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EPAP (expel pressure) help! - berkberk - 01-02-2020
Hi - I'm new to auto BPAP therapy and just received my machine 3 days ago. I've read and read and read (analyst at heart), but am having a problem trying to get a direct answer to the question of which Auto BPAP machine is the best for Mild to Moderate COPD patient with some issues I'm having. I'm trying to compare the DreamStation Auto BiPAP (DSX700T11C which I have now) vs the ResMed Air Curve 10. So far, the main issue I'm having is 3 fold -
1. I have some sinus drainage and dry mouth normally, so I often need to consciously clear my throat/nose and swallow during the night. I do this weird thing where I take a *tiny* pause/inhale while clearing my throat before I swallow. On the DreamStation Auto BiPAP (w/ heated humidity - DSX 700T11C), I've noted several times when I do this, it's initiating an "inhale" series where it goes up to 9 (instead of staying on 4) possibly bc it's sensing I'm taking in the tiniest bit of air? While I only slept 20-30 mins in titration study due to not being able to handle CPAP, when they finally switched me over to BiPAP at 3:45am, I seemed to breath and it wasn't trying to force air while I swallowed. This was on a ResMed testing machine (assume and AirCurve). Does have to do with the algorithms of C-Flex (DS) vs Easy Breath (RM) features of the 2 machines? Any advice on the difference in the 2 machines and my issue is greatly appreciated!
2. Because of the COPD, I need the lowest setting for EPAP (excel pressure). It seems 4 is the lowest you can get with the DreamStation? Does the Res/Med allow for 2 different inhale/exhale pressures or does it have to have a numerical difference between the 2 numbers? Can the Res/Med go as low as 3 EPAP?
3. During my sleep study, I had 16 API overall, but during REM sleep I had 47 incidents with O2 going down to 71%. Since it seems my main issue is when I go into REM sleep which machine would fit me best? I've only been able to sleep with a max of 4/9 or 5/9 (epap/ipap) so far. Not sure if the machine is waking me up as it goes up or if I'd just normally wake up as an event happens.
Last thing, the 1st night I couldn't sleep with it due to the swallowing/IPAP initiating, the 2nd night I slept for 5 hours with it (4/9) with an API 2.8 but woke up with a stuffy nose and my lungs were much more congested/productive cough. AHI details Total Clear Airway Apneas 1, Total Obstructive Apneas 7, Total Hyponeas 6.
Couldn't use it 3rd night due to stuffy nose (got Resprionics DreamWear full face mask with nasal cushion today to try tonight). DME suggested turning humidity down from 3 to 1/2 (0-5 levels). She also suggested putting a cube or 2 of ice in the humidifier due to COPD? Why have a heated humidifier then?
I have about 25 days to change my mind and switch machines to the ResMed Aircurve 10 before I'm stuck with the machine for 5 years. Wish they could let me try the ResMed for a week before deciding if it's better. Not even sure I've gotten into REM sleep to see how they perform when I REALLY need it. All these issues are happening down in the 4/9 (epap/ipap) area.
Thank you for any advice and help you can give a newbie who is trying desperately to make this work! I was referred due to increased Red Blood Cell count they originally thought was Polycythemia Vera, but after genetic test, hematologist sent me for sleep study before going for a bone biopsy. Seems like if I can get this worked out it will help with RBC count due to my bone marrow pushing for more ways to get O2 to my cells due to oxygen tanking at night.
Sleep Study -
Total sleep time - 218 minutes
N1 - 11.9%
N2 - 25.7%
N3 - 47.2%
REM - 15.1%
3 apenas (0 obstructive, 3 central, 0 mixed) 57 hyponeas - 16.5 AHI for Supine Sleep, 47.3 AHI for REM sleep
Dr Notes-
Obstructive events/ RERAS noted frequently during REM sleep with low SAO2 of 72%. Occasional cardiac arrhythmia seen. PLMS were observed.
RE: EPAP (expel pressure) help! - DeepBreathing - 01-02-2020
G'day berkberk. Welcome to Apnea Board.
