spambox925's Therapy Thread - Flow limits and still tired after 1 month

[spambox925]

Hi All,

I'm coming up on one month with Cpap and trying to get some help tuning my treatment to get some good sleep.

I did a sleep study through Lofta which resulted in being diagnosed with moderate Apnea with an AHI of 24.3 and RDI of 30.3. 

I'm seeing flow limits and snoring that seem to persist regardless of minimum pressure increases and I still wake up tired. Does anyone have suggestions on how I should proceed? 

           

[Sleeprider]

I agree, your flow limits are very high and that is going to cause discomfort and arousals. You are already at fairly high pressure and using EPR 3. Can you verify your airway is clear and not obstructed due to sleep position? Your AHI is low but I'm sure if you zoom into the flow rate chart, we would see a lot of inspiratory flattening.

[spambox925]

Thanks sleeprider.

I sleep on my side generally and I'm careful to get a pillow that keeps my neck straight. Its a medium firmness but I have very broad shoulders so a thin pillow puts me at an angle. 

Here's a zoomed in shot of a moment where I had the flow limits and snore readings and one where I did not.

       

[Sleeprider]

It's not the worst I have seen, and you're treated pretty well at these settings. The only thing I know of to improve that is bilevel with more pressure support, but with your apparent efficacy, it's not likely you will have doctor or insurance support.

[spambox925]

I'm ok with paying out of pocket to improve my situation. 2k won't break me for sure.

Do you think a bilevel could tackle the flow limits? I just don't feel well rested and hope this would help.

In the interim I've ordered a collar as well

[Sleeprider]

This is how I got started on bilevel. I bought my first BiPAP as a used machine. It was a Philips System One 60 Series BiPAP Auto. It certainly helped, but I continued to experience hypopnea and some centrals with it. I used the fact I had a BiPAP machine successfully and discussed the results, and how they were improved over CPAP with my doctor. In 2015 I got a prescription for a new Resmed Aircurve 10 Vauto that was insured. The machine worked like a charm. With higher pressure support the flow limits and hypopnea melted away and the ability to change time of inspiration (max/min) and trigger/cycle sensitivity allowed me to eliminate all sources of discomfort and even central events. Your Airsense 10 uses a similar pressure support to the Vauto, but it's limited to 3-cm of pressure difference between IPAP and EPAP. You probably know that if you turn off EPR your flow limits rise. Now consider the benefits of increasing that PS so that each breath got more pressure support. Looking at your chart, your inspiration time is often longer than the maximum time of inspiration built into your current machine of 2.0 seconds. With the Vauto, you can extend that maximum time of inspiration. Mine is at 3.0 seconds. I can also adjust how easily IPAP is triggered from EPAP and either delay or increase the timing or amount of spontaneous flow needed to cause the machine to trigger or cycle. In short, the Vauto is a much more capable machine and will resolve flow limits and respiratory effort related arousals in most people with residual upper airway resistance under CPAP. I was recently approved for a new machine and expect to get a new replacement Vauto from Medicare and insurance in the coming week. The key to coverage is establishing a solid case for improved therapy results with the bilevel machine and making that part of your medical record before you get to Medicare where it becomes much more difficult.

[spambox925]

Aircurve 10 inbound.

Any thoughts on initial settings?

[lexit957]

Did you get the aircurve ASV or the auto machine? The ASV is about 3k. I've been looking into switching my airsense 10 into an aircurve as well.

Looking forward to your update.

[Sleeprider]

Your pressures are already pretty high, but back it off to what I'm using, and we can titrate from that starting point.
Mode: Vauto
EPAP min 9.0
IPAP max 18.0
PS: 4.0
Trigger High
Ti Max 3.0
Ti Min 0.3 (default)
Cycle medium (default)

[spambox925]

First night, inconclusive but I didn't sleep bad but still not incredible by any means. Flow limits seem marginally better than any night before.

   

Should I hold course to get more data or is it worth tweaking?

Edit:

Also thanks a load for your help, it is GREATLY appreciated.