Sierra

It can be confusing as for some reason ResMed and others changed the vocabulary from the APAP machine to the BiPAP. Let me give a go at trying to explain each:

APAP - "Pressure" is assumed to be the IPAP (red on OSCAR). You set this pressure with a minimum and maximum. In your example 6 cm minimum, and 15 cm maximum. The machine will automatically increase and decrease the pressure (IPAP) within that range during the night. Independent from this you can set a pressure reduction on exhale EPR of up to 3 cm. So for example if the machine is asking for 10 cm of inhale pressure, and you have EPR set at 3 cm, it will give you 10 cm on inhale and 7 cm on exhale. On Oscar this is the red and green trace respectively.

BiPAP - For strange reasons that I don't understand they have assumed the convention that "Pressure" is now the exhale pressure or EPAP. This is likely for marketing and hype purposes. You can set a minimum and maximum range of that EPAP pressure just like in an APAP machine which it will adjust automatically during the night. Again separate from this you can set a "Support Pressure". This is like the EPR on an APAP, but is an increase instead of a decrease. This pressure support can be as much as 10 cm. If you have it set at 10 cm, and the machine wants an EPAP of say 8 cm, You will get 8 cm on exhale, and 18 cm on inhale.

The key difference is than on an APAP the maximum differential between EPAP and IPAP is 3 cm and is set with EPR. In a BiPAP the maximum differential is 10 CM and is set with the Pressure Support. Both EPR and Pressure Support create a differential between inhale and exhale which assists in breathing, but the Pressure Support on a BiPAP provides much more.

To get considered for a BiPAP or BiLevel machine like the ResMed AirCurve VAuto you should show your doctor the graphs where pressure is hitting the maximum level of 20 cm of pressure, with flow limitations still spiking high. That is a strong indication that a PAP device with a maximum pressure of 20 is not enough for you.

And I am not sure that this pressure maximum is the the most important issue. It could also be that the 3 cm of pressure relief is not enough. You may need more than a 3 cm difference in pressure to adequately assist breathing and reduce flow limitations. The VAuto can go up to 10 cm of pressure support (differential between IPAP and EPAP). It is possible with a higher pressure support your maximum IPAP pressure could be reduced to a level lower than 20 cm. Just for example you may get away with a maximum pressure of 15 cm, but with a 10 cm pressure support. Then the machine pressure will alternate between 15 cm on inhale and 5 cm on exhale. This could be much more effective and more comfortable than what you are getting now, which is 20 cm on inhale and 17 cm on exhale.

Here is a short article BiLevel Positive Airway Pressure to look at.

In Canada the AirCurve 10 VAuto seels for about $2300 compared to the A10 or A10 AutoSet at $1300.

The only real guidelines are on AHI. It is generally accepted that having an AHI of less than 5 is OK. Not sure there are any hard links between flow limitations and health risks. They would be considered less severe than actual apnea events.

I use a down alternative pillow as it gives and does not push back so much. Have not tried a cervical collar, but it is only likely to help if you are having excessive OA events especially in close succession. A pillow is unlikely to have any impact on CA event frequency.

I find that my nasal pillow mask can help with decongestion, but each person may be different. From time to time I used to use Otrivin just before bed to help with congestion. You can't use that drug too long though or it will make things worse instead of better.

Unfortunately when your IPAP pins at the maximum pressure of 20 cm, that is an indication you may need to look at a BiPAP. Also the flow limitation issue can also indicate the need for more pressure support. The other option is to set an IPAP pressure limit of less than 20 cm and just accept the flow limitations. To a degree that is what my wife's preference is. She has issues with snore and flow limitation that could probably be solved with more pressure, but she says she would rather limit the pressure (14.4 cm), and suffer the consequences! I don't often actually hear her snore, but I also don't sleep with my hearing aids on.

As far as the graphs I always leave the event flag bar showing as it is more informative than the cumulative AHI graph.

One thing you may want to do is zoom in on the flow chart at those times when flow limitation are spiking higher and you are at the maximum pressure of 20 cm. You want to zoom in to the point where you can see each individual breath flow. My understanding is that flow limitation can be seen as a flat top on the inhale (upward) flow part of a breath cycle.

The other possibility is that if there are issues of asthma or COPD there may be medications (inhalers) which could help too. You would want to discuss with your doctor of course.

Yes. I didn't see this post when I posted above. Turning EPR off is probably not a good thing for you.

OK, if your EPR is off then IPAP and EPAP will be the same. Perhaps OSCAR chooses to display the green line instead of the red, but they are the same when EPR is off. Having EPR off may be contributing to your flow limitation which is in turn driving your pressure up.

Make sure your SD card is plugged in to the machine. If it is the detailed data will still be collected there. You can view it with OSCAR. The data which should be sent to MyAir is very limited summary data for each night.

What I see unusual about the first session is that from 1:20 to 2:40 your EPAP is 16 or less, but there is no IPAP (red trace) showing. I assume your EPR is at 3 cm and your IPAP should have been at 19 cm or less. Perhaps an OSCAR display problem. Your second session is showing a requirement for even more pressure and some events. The number of events is not that concerning, but it looks like you may get some benefit from a BiPAP machine which can provide more than 3 cm of pressure support and IPAP can go up to 25 cm. Overall it looks like flow limitations are driving your pressure requirement up.