I can't really answer the detail of your questions, but somebody will be along shortly who can help.
In the meantime, these pages from Resmed gives a lot of technical background about COPD and how Resmed machines are the best to treat it (they would say that, of course). The Lumis machines referred to in the article are known as Aircurve in the US.
https://www.resmed.com/au/en/healthcare-professional/diagnosis-and-treatment/ventilation/copd/what-is-copd.html
https://www.resmed.com/au/en/healthcare-professional/products/innovation-and-technology/ventilation-innovation-and-technology/niv-technologies-for-copd.html
RE: EPAP (expel pressure) help! - Matt00926 - 01-02-2020
With COPD I don't believe you need an extraordinarily low EPAP, especially if you have OSA as well. Many people with COPD also need EPAP to overcome what is called "intrinsic PEEP" as well which is basically air being trapped and not expelled which causes hyperinflated lungs.
I don't think you'd notice the difference between EPAP of 3 versus 4. You need a certain level of EPAP otherwise you would rebreathe air and get a real nasty carbon dioxide headache.
Your main issue will be the desire to fill your lungs up with air fast, and then to have a much longer time to exhale. This is done by using a faster Rise Time setting. Both Respironics and ResMed have this setting.
Where the ResMed excels is in the additional comfort features, such as cycle sensitivity and Ti Min and Ti Max control, which further help control how long inspiration and exhalation last.
RE: EPAP (expel pressure) help! - Sleeprider - 01-03-2020
Welcome to Apnea Board. I'll first answer your question, then explain why based on the three issues you listed. You want the Resmed Aircurve 10 Vauto.
Quote:1. I have some sinus drainage and dry mouth normally, so I often need to consciously clear my throat/nose and swallow during the night. I do this weird thing where I take a *tiny* pause/inhale while clearing my throat before I swallow. On the DreamStation Auto BiPAP (w/ heated humidity - DSX 700T11C), I've noted several times when I do this, it's initiating an "inhale" series where it goes up to 9 (instead of staying on 4) possibly bc it's sensing I'm taking in the tiniest bit of air? While I only slept 20-30 mins in titration study due to not being able to handle CPAP, when they finally switched me over to BiPAP at 3:45am, I seemed to breath and it wasn't trying to force air while I swallowed. This was on a ResMed testing machine (assume and AirCurve). Does have to do with the algorithms of C-Flex (DS) vs Easy Breath (RM) features of the 2 machines? Any advice on the difference in the 2 machines and my issue is greatly appreciated!
I have experienced a similar problem and use the generic equivalent to Flonase (Fluticasone Propionate). It takes about a week to have full effect and is safely tolerated by most people. In my case, my exhale was completely blocked by a post nasal drip which require me to sniff/inhale/clear as you describe. My Aircurve 10 Vauto does not switch pressure to IPAP because the algorithm is designed to follow spontaneous inspiration and expiration, not lead it as often is the case with Philips. In addition, with Resmed you can change the sensitivity to cycle to EPAP to high which will quickly drop pressure upon sensing expiration and you can set inspiration trigger to low or very low if needed to avoid false inspiration when you have unstable triggering from EPAP to IPAP. We can also set the maximum inspiration time to provide the boost in IPAP you need with COPD but preserve time for expiration. The effect of Rersmed trigger and cycle sensitivity is shown below:
Quote:2. Because of the COPD, I need the lowest setting for EPAP (excel pressure). It seems 4 is the lowest you can get with the DreamStation? Does the Res/Med allow for 2 different inhale/exhale pressures or does it have to have a numerical difference between the 2 numbers? Can the Res/Med go as low as 3 EPAP?
Both Philips and Resmed provide a minimum EPAP of 4.0. The Resmed can provide any pressure support (PS) you need from zero to 15 cm difference from EPAP. With the Vauto you can set a minimum EPAP, pressure support and maximum IPAP and the machine will operate in auto mode, or you can use fixed EPAP and IPAP pressure.
