[Treatment] Treating UARS with CPAP and bilevel

[Gideon]

That shows both inspiratory and expiratory flow limitation with some minor snoring on expiration.

Do you mind changing settings?

1. set to straight AutoSet mode, not the for her mode, I don't want the algorithmic limitations limiting anything right now. If you wish we will try it again after we tweak some.
2. You do have flow limitations so we are going to emulate a PS (Pressure Support) of 3 cmw
2a. Set Min Pressure to 7 (compensate for the EPR)
2b. Set EPR to FullTime and EPR= 3 (cmw) This will start you with an IPAP (inhale pressure) of 7 and an exhale pressure of 4 This should help a lot with the flow limitations

That is it for now, try this and see how it does, Changes will depend on how you perceive the changes and what you find flow limitation wise.

[slowriter]

That shows both inspiratory and expiratory flow limitation with some minor snoring on expiration.

Do you mind changing settings?

1. set to straight AutoSet mode, not the for her mode, I don't want the algorithmic limitations limiting anything right now. If you wish we will try it again after we tweak some.
2. You do have flow limitations so we are going to emulate a PS (Pressure Support) of 3 cmw
2a. Set Min Pressure to 7 (compensate for the EPR)
2b. Set EPR to FullTime and EPR= 3 (cmw)  This will start you with an IPAP (inhale pressure) of 7 and an exhale pressure of 4 This should help a lot with the flow limitations

That is it for now, try this and see how it does, Changes will depend on how you perceive the changes and what you find flow limitation wise.

Will do.

But just so I'm clear, I already have had EPR set to 3; right? Does that change your recommendation at all?

Also, best way to assess that very last bit? Just look at the flow limitation graph?

[Gideon]

It is at 3 on 6 Aug, It was unclear on the Jul 22 chart.

[slowriter]

It is at 3 on 6 Aug, It was unclear on the Jul 22 chart.

Yeah, the DME provided it to me with that setting, and I haven't modified it.

They also set it up with auto ramp, but I turned that off early on.

[slowriter]

Do you mind changing settings?

1. set to straight AutoSet mode, not the for her mode, I don't want the algorithmic limitations limiting anything right now. If you wish we will try it again after we tweak some.
2. You do have flow limitations so we are going to emulate a PS (Pressure Support) of 3 cmw
2a. Set Min Pressure to 7 (compensate for the EPR)
2b. Set EPR to FullTime and EPR= 3 (cmw)  This will start you with an IPAP (inhale pressure) of 7 and an exhale pressure of 4 This should help a lot with the flow limitations

That is it for now, try this and see how it does, Changes will depend on how you perceive the changes and what you find flow limitation wise.

Results of these settings below. 

I had a pretty bad night, though, in the sense I woke up early, and I think spent most of remaining night alternating waking and going back to sleep; something I only experienced at very beginning of treatment. Those CAs you see on the right are when I am awake.

Is this still helpful?

[slowriter]

Also, you may note I have the optional user event flagging turned on. I am using the default values there.

[slowriter]

I couldn't use the machine last night; for some reason (completely out of the blue) could not get a seal on the mask. Turns out the humidifier wasn't properly seated.

In the meantime, I wanted to add something I should have in the first post, since it might influence how to pace tweaks.

I have a followup appointment scheduled with the sleep doc for the 23rd, which gives me two weeks to sort out my strategy for that, with your help. 

Ideal would be that we can dial things in properly with the APAP, the doc can certify my compliance for the insurance company, and I can be confident I'm on the right path.

But if not, then would also seem the time for me to advocate for any alternative approaches or hardware, per what I contemplated in my original post in this thread (namely, a titration study and/or considering a BiPAP). I am currently renting the APAP.

In short, I hope to go to that appointment armed with more information and direction than I currently have.

[Sleeprider]

Slowriter, I noticed your first set of graphs had a minimum pressure of 9.0, but that was reduced to 5.0 in the second set of charts. The lower pressure meant that you could not take advantage of the full pressure support (EPR) of 3 as the minimum pressure for EPAP is 4.0. This lower pressure also allowed more expiratory flow limitation since the pressure was not sufficient to support your airway during exhale. This difference showed up in the charts and the statistics. When you followed Bonjour's suggestion for a minimum pressure of 7.0, the flow limitations were again effectively controlled. CA appears mostly during periods of sleep transition or when you are awake, and this may be sleep wake junk (SWJ), and we usually see this clear up with time in therapy. The increase in pressure was the result of the three OA events the machine detected.

I think you are sensitive to pressure changes, and that you don't benefit a great deal from pressures above 7.0/4.0. I'd like to see you set the minimum and maximum pressure to 7.0 and EPR to 3.0. This can be done in Autoset mode or CPAP mode. The idea is to remove the effects of variable pressure to see if a single pressure works better and controls events at least as effectively, and avoids sleep disruption from changing pressure. Some individuals do find constant pressure better than variable pressure. In your case, the pressure support appears to be beneficial, and your minimum pressure needs to be maintained at 7.0 or higher to achieve the 3.0 cm pressure support. If obstruction appears at a pressure of 7.0, the we will consider a higher constant pressure of 8.0. Good luck!

[slowriter]

Interesting; thank you sleeprider! I'll give it a go for a few days.

To explain the confusing sequence of graphs:

I in fact started at 5, per the prescription. After a couple of weeks mostly not feeling better, I experimented with slowly raising that number over time, up to a maximum of 11, in part because I was reading that a lot of people with UARS often benefit from higher pressures. 

I saw no benefit over those sequence of changes, so backed off to 9. 

One of the other users asked me to post what the data looked like at lower minimum pressures. Hence ...

[Sleeprider]

Your thinking is along the same lines as mine, that higher minimum pressure is more effective, however the use of constant pressure my produce more restful results...at least that is my hope. What pressure you ultimately find most comfortable and effective is still the question.