+- Apnea Board Forum - CPAP | Sleep Apnea (https://www.apneaboard.com/forums)
+-- Forum: Public Area (https://www.apneaboard.com/forums/Forum-Public-Area)
+--- Forum: Main Apnea Board Forum (https://www.apneaboard.com/forums/Forum-Main-Apnea-Board-Forum)
+--- Thread: Started BiPaP treatment, makes things worse. Struggling with the settings. (/Thread-Started-BiPaP-treatment-makes-things-worse-Struggling-with-the-settings)
RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - ldinks - 02-04-2021
Hey! Thanks again for helping me out.
So I turned backup rate BPM off and PS max to 5.0 as you suggested.
I dreamed a fair bit, woke up a little easier than I have been doing, but nothing outside of typical everyday variation.
My "Clear Airway" events are higher, but my AHI is higher. Are clear airway events a bad thing?
My data seems quite different. No OA! Lower FL. Higher H and lots more clear airways. I've attached the data (basic, advanced, and showing a specific zoomed period with lots of H events).
All of the random grey (with purple tips) are "Pressure Pulse (14)".. not sure what these are!
What do you think?
RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - Sleeprider - 02-04-2021
Our little experiment with limited pressure support and turning off the backup rate produced some interesting results, and some were unexpected. First of all, I think you are actually experiencing therapy onset central apnea that may required an ASV device to resolve, if you continue to use pressure support to address UARS. What I had not anticipated was that with the backup rate off your Philips BiPAP AutoSV would fail to even deliver even the minimum pressure support set, when events occurred. What we learned is that when you have central apnea as a result of using this machine, the pressure support from the backup rate is why you have what looks like flow limited breaths. What we are actually seeing is a lack of spontaneous effort and the triggered breaths being flow limited due to lack of spontaneous effort. Flow limitation in central apnea patients is fairly common because the lungs are filled by the pressure support of the machine, and when that pressure support is inadequate to fill the lung or pressure support cuts off too soon, we see that flattened inspiratory peak. In the zoomed image you provided, there is a classic central apnea pattern of periodic normal breathing interspersed with periodic central apnea. In this case Hypopnea was flagged due to enough response to move your lungs. What was unexpected is that your machine failed to deliver even the minimum set PS.
Your machine is responding exactly the opposite of what is needed, and not even providing the minimum Pressure Support in the settings. In this segment, we see good pressure support until you need it, then the machine just lets you down and drops pressure support to about 2.0 cm. I can't begin to correct this improper response of the machine to not only allow events, but to be complicit in their cause. Compare your chart to the function of the Resmed ASV:
Compare to the Resmed which has higher mask pressure during hypopnea:
I know you are treating UARS with this AutoSV, but when the machine does not provide even the minimum pressure support when your flow limits kick in and cause hypopnea, it's hopeless. I continue to think you would do much better if you can move to the Resmed Aircurve 10 ASV, or even the Resmed S9 VPAP Adapt.
I'd like to do one more experiment if you don't mind. I think your BiPAP AutoSV is very wrong for you, and I want you to set it to CPAP mode at a fixed pressure of 8.0 for one night. You can add in C-Flex at 2 if it is more comfortable. I want to get a look at fixed pressure to verify the CA events go away and to get an ideal of how much residual flow limitation remains. I know this seems a bit drastic, but by backing up your therapy to CPAP we will finally get a real picture of what we are dealing with.
RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - ldinks - 02-04-2021
Wow, that doesn't sound good! Would a higher pressure not remedy this, if the pressure is filling the lungs enough to be classed as a H but not enough to emulate breathing?
I'm happy to run another experiment - How do I set it to CPAP mode? I can't find anything like that in the therapist-specific settings. By fixed pressure, do you mean PS min and max both set to the same pressure?
Also, how do you know it drops pressure support? The image I used (the one you posted back to me) has the stats that minimum pressure support is 3.5 up to 5.88, and the graph for mask pressure is never under 6. Where's this 2 coming from?
RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - Sleeprider - 02-04-2021
I was looking at the clinical manual, and it appears that unlike the Resmed, you can't select CPAP mode, but we can reduce the pressure support. and that is what I would like to try. You are currently using EPAP min 6.0, and it does not usually seem to rise much above 8.0. The EPAP pressure is what we use to deal with obstructive apnea, and we will set it to that range. The pressure support should help to relieve flow limitation and hypopnea, but when it is too high, centrals can be triggered. I'm going to give you settings that will keep pressure support at 2.0 which should avoid the centrals and provide comfortable therapy. If these settings continue to be a problem, we will probably conclude your central apnea is a therapy onset problem, and get back to conventional AutoSV settings where we can treat the problem as complex apnea.
EPAP min 6.0
EPAP max 9.0
PS min 2.0
PS max 2.0
Max Pressure 11.0
BPM Off
I want to be sure I am working from the correct assumptions. You are self-treating using the BiPAP AutoSV. Your only diagnostic was a WatchPAT study that found an RDI of 59, AHI of 11.0 including CAI (central apnea) of 6 per hour. You have not been titrated by a clinic for CPAP therapy, and the AutoSV is your response to treating what you think is UARS due to the high RDI from your study. When this thread began, you were using EPAP min 6.0, PS 4-10 and a high max pressure. Your chart at the beginning of this thread shows an AHI of 2.