Quote:3. During my sleep study, I had 16 API overall, but during REM sleep I had 47 incidents with O2 going down to 71%. Since it seems my main issue is when I go into REM sleep which machine would fit me best? I've only been able to sleep with a max of 4/9 or 5/9 (epap/ipap) so far. Not sure if the machine is waking me up as it goes up or if I'd just normally wake up as an event happens.
It appears you are using pressure of 9/4 (PS 5) or 9/5 (PS 4) Normally we would want to use the same pressure support and use higher EPAP pressure to clear obstructive events. Without seeing data from your current BiPAP experience we cannot tell why you are experiencing arousals, however if you download OSCAR and post some charts, we can probably focus on any issues you are having.
Quote:Last thing, the 1st night I couldn't sleep with it due to the swallowing/IPAP initiating, the 2nd night I slept for 5 hours with it (4/9) with an API 2.8 but woke up with a stuffy nose and my lungs were much more congested/productive cough. AHI details Total Clear Airway Apneas 1, Total Obstructive Apneas 7, Total Hyponeas 6.
Your AHI is pretty good, but again, I think you should set the machine ins B-auto mode with EPAP min 4.0, PS min 5.0, PS max 5.0 and IPAP max 11.0. This will keep pressure low, in the range of 9/4 to 11/6 but allow the machine to provide increased EPAP pressure when obstructive events occur. Again the Resmed is more responsive to precursors of obstructive apnea and will more effectively prevent events rather than respond to them. In addition the way pressure is applied in a Resmed is much more comfortable with a wave shape. Philips pressure feels like it is on or off, but Resmed is much less disruptive. The chart below shows the shape of the Aircurve 10 pressure and how it responds to respiratory flow. Note that in the Flow rate, all flow above zero is inspiration, and below zero is expiration. You can see that when breathing is disrupted at 02:54 in this example, the Aircurve 10 follows and does not trigger full pressure. This is what clearing nasal obstruction looks like, note how exhale is interrupted and a swallow occurs. Pressure goes briefly positive as you describe, but the machine pressure does not move to IPAP and immediately resumes EPAP. The next breath is a nasal sniff followed by a brief obstructed exhale and a swallow where flow goes to zero before inspiration starts again. Again the Aircurve 10 follows this maneuver perfectly.
Quote:Couldn't use it 3rd night due to stuffy nose (got Resprionics DreamWear full face mask with nasal cushion today to try tonight). DME suggested turning humidity down from 3 to 1/2 (0-5 levels). She also suggested putting a cube or 2 of ice in the humidifier due to COPD? Why have a heated humidifier then?
Get the flonase and I think you will notice considerable relief. Excess humidity can increase nasal congestion, but your settings do not seem very excessive. Ice won't last long in the humidifier at any setting, and you'd be better off with passive humidification (set to zero) and just let the air pass over the water. Your profile indicates you are in Georgia, so you are heating your house this time of year and humidity is probably low. I think you will be uncomfortable with much lower humidity settings (less than 2). I don't think humidity is the issue here, but the need to address the nasal congestion. I think I have been clear on what machine I think is best.
RE: EPAP (expel pressure) help! - SarcasticDave94 - 01-03-2020
I'll agree with Sleeprider. As a respiratory overlap patient, you'll want at a minimum a VAuto. I think the VAuto will be a good move.
RE: EPAP (expel pressure) help! - berkberk - 01-03-2020
Thank you so much for the help here! I'm determined to make this work and have appt with Pulmonary Physician's Assistant next week.
This are the readings from the *one* night I was able to sleep a few hours with the machine. I couldn't figure out how to get rid of the VS2 despite trying but *think* I have everything else like you request. The "gray area" no breath is bc I took it off and put it on my forehead in my sleep and didn't realize it. Anything jump out? Added second graph to show resp rate in case that helps.
