machine was trying to force me to breathe. The much lower number is definitely more comfotable. In any case, i agree with SleepRider and will soon try "S" mode (think my tech and i tried ST mode before for awhile and I'm uncertain why we switched to Auto mode; currently I'm using Auto ST mode, based on advice from my sleep tech. SingleH is also using Auto ST mode) 

So, i'm just writing to ask you have you got any advice from SleepRider? Your issues seem more complex but i used to get numerous CAs and now don't, for which i am very grateful; but i believe the change has come through switching from a ResMed Aire10 AutoSet for Her machine to the iBreeze machine (i am uncertain the Aire10 is actually functioning correctly, as it began to make a "cracking" noise when it first started and i breathed in, something like that and my DME tested it and said it was fine).

SleepRider suggested i must increase my pressure (i was at 1.7 this paqst week) and i did so and it helped a lot.

I hope i can help in any way. 

Cheers


Paul
Note: last year was the worst year of my life apnea-wise as i started having severe panic attacks and had to call the ambulance as i was afraid to enter my apartment building and go to our apartment to sleep; that was partly because my doctor prescribed several SSRIs at the same time (4 in one month) and i actually suggested three of them, knowing nothing much about their effects. The SSRIs made me much worse, since i also take Propranalol (beta blocker) and i think it's common knowledge amongst some doctors that SSRIs and Beta Blockers shouldn't be used together (I don't know for sure).

[TechieHippie]

I'm also using Auto ST mode with a backup rate of six and a rise time of 600.. even though my respiratory rate is 12-13. My machine says that 99% of my breaths are spontaneous, but still there is something better about the auto ST mode than the auto S mode for me.

Lisa

[ewriter]

Hi Lisa,

Thank you for the helpful reply :0). I take note and may switch to the Auto S mode. Sleeprider has advised i would get good therapy from S mode itself (no Auto and no Timed Breaths, Rise Time or Trigger as far as i know); so i might try that instead (I was on S mode before but i still had "flutter" issues so i continued to Auto mode (but as Sleeprider has pointed out, very correctly, my Tech set me at 17 BPM as backup as that is what the machine had inferred; but with PS at only 1.7 which was inadequate -- but that wasn't his fault because two months ago, it seems i couldn't take a PS of 4 but that might have been because i was still using the Aire10 back then on APAP of 6/13 i don't know).

When i lie down my BPM is only about 8-9 but when i am sitting up it's about 15. So i followed Sleeprider's advice and set the BPM to 6 (9 - 3) and so far this seems to be OK.

Last night was very good for me as, thank God, i was not forced awake by "flutter". My AHI and all other HI etc were all zero.

Do you find that even when you get AHI all zeroes, you still have issues with broken sleep, being forced awake, etc.? 

Thanks again for your great help!

Cheers!

Paul

[TechieHippie]

Yes, sometimes. The AHI difference for me for example between auto S and ST is negligible, and as I said auto ST mode says that 99% of my breaths are spontaneous, but when I go look into the Oscar data, I see a lot more irregularities with auto S. But even with the auto ST mode, some nights are more restless than others. Usually it's more about stress and chemical exposure during the day for me then about the settings.

I think once you get in the right range, you can't then fine tune a little too. Once you get close it just takes more time because you are then dealing with day to day differences. Do you know about the setting to change the increment to .1 instead of .5? It's buried pretty deep but it helps a lot because then you can change things little bits at a time. I find with this machine that makes a big difference. For example, PS of 4.0 vs 4.1 versus 4.2 makes a difference for me, But over time I have to change it a little bit here and there as I get used to it.

I'm not sure what you mean by flutter?

[SingleH]

To answer SingleH:

• In S mode, CAs are prevalent even at low PS if trigger is kept at medium e.g. IPAP=12,EPAP=8 gives around 5 CA/hr. Perhaps try the middle ground setting of high, you may find a compromise between Medium and Very High.
  