I want to clarify what we are doing now is to rule out that you can be treated by CPAP or BiPAP with low pressure support. Everything I have seen so far point to you having complex apnea, including your original study which showed more than half the events were central. If you have complex sleep apnea, the settings I have suggested above will result in a relatively high AHI like last night because it will not treat central apnea. If it turns out as expected, you can safely conclude you actually need the ASV, and we will resume therapy settings to treat that like central or complex apnea. While doing all of this with the assistance of a forum in interesting and will likely answer a lot of questions by experimenting with your therapy settings, we are not a medical organization. You appear to have moderate to mild complex apnea and should eventually seek medical advise on its treatment because the premise that we started with, that you have UARS, is superseded by a more significant problem that seems to be coming to light. Ironically, you chose one of the machines that will actually help with this problem.
RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - ldinks - 02-04-2021
Thanks for clarifying everything for me.
So I'll try the settings you listed above tonight (thanks for that!) and report tomorrow, and that should highlight our next move? Is there any chance this will work?
In the case that it's all more complicated than just UARS, and I have to try the ASV, is there a good chance we can sort it out? Or is there an element of "this is untreatable" that I'll be dealing with?
RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - Sleeprider - 02-04-2021
The point is, if you still have central apnea with minimal pressure support at 2, then we pretty much confirm the central / complex apnea diagnosis and proceed to treat this with settings appropriate to that. These are basically auto-CPAP settings, or as close as your machine can get. In fact if you wake up at night and find your AHI is already high feel free to change:
Our next move, contingent on deciding this is complex apnea, is to use these settings:
EPAP min 6.0
EPAP max 9.0
PS min 2. 0 (maybe 3)
PS max 15.0
Max pressure 30.
BPM Auto
RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - SarcasticDave94 - 02-04-2021
Interesting thread, especially that ldink has an SV Auto. Unfortunate bit is the Philips Achiles gets in the way, at least somewhat.
RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - ldinks - 02-05-2021
I slept with the settings you've asked for, no other changes. Basic, advanced, and zoom attached.
Some stats compared to other nights, in numerical order, with last night bolded/underlined:
Flow limitations: 2 3 4 4 5 7 8 8 11 11 (The 2 FL night was my first night - with only 4 hours sleep, leaks, and higher other numbers).
Hypopnoeas: 5 6 6 7 7 12 13 14 16 34
Obstructive: 0 1 1 1 2 3 6 7 8 12
Vibratory Snore (VS2): 0 1 2 3 4 4 8 10 16 28
Large Leak: 0 (All nights 0 since sorting mask)
Clear Airway: 0 0 0 1 1 1 1 2 2 42
AHI isn't the absolute lowest, but most of the days that had lower AHI were only slightly lower and they had high flow limitations - which seems to correlate with an awful day of symptoms the next day (the 8 FL days weren't great and the 11 FL days were absolutely dreadful).
I realise it was an experiment, but it might be useful to know that at least comparing stats to other nights, it's amongst the best that we've/I've had so far.
RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - Sleeprider - 02-05-2021
What we learned is that your central apnea is mainly a therapy onset problem related to pressure support. With PS at 2.0, the problem does not appear. At 4.0, it's very noticeable. So since this apparently resulted in one of the best nights and you don't seem to be complaining of discomfort or of being especially groggy, I think the next step is to repeat this to verify what we have. If this repeats, I think we will take EPAP min to 6.5 for some of the hypopnea, and leave the rest alone. The respiration zoom looks to be one of the best I have seen since we started this. We know that in your WatchPAT study, there was considerable obstructive and central apnea and hypopnea which resulted in an RDI of nearly 60 (1/minute). That is treated with this solution.
This low steady pressure with low PS looks very promising, and suggests your ideal solution is actually simple bilevel/BiPAP therapy, which your current machine is capable of providing. Advantage to Philips on that one, because Resmed cannot have the backup rate turned off, and required a maximum pressure support 5 cm higher than the minimum PS.
RE: Started BiPaP treatment, makes things worse. Struggling with the settings. - ldinks - 02-05-2021
I slept a little less than I should have (6hr 15m according to OSCAR, I aim for 7.30-8.30) and do feel a little nauseated and tired today. Too little sleep? General illness? Uars? The settings? Just not being used to sleep as it currently is for my brain? I've no idea. Definitely in the top 25% of days I'd have due to my "natural variation", so I think repeating these settings sounds good.
Same settings tonight, if results aren't much different then slightly higher EPAP tomorrow night. Simple enough!
If nothing changes, or the 6.5 EPAP Min does help a little, is that as far as PAP therapy can take me? Would last night's data be considered "fully treated" to you, or would you expect me to have some level of issue going forward (even if greatly reduced)?
Oh, and do you think a collar for the chin-tucking theory is still a good idea, or shall we ignore that unless I'm getting random clusters again?