26 October 2020

Use BiPAP ST with iVAPS or AVAPS for REM sleep issues

 “It does not matter how slowly you go as long as you do not stop.”

- Confucius (Chinese Philosopher – 551 BC – 479 BC)

In previous blog posts including The Secrets to Success using CPAP and Bilevel and Guide to Success using CPAP and Bilevel, I mention to consider using a similar machine that I use, being the ResMed S9 VAuto or AirCurve S10 Bilevel machine. Doing so will enable you to overcome CPAP side effects and issues. Consider using BiPAP and Bilevel ST machines with iVAPS (intelligent volume assured pressure support) or AVAPS (average volume assured pressure support) to overcome the very difficult issues with sleep therapy. These issues include REM sleep and obstructive sleep apnea (OSA) causing bruxism.

To avoid confusion, BiPAP is a Registered Trademark owned by Philips Respironics. Bilevel refers to all other brands such as ResMed.  

As detailed on a previous blog post Are BiPAP and Ventilator Settings contributing to COVID-19 Deaths?, the ST machine has a Back-Up Breathing or Respiratory Rate (BURR). This feature will be critical should a patient’s medical condition deteriorate and serious breathing issues arise. The BURR assists in stopping a patient’s breathing rate to go below a certain limit such as 12 breaths per minute.  

When iVAPS or AVAPS is added to the ST machine, a person can have total control and flexibility in overcoming any sleep issues. This particular feature allows a person to set a target rate to control the ventilation of a patient and the volume of air. The machines are marketed for patients with severe respiratory disorders including:

- Neuromuscular/restrictive disorders

- COPD (Chronic obstructive pulmonary disorder)

- Obesity hypoventilation

These machines are being used extensively during the Coronavirus or COVID-19 Pandemic.

Many people may not be aware that these machines can also be used for Obstructive Sleep Apnea (OSA) as noted on Page 1 of the ResMed AirCurve 10 ST-A Clinical Guide. Other people who may benefit from these machines are those that have a combination of serious issues including respiratory issues and Complex Sleep Apnea (obstructive and central sleep apnea).

Note that these machines are very expensive. Pre COVID-19 recommended price was US$5,000.00. During COVID-19, I note that the price has dropped to below US$3,000.00.

https://www.cpapdirect.com/cpap-machines/resmed-aircurve-10-st-a-bilevel-with-humidair

Due to price as well as the knowledge required to set the machines with iVAPS and AVAPS correctly for you, I recommend you first use the auto adjusting CPAP machines and the basic BiPAP or Bilevel machines. In many cases these machines can resolve your sleep disorder issues.

What sleep issues do I have that warrant using the high level ResMed VPAP ST-A with iVAPS machine?

Over the last few months, I have been grappling with the issue of obstructive sleep apnea (OSA) occurring during REM (Rapid Eye Movement) sleep. From personal experience, any waking up during REM sleep may lead to insomnia and not being able to go back to sleep. This will cause further issues with you feeling a lot of sleepiness and fatigue after waking up for possibly the rest of the day!

Gabryelska, A., BiaƂasiewicz, P. Association between excessive daytime sleepiness, REM phenotype and severity of obstructive sleep apnea. Sci Rep 10, 34 (2020) 

https://www.nature.com/articles/s41598-019-56478-9 

Below is a diagram of the Stages of Sleep.


During a typical night, our sleep cycles move between REM and non-REM sleep, with each cycle repeating at about 90-minute intervals. The deeper non-REM sleep stages usually occur earlier in the night.

https://2012books.lardbucket.org/books/beginning-psychology/s09-01-sleeping-and-dreaming-revitali.html

REM sleep is believed to benefit learning, memory and mood. It is also thought to contribute to brain development in infants. A lack of REM sleep and having obstructive sleep apnea may have adverse implications for physical and emotional health including dementia, Type 2 diabetes and mortality.

https://www.aan.com/PressRoom/home/PressRelease/1574

https://aasm.org/obstructive-sleep-apnea-occurring-during-rem-sleep-is-significantly-associated-with-type-2-diabetes/

https://www.webmd.com/sleep-disorders/news/20200707/as-rem-sleep-declines-life-span-suffers

More details on REM and non-REM (NREM) sleep, sleep stages and how you can improve REM sleep are on the following articles:

https://www.medicalnewstoday.com/articles/247927#what-is-rem-sleep

https://blog.fitbit.com/sleep-stages-explained/

From the various articles mentioned above, REM sleep is critical and essential for everyone to have in sufficient quantity and quality. Unfortunately, during REM sleep a person’s breathing becomes irregular and erratic. The challenge with obstructive sleep apnea occurring during REM sleep is how to overcome this issue using sleep apnea therapy with CPAP and BiPAP and Bilevel machines. 

