[Treatment] Treating UARS with CPAP and bilevel

[slowriter]

Last night looked cleaner overall, though still some odd fragments.

[alexp]

I think you are getting there and probably will need a higher pressure to clear the remaining events. If I were you, I would try it at 10 in a couple of days (if you can tolerate it) just to see if it keeps getting better with higher pressures. 

I would also try to convince my doctor to switch to a Bipap. This way you'll be able to experiment with higher pressures to clear the remaining flow limitations. Just bring some graphs and show your exhalation and tell him you have trouble breathing on a higher pressure. Insurance usually requires you to fail CPAP before switching to a Bipap.

[slowriter]

Right. 

And based on the pattern here, we'd expect the inhalation curves to continue to improve at higher pressure, and the expiration ones to get worse.

Interestingly, my sleep center's prescription forms have a pretty straightforward, patient outcome-focused, checklist for justification of bilevel.

[slowriter]

Pressure=10

Again, CAs at end are while awake, after what seems to be a RERA.

I don't think this changes my view that I should see about getting a bilevel.

[Dormeo]

Just a few thoughts.

Some of the zoomed in shots appear to show awake breathing, although without surrounding context it’s hard to tell.

The oscillations that are right on the x axis between breaths may be cardioballistic, meaning they reflect some pressure changes exerted by your heartbeat. Nothing to worry about.

I hope you’ll be able to get a prescription for a ResMed VAuto, but if you can’t, you might consider buying one yourself. I did that recently to address flow limitations, knowing that my low AHI would mean my insurance would never cover a bilevel machine. I’m still working on adjusting my pressure settings, but from the very first night the improvement in FLs was striking.

[slowriter]

Thanks. I tried to include a detail graph that also captured "normal" breaths, since they are more representative.

[slowriter]

... I’m still working on adjusting my pressure settings, but from the very first night the improvement in FLs was striking.

And did those improvements correspond to improvements in subjective outcomes for you?

[Dormeo]

The answer is: some, but.... The “but” is there because I have a separate sleep problem that will keep limiting how good I feel until I can resolve it. (I have a lot of pain at night from hip-tendon inflammation; I’m working on it with an orthopedic doctor but it’s going to take time.). But I believe the FLs would have been causing me to feel unrested even if the hip stuff weren’t there. So glad I’m very glad to see improvement in the FLs and will post about that when I finish inching up my PS.

[slowriter]

I wonder: does anyone have any thoughts about how to approach a possible titration study, which I am guessing the doc will recommend (and insurance may require for a bilevel?)?

It seems to me, there are two basic methodologies:

1. to raise pressure to eliminate OSAs, hypopneas, and RERAs, and call it a day.
   
2. Another, advocated by Krakow, is to go beyond that, and seek to normalize the airflow (both inspiratory and expiratory) and consolidate REM sleep. Hence, his argument in general for higher pressures, and greater pressure support.
   

The latter intuitively makes more sense to me. How common is that methodology in 2019? Any reason I can't insist on them using that methodology?

[slowriter]

I wonder: does anyone have any thoughts about how to approach a possible titration study, which I am guessing the doc will recommend (and insurance may require for a bilevel?)?

It seems to me, there are two basic methodologies:

1. to raise pressure to eliminate OSAs, hypopneas, and RERAs, and call it a day.
   
2. Another, advocated by Krakow, is to go beyond that, and seek to normalize the airflow (both inspiratory and expiratory) and consolidate REM sleep. Hence, his argument in general for higher pressures, and greater pressure support.
   

The latter intuitively makes more sense to me. How common is that methodology in 2019? Any reason I can't insist on them using that methodology?

Based on my discussion with the doc (who, despite telling me clearly at initial appointment I had UARS, was more focused on OSA), answer to my question is "not really."

I did get a prescription for an in-lab titration study, though, with instructions to make sure I'm entering REM sleep.

Am thinking I'll discuss some of this with the sleep tech (who initially told me I had UARS) when I go in, to hope the study is helpful.