• I've tried tongue retainers and, like MADs and iNAP, I can't tolerate them. OK
  
• I'm not sure what to make of the CO2 comment. My experience keeps pointing to symptoms of hyperventilation/overbreathing i.e. hypocapnia. I did some research into Buteyko breathing and it asserts that most us, especially with anxiety (which I definitely have), are actually overbeathing and the resulting hypocapnia causes a number of serious health consequences, namely; a reduced ability for oxygen to unbind from haemoglobin and become available to cells (the Bohr effect), vasoconstriction of arteries and capillaries (especially to the brain), bronchoconstriction and nervous system overactivity (low CO2 raises pH causing hypocalcemia). You can read more about it here: https://www.normalbreathing.com/co2/
  I have been using a Frolov device (hypoxia and hypercapnia training) for the past few days and I feel much better after each session i.e. calmer, more energy, breathing is more slow and even, so this suggests to me that my body is lacking in CO2. Unfortunately it hasn't improved my sleep as advertised (yet). I myself am still on the learning curve with all this, so I'm afraid I cant give you much in the way of guidance on this.
  

• I suppose there might be microscopic levels of mould or other irritants in my room. Without buying an air purifier, is there any way to know? If there were irritants in the air though, surely I should have experienced nasal congestion during the day by now, or found relief when using a nasal steroid before bed, no? I probably made more of an issue out of this than it needs to be, the key point was to ensure that you have a relatively clean, dust free environment with air being delivered to the room either via the window as oppose to ventilating the room, then sealing it as if its a small room, your CO2 will just increase drastically from evening to morning.
  
• In S mode I do use EasyBreathe. Having it disabled feels like an airbag is going off in my face. I have heard that maxing out the rise time can reduce CO2 washout, so perhaps I could try that in the future. Adjust the Rise time, by increasing the the rise time, you will avoid the airbag effect and as you say potentially affect CO2 washout.
  
• Yes, there is an iVAPS mode on my device, though I haven't tried it yet. The settings available are: Target Pt Rate, Target Va, EPAP, minPS, maxPS, Ti Max, Ti Min, Trigger and Cycle. I dont know if you are familiar but iVAPS focuses on volume rather than pressure, so it tries to ensure you get the same volume with each breath and therefore adjusts its behaviour for each breath to deliver a "target" volume. Its used for a more complex cases typically people with restrictive lung conditions like COPD and Scoliosis. However there is nothing to stop you testing it out. One of the features I like is the auto adjusting PS which can expand and contract accordingly on each breath as opposed to the fixed PS range on Vauto mode. You have the US firmware version by your description as you dont have the minEPAP,max EPAP option.
  Do you have a "learn targets" option, its quite complicated figuring out the target Pt and Va, so there is an automatic mode where the machine estimates what you need and then does that part for you. Whether this mode is suitable for you is another thing, but as it sounds like you are suffering you may want to give it a try and see. There are some posts on this forum with more information on setting this up.

I noticed your Timin is set to 0.70, is there any reason for this, do you have any restrictive disorder in relation to your breathing?

Do you use any supplements or anything else to improve your sleep. I find Camomile tea reliably increases my deep sleep figures according to my smartwatch and I certainly feel a lot more rested on the nights I drink it beforehand.

[SingleH]

One theory I have, over than leaks, is overventilation. As outlined in the previous post, I think hypocapnia has the potential to cause arousals/put the body into a state of stress and we can certainly expect hypocapnia at high PS. What I'm concerned about is that things like backup rate and trigger sensitivity do nothing to address this, and only address the lack of respiratory drive hypocapnia causes — by forcing a breathe it aborts a CA event, but it does not address the lack of CO2, in fact, I would imagine that backup rate/trigger actually exacerbate the problem by forcing you to overbreathe.

SingleH, you mentioned that I could treat my TECSA by slowly increasing PS in 0.2 increments until I could tolerate PS=9.5 i.e. waiting until my chemoreceptors adapt to the low CO2 levels. For the same reason as above, wouldn't this also be unhealthy? My respiratory drive may have adapted to the low CO2 levels, but my body would still be in a state of hypocapnia, won't it? And by making my breathing more sensitive to CO2, won't it mess with my daytime breathing i.e. encourage me to hyperventilate?

It seems to me that the treatment for TESCA should focus on retaining CO2/lowering washout e.g. EERS, rather than trying to adapt to unnaturally low CO2 levels.

I also wonder about your first comment, the backup rate as I understand it is papering over the cracks so CA's disappear, but I would assume that its still better to paper over the cracks than simply tolerate a high burden of CA's.

I notice on your second set of respiratory waveforms the breathings have those longer extended periods between breaths with the squiggly lines. I dont know if this is normal or not and something I am still trying to identify myself.

