UARs, Aerophagia, and Bilevel Pressure Settings

[ATeam91]

Hey Papper People,

I am progressing with my therapy and am seeking your advice. I started on CPAP but could not tolerate due to EPAP, but bilevel has been much easier. I have been on bilevel for about 7 months now and noticed an improvement in resilience and quality of sleep, but recently my sleep has been subpar and I am waking up more than once to pee and have morning headaches again. I'm using a Resmed AirCurve 10 VAuto with 10/6.4 pressure, and an F20 full face mask. I have a wickedly deviated septum which I am due to have fixed, but until then I can only use a full face mask as I cannot reliably breathe out of my nose all night.

I sleep with an intake nose strip under the mask, and a sleep positioning device on the back of my shirt that keeps me off of my back, reliably (I have measured). These both help. Have optimized my pillows and bed, and the cervical collars did not make an improvement.

I have titrated up EPAP to eliminate most OAs, with 6.4 on average being the best at reducing AHI. I have experimented with higher EPAP (up to 8), but have not noticed an improvement over the 6 to 6.4 range. My AHI and waveforms look about the same, and it becomes harder to exhale at the higher EPAPs.

I have also increased IPAP as much as possible. If I go over 10 IPAP, I get terrible aerophagia that wakes me up burping. I have tried all of the tricks to eliminate this but 10 is as high as I can go. I feel it is a balance between having high enough pressure to eliminate flow issues that disturb my sleep and having too high pressure that causes aerophagia that wakes me up.

Attached are screenshots of some of the more messy patterns I see. Low OAs but many hypopneas/RERAs. In the 1st screenshot you can see a common pattern of decreasing ventilation followed by what I believe is a recovery breath. This repeats throughout the night. Is this a symptom of too low pressure, or what?

I am still having disturbed sleep and would like some advice after looking at my waveforms. What would you recommend given my symptoms and data?

Thank you

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Attached are the overall night views for the two nights I took these screenshots from. Let me know if you would like to see any areas more zoomed in.

[Jay51]

Your charts puzzle me personally.  A 0.00 95% flow limitations.  A very quick inhalation.  But, some really knarly waveforms (at times high, sharp, pointed peaks on the top; at times some double tops).

Your PS is 3.6, so you could raise it to 4 I think with your VAUTO.  

You could try lowering your pillow height, side sleeping rather that back sleeping, and if you wanted to you could try a collar to reduce some of your H's.  

I don't know whether to go up or down with the pressures either since you get aerophagia with higher pressures; but will probably get less effective therapy with lower pressures.  Do you think it might be related to your current mask?

If anyone else sees anything in these OSCAR's please post.

[ATeam91]

Thanks Jay51. I have tried lower pressures but get air hungry and my AHI gets worse. My sleep is worse on my back, I have experimented with that. I side sleep 100% of the night due to the positional device on my back, which dictates a certain pillow height to be comfortable and prevent my shoulders from going numb. A cervical collar didn't help, unfortunately.

The F20 full face mask is the best by far I have tried, and I tried about 10 different ones. It is the only one that lets me breathe reliably and comfortably.

I am wondering if my obstructed nose has a larger impact on my therapy than I think, and if I should hurry up and have my deviated septum fixed sooner rather than later.

[Jay51]

Your "wickedly deviated septum" might (or it might not) have something to do with this.  I had the septoplasty (and turbinate reduction) and was pleased with it.  A little more tidal volume and more comfortable using this ventilator.  Less congestion and easier to breathe in general also.

Your choice as to when/if you have it though.

[HalfAsleep]

I recently had the septoplasty surgery myself after finding one nostril was not functional when I started xPAP therapy. I would say the most important improvement is in my regular quality of life, and is not specific to xPAP usage. Although both nostrils operate nicely, and I can breathe freely, my mouth still drops open when I’m sleeping, and I use an FFM. At any rate, don’t assume a septoplasty will obviate the need for an FFM, but do consider general quality of life.

[ATeam91]

Interested in what @sleeprider and @sleepyhead think about this as well, they have good experience.

[gainerfull]

Have you tried experimenting with more pressure support? The first attachment that shows gradual rise and fall in sequence looks like central hypopnea which is solved with more IPAP / PS. Have you noticed any reduction in aerophagia w/ a soft cervical collar?

[ATeam91]

Any IPAP over 10.2 results in aerophagia, and any combination of pillows, chin straps, and cervical collars has not improved that. So I have been limited with how high I can push both IPAP and PS.

[Jstalez]

Hi can I ask are you diagnosed with UARS through a sleep study? Did they prescribe BIBPAP? I believe I have this issue as my soft palate collapses as I fall asleep, but doesn't show on sleep study. Very uncomfortable

[ATeam91]

Yes and yes. Failed CPAP first. Couldn't tolerate pretty much any pressure breathing out. Took 18 nights in a row before I could even fall asleep with it for a few hours.

They then switched me to bilevel, slept the entire night day 1. Amazing. I recommend everyone does this from the start.

If they can't "find" it on the night of your sleep study as you can have varying results each night, you can always tell them you are tired and snoring and waking up gasping for air, your partner confirms it, xyz, and ask for a script to try a machine yourself. Insurance probably won't cover it and you will just have to buy it (I had to), but it gets you started.