In addition, this particular issue has led to a detailed examination of the connection with Awake Bruxism (AB). The bruxism involves tooth clenching or tapping while you are awake. Unfortunately, the bruxism may drive you crazy and frustrated as some days I have had to wear a mouthguard after lunch to soften the tooth clenching or tapping.  

https://www.sleepfoundation.org/sleep-apnea/link-between-sleep-apnea-and-teeth-grinding

Whilst this article refers to sleep bruxism (SB) (bruxism while you are asleep) and obstructive sleep apnea, from personal experience OSA will also cause awake bruxism. Obstructive sleep apneas occurring during REM sleep which wake you up and you are not able to go back to sleep or go back to sleep after some time, say 15 minutes to 20 minutes or more may cause you awake bruxism and a lot of sleepiness and fatigue for the rest of the day after waking up. 

The issue of Insomnia and how I overcame this issue are detailed on the blog post Stop CPAP causing Insomnia: Use Bilevel.    

After reviewing various research articles, there seems to be very little research as to how to overcome the issue of OSA occurring during REM sleep causing awake bruxism using sleep apnea therapy. Most research has concentrated on sleep bruxism and OSA using CPAP. This may be due to potential consequences including damaged teeth and jaw joint issues known as temporomandibular joint (TMJ).

However, CPAP is not well tolerated by many people as mentioned on a number of previous blog posts including Why is CPAP Compliance Rate Low? and Are BiPAP and Bilevel and Ventilators reducing Deaths during Coronavirus? There is an estimated 80% or more than 15 million people who are non-compliant, failing and non-successful on sleep apnea therapy.    

Making the issue of overcoming obstructive sleep apnea occurring during REM sleep more complicated are some of the CPAP side effects and issues that need to be reconsidered. These are the same issues that I have already overcome when using sleep apnea therapy over more than 10 years.

Any treatment options that I consider with overcoming the issue of OSA occurring during REM sleep will also need to revisit these side effects and issues including aerophagia, potential mask problems including mask leaks and air coming through eye tear ducts and out the eyes. These issues will arise should my starting IPAP (inhale pressure) and EPAP (exhale pressure) be increased significantly to cover the obstructive sleep apnea occurring.

It for the above reasons that I am using the ResMed VPAP ST-A with iVAPS machine together with my current machine, ResMed S9 VAuto Bilevel machine.  

The Bilevel settings that I have used for a number of years until recently are detailed on the blog page Different Bilevel Settings Example. Since writing this blog post, I have adjusted the settings on one of the machines.

I thought that over the last 10 years being on sleep apnea therapy that I had encountered most of the CPAP side effects and issues. Alas, life does not always work out as planned. Hence the quote at the top of the page:

“It does not matter how slowly you go as long as you do not stop.”

– Confucius (Chinese Philosopher – 551 BC – 479 BC)

Should you be having any issues with your sleep apnea therapy, keep going until you find an answer and succeed.

When iVAPS or AVAPS is added to the BiPAP or Bilevel ST machine, a person can have total control and flexibility in overcoming any sleep issues. In addition to being treated more effectively than with other sleep machines, a person can have the machine work as they would like it to work. For example, adjust the time to inhale and exhale and breathing sensitivity.

By setting a target alveolar ventilation rate based on a person’s height, the ventilation of a patient and the volume of air can be controlled. These are fantastic machines and the great thing I like with iVAPS is that the median tidal volume will not change from one night to the next even though my respiratory or breathing rate may change.

On the next blog post, I will provide further details of the issues of OSA occurring in REM sleep and awake bruxism and what I have done to reduce and minimize these issues.

I suggest that once the COVID-19 pandemic subsides, that there may be the opportunity to buy a second hand BiPAP or Bilevel machine including machines with iVAPS or AVAPS. Should you have the opportunity to buy these machines at a very good price, I would strongly recommend that you take advantage of what may be a once in a lifetime opportunity to buy a great machine.

If you are new to sleep apnea therapy or you want to know whether you have sleep apnea, recommend that you consider renting an auto adjusting CPAP machine for a short time such as 1 week or 1 month from a Sleep Clinic. The clinics can give assistance as required in using the machine. In addition, any rental cost will likely include a data retrieval and diagnosis service to give you an understanding of your sleep results and whether you have sleep apnea.

Should you be having side effects and issues with your sleep apnea therapy; CHANGE what you are doing so that you can wake up feeling refreshed and energized each day.

“Have courage. Be adventurous and Go for it! Overcome your fear.”

- Mrhelpful