Regarding TESCA, just to clarify, I didnt mean you can treat your TESCA by slowing increasing PS. What I was advising was a method to increase PS to minimise triggering excess CA's when trying to get to a higher PS level. If you make a large PS change it tends to send CA's skyrocketing so what I was advising was to make a small 0.2 change, wait, let the body adapt, then make another change and so on. However I would still expect you to experience some small jump in CA's each time you do this, but they would be "minimal" rather than excessive in nature. Then once you have reached the PS you desire, you will then need to wait even longer to let the brain adapt to the new level you find that works for you. Regarding the effects on daytime breathing, again I cant comment and hopefully Sleeprider or someone else with more experience can comment.

[ewriter]

Hi Lisa,

Thanks for the input. My tech explained how to find the option to change settings in increments of 0.1.

By "flutter" this is a long story but basically i suspected it was a cardiac issue which i experienced as a mild "chest buzzing" in my left breast, starting in 1997. I went to a Cardiologist, who promptly sent me to the allergy specialist. After testing, the allergy specialist found i am severely allergic to dust mites, dander, mold, pollen, probably chemicals and fragrances, etc. and he prescribed Vancnase, a Corticosteroid spray. I had been waking up "for no reason" with shaking, chilled legs and a feeling of suffocation or "something" and, when i used the spray, i slept the night through for the first time in months (note that this is 27 years ago and I still remember it).

It turns out that the room i was renting in a shared house, was directly adjacent to the furnace room; and the furnace filters probably had not been changed in years.

I left Canada in 2000 and moved to work in the UK. Unfortunately, i did not know i probably had sleep apnea then, and was getting by and working until i started having (apnea, i guess) issues, waking up in the middle of the night for "no reason" and experiencing a more intensive "flutter" in my chest and a rapid heartbeat. I still didn't know what was wrong; and i went desperately from doctor to doctor, having worse and worse panic attacks.

Eventually, a doctor in the UK gave me 120 mg Propranalol daily, and this calmed down all the "flutter" symptoms (it feels like a pulsation/wobbling in my heart or chest). In general, i only experience this when i am starting to fall asleep, or when i am already asleep and it forces me awake.

To cut the story short, i was tested for sleep apnea in Canada in 2005 and they said I needed a CPAP (AHI 23) but i refused to get one. I continued on without CPAP until 2011, still on the Propranalol, and was very active and busy. Unfortunately, i also drank 1-2 bottles of red wine a week, and some liquers; and eventually, my sleep apnea caught up with me.

Thank God, in 2011, i got tested again (this time in Singapore, where i am at the moment) and was told i needed a CPAP as my AHI was 23. I finally gave in, and bought a Respironics System One and started CPAP, using that machine for about 9 more years (pressure started at 12.5 and ended at 14). The machine started making a lot of whining noises in perhaps the third year, and i removed all the insulation.

I used an Aire10 on APAP (6/13) for 3.5 years after that and i am now on the Resvent BiPAP.

The BiPAP does help with the "flutter". However, it has taken 20 months to find the correct optimal pressure and other settings, since DMEs and doctors in Canada do not help much.

[Humancyclone7]

Hey ewriter,

I agree that a backup rate can be very uncomfortable when it exceeds your natural BPM. I have heard of some people seeing flow limitations appear purely because of an excessive backup rate messing with their breathing, and I suspect the backup rate is what's causing so many full-awakenings when I'm on ASV mode. Unfortunately my jailbroken machine doesn't allow me to change the backup rate, so that's why I'm keen to fix my sleep-disordered breathing through S mode if possible.

I haven't gotten any advice from SleepRider yet, but then again this is my first and only post on Apnea Board so far.

I can recommend vagus nerve stimulation as an alternative to SSRIs for treating anxiety and depression, and it should help with the palpitations too. By stimulating the vagus nerve you can directly lower your heart and breathing rate, and force your autonomic nervous system into the parasympathetic state which is conducive to recovery. The more you do it, the easier it becomes for your body to naturally calm itself down after a stressful event. Just be aware that it worsens sleep-disordered breathing, so you can't do it too late in the day. Obviously consult with your doctor first if you want to discontinue SSRIs and to make sure vagus nerve stimulation isn't contraindicated for you.
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[url=https://nurosym.com/]Here's a link to the device I use (Nurosym).