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+--- Thread: BiPAP Pressure for Possible UARS (/Thread-BiPAP-Pressure-for-Possible-UARS)
RE: BiPAP Pressure for Possible UARS - SingleH - 04-16-2024
Hi Berchtintus,
Regarding the gap where your machine wasnt running, is it possible that the machine is in a position whereby you could either accidentaly hit the on off switch and switch it off. I can see from your screenshot you have "smart start" set to off. Please enable this. Once done so the machine will automatically switch on as soon as it detects a breath.
Secondly check where the power lead is plugged in the back, there is a securing mechanism that needs to be engaged to hold the power lead into the back of the machine. If this is not fully engaged its possible to pull the lead out of the back if you know the machine during the night.
As TechieHippie suggested I would adjust your trigger settings from Medium to High and see if that helps. Increasing trigger can help address the CA's you are experiencing and users have found High or Very High settings can help with the Resmed machines in this regard.
Your Timax seems to be sufficient as if it was not, you would expect to see the blue line of the inspiration time graph pushed up flat against the top of the graph window along the 2.0 second line which you are not seeing. However with that said you have a high respiration rate and I have found as that as PS is increased respiration rate goes down. I would have suggested trying to increase PS to see what happens but that runs the risk of increasing CA's. As your flow rate and waveform looks good, I would suggest increasing Min EPAP as suggested.
Avoid making too many changes are once as it becomes hard to track what is having the beneficial effect. Either adjust Trigger or Min EPAP then observe for some days, then make the next change.
RE: BiPAP Pressure for Possible UARS - Macka - 06-02-2024
Hows it going Berchtintus?
RE: BiPAP Pressure for Possible UARS - bertchintus - 06-03-2024
Hi Macka! Thanks for checking in.
I tried raising my EPAP pressure but experienced a lot of aerophagia which would worsen my sleep quality. I am still very fatigued throughout the day and suffer from constant brain fog and lack of concentration which makes me unable to enroll in college again.
On a positive note, I believe I have found the cause of my health issues. I went to an orthodontist who specializes in sleep and he did a CBCT scan on my airway. My airway is very restricted, with my minimum airway space being 56.2 mm^2. This is nearly 3 times less than the average minimum area.
Two weeks ago that same orthodontist installed an expander (MSE) to expand my upper palate in hopes that it will help my airway and nasal breathing. The orthodontist's plan is to expand 6 turns a day for a total of 84 turns. Unfortunately, I have had to turn less than that. 38 turns in and my suture has yet to split, also the expander is pushing into one side of my gums and the screws look tilted. At this rate, there is a large possibility that this expander will fail.
Surgery might be the next step. My ENT hasn't done an endoscopy yet, but he told me that he doesn't see any large tonsils or adenoids. He did mention how my tongue is on the larger side but warned about the high rate of relapse/pain that comes with tongue reduction surgery. Jaw surgery may be necessary in my case but I can't say for sure until I get more opinions. I really don't mind surgery, I'll do anything to get my life back.
If anyone has questions or possible insight please let me know. Also, does anyone know of any communities or message boards for palatal expanders/jaw surgery?
RE: BiPAP Pressure for Possible UARS - SingleH - 06-04-2024
Hi Berchtintus,
Thanks for the very interesting update.
Thats brilliant that you have managed to get a CBCT of your airway, the hole orthodontic, airway related aspect of sleep apnea and UARS is something I have been reading about extensively for some time now, as I believe I have UARS due to prior tooth extractions. There are a growing number of people with Sleep apnea/UARS who are now realising a possible palate connection to their problem and starting to look at this treatment.
Did you ever have any teeth extracted as a child or adult? Many of the people who are suffering from UARS had dental extractions as child.
I'm very familiar with MSE and its variants, MARPE, DOME, EASE and both surgical and non surgical palate expansion techniques. Lots of people have had success with improving their breathing following these procedures, but splitting the mid palate suture effectively is quite difficult. The probability of a successful split declines with age and it is easier to split the suture in females than it is in males. Generally the rule is that in females upto the age of 30 there is no issues, but then after 30 it starts to become more difficult but at a slowly increasing rate, so 40 year old female might still be fine, whereas the chances in a 40 years old male would be far lower. This has to be assessed on a case by case basis though as its not always clear cut.
The issue you described with failed expansion and bending of the screws is a common one. Another thing to be very careful of is asymmetric expansion, where the jaw expands only on one side, which can causes a number of serious problem and needs to be closely monitored and with regular scans and checks to make sure this is not happening. If it does the expander should be "turned back" to reverse this before the bone sets as it becomes impossible to reverse otherwise. From what I have read much more conservative number of turns per provides better result when expansion starts with less risk(some people just do one turn a day) . Some people have done 10 turns a day, overexpanded and then had problems. Anyway with that said you suture has not split, so that is not an issue for you at the moment.