Feel like I'm going to change to the RESMED aircurve 10 next week... the Dreamstation is just feeling so forced breath and hope I like the RESMED better based on everyone's suggestions. Also, I feel like I'm just wide open on the settings and would like to slowly dial those in even if it means starting low and working my way up. I'll be glad to talk to PA about those next week if you have suggestions.
Again, thank you so much to those who take the time to help us new users!
RE: EPAP (expel pressure) help! - berkberk - 01-03-2020
Sorry... didn't change the thumbnails into attached graphs. I'm learning!
One thing I *don't* understand is why when I'm not having events my IPAP is cycling up to 10 and back down every 7 minutes or so? Is this some setting they have turned on to make me get use to the pressures moving around? I spent an hour with the mask today wearing it while watching TV and noticed it kept doing it. My EPAP even cycled some as I was watching it during my test today while awake. By downloading my graphs, I realize that seems to be something programmed into this machine?
Again, major thanks to those who take the time to help us trying to help ourselves.
RE: EPAP (expel pressure) help! - Sleeprider - 01-03-2020
The fluctuation in IPAP is a part of the Philips algorithm for all auto CPAP and BPAP machines. It occurs at an interval of about every 18 minutes and "tests" an increase in pressure of 1.5 cm over a 2-minute period. It evaluates respiratory flow and returns to baseline if an improvement is not detected. This has been a feature of Respironics since the 90s and is inferior to the Resmed algorithm that relies on flow limitation (flattening of the inspiratory curve) to determine the need for increased pressure. As soon as you make the switch you will get it.
RE: EPAP (expel pressure) help! - berkberk - 01-03-2020
Sleeprider - can I just say, your detailed explanation yesterday with the flow curves on inhale/exhale, and the graphs showing how a swallow/throat/nasal clear was handled with the AirCurve made the world of difference to me in understanding. Flonase on hand, even read about cervical collar (I fall asleep in recliner most nights due to reflux so assessing if that's an issue - original sleep test I slept in recliner, but it threw my chin down to my chest due to wear of recliner). Just... THANK YOU!
When your DME is saying things like the DreamStation is superior in how it handles events and are on top of them faster (vs the ResMed), how your "doctor" prefers the DreamStation, how the ResMed machines you used in the Sleep Lap were probably different older models, and has an answer for EVERYTHING you say, in opposition to everything I've read... well, it starts to feel like a sales pitch. Was going to wait until after I saw the Pulmanary PA on Wednesday, but think I might try to get in Monday or Tuesday to switch out machines. Was worried, what if the ResMed is worse, but at this point, I'll buy a refurbished unit if needed to get things right. I'm TIRED of being TIRED every day, despite 9+ hours of sleep. Not to mention things like the sleep test noting arrhythmia's and what not. This is a matter of my health and life, and no one will take it more serious than me!
If you have any suggestions for the limited night of graphs I posted, totally welcome your assessment. And again, Thank You - everyone here!
RE: EPAP (expel pressure) help! - Sleeprider - 01-03-2020
Your graphs are fine, and the only thing that will help us better understand issues is to zoom into 2 minute segments like the chart I posted in my first post. This shows us precisely what is going on in each breath and whether there is any restriction, the actual timing of inspiration and expiration and how the machine is responding. Not sure if the Philips will produce the mask pressure chart, but it would also show you how different things are. By the way, I'm really glad you came back to read that, it was a piece of work.
Philips pays a lot of doctors and suppliers and provides sales incentives that Resmed does not. The machines are also a bit less expensive, and therefore more profitable. If you want to know who is paying your doctor, check this link https://projects.propublica.org/docdollars/ I live in Murrysville, PA where Philips Respironics was founded and the machines are designed and made. I am disappointed I can't enthusiastically recommend my hometown manufacturer. It's a good product but has numerous inferior features and design flaws, and the proof is in the thousands of individuals I have coached on these forums. Unfortunately both Philips and Resmed consider the DMEs and doctors as their customers rather than the patients, but Resmed has done much more to build in better comfort features in their devices, and even their CPAP has limited bilevel capability that Philips can't touch.