There are various options such as surgically assisted expansion, which comes in a couple of varieties. One is done by a few orthodontists in their clinic, where they use a piezo devies to carry out a "corticopuncture" which is a series of a small cuts into the suture to weaken it, thus reducing the work the MSE expander has to do. Not a lot of orthodonists do this, but its something that can be done in clinic as there isnt any blood or complex surgery going on, its just very fine tiny cuts. There is then surgically assisted (SA) MSE or MARPE/SAMARPE (Surgically Assisted Mini-Screw Anchored Rapid Palatal Expansion) where a surgeon will split the suture completely and then leave the device to do is expansion work, this is done as a surgical procedure.
Some other varients of this exist called EASE and DOME. EASE is endoscopically assisted skeletal expansion and essentially its the same as above, but instread of cutting the palate from inside the mouth, they cut the suture via entering in from the Nose, there are various pros and cons that people argue over regarding this and the other procedures.
You then also have SARPE (Surgically Assisted Rapid Palatal Expansion) this is a full surgical procedure done by a maxillofacial surgeon. The palate is expanded surgically to the desired width there and then with no expansion process taking place afterwards. Bones are cut and moved accordinly and then held in place to set. The benefit of this process is you get instant expansion of the palate, without any expansion device, however some people argue with this method you dont get "expansion" or "growth" of the nasal cavity that occurs with the MSE and MARPE method.
To clarify there are two goals to palate expansion that people want to achieve (assuming their are tying to fix their airway problems)
1. Widen/flatten and spread the top of their palate to expand the width of their dental arch. This allows more space for the tongue to sit flat, by doing so it reduces the chances of the tongue obstruction your airway.
2. Expansion of the intenal nasal cavity structures to allow for better airflow through the nose, this occurs with the suture splits and widens. CBCT's have also shown that with the long term expansion devices like MSE and MARPE the bones remodel and in some people their cheekbones shift outwards a little and this whole area widens with an associated expandion of the internal cavity.
People have used various techniques to achieve the above and there seems to be some degree of consensus as to what results you can expect:
1. Tooth-borne expansion: Devices such as invisalign, these do not affect the suture, they simply shift the position of your teeth in your mouth outwards. This allows you to achieve a wider dental arch (point 1 above), so your tongue can have more space to lay flat, but does nothing to expand the bone and doesnt expand the nasal cavity. Tooth borne expansion can be bad as it can flare out your teeth which can cause dental problems. CBCT will reveal what scope you have to use Invisalign
2. Bone-borne expanders: MSE or MARPE with or without surgical assistance. This is believed to be the most effective as it allows you to both move teeth and expand the bone in the palate as well as the nasal cavity. The bones in the skull remodel and have a permanent effect for life. It can be problematic if not managed very carefully and closely and should not be expanded over agressively. Surgical assistance seems to be worthwhile in older males.
3. Surgical expansion: This gives instant results, the palate is expanded, there is more space for the tongue instantly and there is none of the risks of using MARPE or MSE, but its not clear how the nasal cavity expands, at least from what I have seen. As its a surgery it does of course come with its own set of risks.
All of the above is addressing transverse expansion. however in a number of countries full Bi-maxillairy surgery is used for the treatment of sleep apnea and for expanding the airway. This is often the first option used rather than MSE/MARPE. By advancing forward the maxilla and mandible, all the tissues around the jaw and neck are pull forward and and associated opening of the airway is achieved.
You are already in a very good position by having an airway focused ortho who has attempted MSE (most are not airway focused or even aware of techniques like MSE and many even reject there is any connection between dental issues and the airway) it probably would be worth speaking to an airway focused Maxillofacial surgeon. Again you are very lucky to be in the US, as almost all the the surgeons who are aware of the airway, UARS apnea issues and the need for palate expansion are in the US.
The resources I would recommend are Jawhacks channel on Youtube and also a number of groups in Facebook. There are dozens out there but look for palate expansion groups, MSE/MARPE, victims of dental extractions, extraction orthodontics reversals, adult expansion. Look out for Karin Badt in these groups, she is a university researcher who has produced some detailed reports with a whole load of useful info on surgeons and ortho's who can assist.
RE: BiPAP Pressure for Possible UARS - Macka - 06-04-2024
Dr Kasey Li. Good primer on many aspects of expansion. He has practically done them all.
https://www.youtube.com/watch?v=40kaP9MmCP8&t=5974s
RE: BiPAP Pressure for Possible UARS - bertchintus - 06-04-2024
Thank you all for your responses and thank you SingleH for taking the time to type all that information out.
For the past few months I have also been researching all this and I'm familiar with most of what you thoroughly explained. To answer your question SingleH, I have had teeth pulled. I had an extra incisor on my bottom row which was pulled for braces. 3 years ago, I also had all 4 wisdom teeth pulled which is around the same time when my sleep started to worsen. I believe that I always had some form of sleep disordered breathing and that getting my wisdom teeth removed was enough of a push to create the symptoms I have today.
I also plan to stop turning my MSE until my orthodontist appointment next week. I highly doubt I will have a successful expansion with my current MSE but I really do want it to work. My intermolar width is 37 mm which isn't all that narrow but I could still benefit from expansion. With my tongue being on the larger side, it doesn't completely fit on the roof of my mouth which may be causing it to fall backwards while I sleep. Also the added benefit of midface expansion could provide better nasal breathing benefits than the other expansion options, but there doesn't seem to be any sort of consensus if that really is the case. It may be the case that I will need SARPE, and if that is true, I would rather have it done during a double jaw surgery. It is the opinion of Dr. Alfi from Houston that SARPE provides the same breathing benefits of MSE.
I will also look into some of these MSE and jaw surgery facebook groups, thank you for the recommendation. I am incredibly lucky to have MSE providers/airway focused doctors in my country, let alone in my local area, and I pray that the number of these professionals only continues to increase around the world.
RE: BiPAP Pressure for Possible UARS - SingleH - 06-05-2024
Somehow I knew you were going to confirm you had extractions. Interested to read you observed the problems start with the wisdom teeth extractions. You hear a lot more people talking about the premolar extractions being the cause of the problem, but I think its simply any extractions. There is a jawhacks video where he talks about how the wisdom teeth act like anchors preventing the teeth shifting backwards.
There is no point turning the MSE device as you only risk causing damage. I dont know if it would be practical to find another provider who does the Piezo cut to assist and then you carry on with your current ortho. Some orthos call this MSE II, but it would certainly help increase your chances of expansion.
The airway expansion benefit seeems to come from successfull expansion when the suture has split with an equidistant split from front to back of the mouth, vs a V shape which is more often the result with MSE/MARPE.
Dr Alfi along with Dr Kasey Li from the Video Macka suggest seem to be two of the very common names discussed in these groups, I know there are lots of discussions as to who is best or what technique is best, but I'm not sure what is the best way to go.
What are your thoughts on extraction reversal, i.e reopening extractions spaces and fitting implants? This is another topic that is heavily disussed in some of these groups. The consensus seems to be that trying to re-open extraction spaces in a jaw thats already shrunk due to prior extractions is a really bad idea that can cause problems, but if you are having Bimax, you are then creating forward space in the jaw via advancement thus creating more real estate to put teethback. With that said most people who are doing this are replacing their pre-molars. Not seen much discussion on wisdom teeth replacement.
RE: BiPAP Pressure for Possible UARS - bertchintus - 06-05-2024
I believe my orthodontist placed my MSE more posteriorly to avoid that V-shape but it sadly has not split my suture. I wonder if placing the MSE more posteriorly, instead of anteriorly, makes it harder to split the suture? It might not always produce a split but might be worth doing if the airway benefit is greater than an anterior placement.
As for extraction reversals, I don't believe it would help my case all that much. I haven't seen any cases so far where wisdom teeth are replaced and it has improved peoples breathing. If I do end up getting jaw surgery I plan on wearing a retainer for the rest of my life to prevent my teeth moving further back.
RE: BiPAP Pressure for Possible UARS - SingleH - 06-05-2024
There are few different videos on jaw hacks on this topic. Some custom MARPE applications use upto 8 screws in a row on either side of the suture to try and distribute force more evenly the whole way along.
Regarding wearing a retainer, have you read anything to the effect that it helps prevent teeth shifting back over time. I read about how it helps maintain the arch, but not really seen anything to say it stops the teeth shifting backwards. Is this something retainers can do? As for sure it would be preferable to having implants. I kind of envisioned that wisdom tooth implants would act like anchors in the bone preventing any back shifting over time of teeth.
RE: BiPAP Pressure for Possible UARS - bertchintus - 06-05-2024
I agree that wisdom teeth do act as anchors for the other teeth and if I would have like to have kept them. But, it was the opinion of my dentist that they needed to be removed. If I remember correctly he said all four were impacted and needed to be removed ASAP.
Also, I believe retainers are supposed to stop any type of improper teeth movement, whether it be backwards/forwards or left/right. Ron from JawHacks says he will be wearing his retainers for the rest of his life to preserve the work he did on them. Before he started his channel, I believe he had a total of 8 teeth removed, including his wisdom teeth.
https://www.youtube.com/watch?v=78uKkWOWQ2s
As for the custom MARPE, that is a good question I should bring up to my orthodontist. Sadly Dr. Marianna Evans, who is a known custom MARPE provider, lives quite far from me and may not be in network with my insurance.