Why can't I get my AHI down?

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
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OkyDoky
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Re: Why can't I get my AHI down?

Post by OkyDoky » Tue Jan 24, 2017 5:54 pm

Pugsy wrote: Without knowing more particulars I am a bit leery of going down my usual more drastic "let the machine sort it out" route.
The history of heart attack bothers me.
I kinda wish this machine was of the Air Curve variety...so that CSR would/could be flagged by the machine if it were happening.
This is why I dropped out. I didn't feel able to evaluate enough. The words "massive heart attack" and shortness of breath put me on alert and October ?2016? is not that long ago.
Another thing I wasn't sure if this is a frequent waking issue, sleep quality issue, or looking for better numbers.
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zimm4er
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Re: Why can't I get my AHI down?

Post by zimm4er » Tue Jan 24, 2017 6:20 pm

What would be The most advanced3 resmed machine. I was given this machine by my DME presumably because That is what my insurance would pay for. I am rhinking of buying a machine outright, what would you suggest?
My heart function/ ejection fraction is 55%. Which is pretty much back to normal. I do not know if my osa is worse in rem or not. The heart attack created some kind of brain damage that gave me central sleep apnea. I did not have this before my heart attack, ie i did not have shortness of breath before my geart attack. This is shortness of breath not necessarily with activity.

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Re: Why can't I get my AHI down?

Post by palerider » Tue Jan 24, 2017 6:35 pm

zimm4er wrote:What would be The most advanced3 resmed machine. I was given this machine by my DME presumably because That is what my insurance would pay for. I am rhinking of buying a machine outright, what would you suggest?
My heart function/ ejection fraction is 55%. Which is pretty much back to normal. I do not know if my osa is worse in rem or not. The heart attack created some kind of brain damage that gave me central sleep apnea. I did not have this before my heart attack, ie i did not have shortness of breath before my geart attack. This is shortness of breath not necessarily with activity.
the ST-A is the most advanced machine, followed by the ASV.

you're using it in 'dumb timed mode' though.

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Re: Why can't I get my AHI down?

Post by zimm4er » Tue Jan 24, 2017 6:47 pm

Can i change it so it is not in dumb timed mode? My flow rates are constient. Not sure what you mean by looking at my flow rates then?

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Re: Why can't I get my AHI down?

Post by Pugsy » Tue Jan 24, 2017 6:51 pm

Actually your DME should be supplying the machine the doctor ordered and at the settings the doctor requested.
It's not up to the DME to make the decision when it comes to these types of high end machines.
Doctors write the orders and the DME fills them.
Insurance doesn't decide either...the doctor does.
Now the DME might elect to use one brand over another because that's the brand they stock but the model/function of the machine comes from the doctor.

The S9 is a discontinued series. Replaced by the Air Curve 10 series.
I am not all that familiar with every little function or feature on your particular S9 machine. I have a S9 Adapt which is an ASV machine but it's different than yours and I have never really studied up on just exactly what yours does but maybe PR could hit the high points for me (compare what it can do to what mine does so I can understand better)
And we don't know what the original RX from your doctor said...maybe there was something in the RX that could only be met with this particular model.

Ejection rate of 45 is the cut off for the ASV machines like mine...or at least that's the general line in the sand when someone needs a cpap machine that will treat both central apnea and obstructive apnea.
If yours is 55...that's well above the cut off line but maybe the doctor wanted to play it safe with you anyway.

I think you should sit down with your doctor and have him explain how he came up with these settings and why and why this particular machine. It's what I would be doing if I were in your shoes.
So that you understand better the "why" of all this.

There's more than one way to treat central apnea or obstructive apnea or in your case...both at the same time.
I use the ASV machine but I don't have a problem with centrals. I use it to treat plain jane obstructive apnea because I just like it better. I bought it on a lark (privately) just to try it because someone told me how nice it was and I got hooked.
I do sometimes need pressures up around 18 for my REM OSA but other times I can get by with around 8 cm. With this machine and it's rapid response I spend most of my time in single digit pressures and it only goes up briefly when needed. That's a lot more comfortable than using the higher pressures all night so for me it's strictly a comfort thing.

Your machine will treat OSA and treat central apnea too...mine will do the same thing but they go about it differently...but they both can do the job. Your machine set up the way it is set up (for whatever reason your doctor decided) will both prevent the airway collapses and breathe for you if a central pops up and you don't breathe.
There's more than one way to skin a cat you know. You pressures are consistent all night long...mine vary wildly all over the place but I sleep through it all so I don't care.

I don't know if settings more like mine would be something you could or should use. Your history of a recent heart attack and the centrals makes me ultra cautious about offering any ideas that might differ from your doctor. It's not my place really and in all honesty this way of "skinning the cat" seems to be getting the job done. I don't know that my way is any better and I sure don't want to suggest something that might cause a problem. That's way I have been super cautious with my thoughts.

These changes you have done...really relatively minor changes in the grand scheme of things but it's all that I felt comfortable with offering my thoughts on.

I assume that you have some sort of follow up scheduled relatively soon to see how you are doing on therapy. If you don't...make the appointment because you really should have the doctor's input about all this.

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Pugsy
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Re: Why can't I get my AHI down?

Post by Pugsy » Tue Jan 24, 2017 6:58 pm

I am not going to suggest changing from the timed mode....I am not comfortable suggesting that change.
I have to assume that the doctor did it for a reason. Now maybe the reason is he is an idiot and doesn't really understand complex sleep apnea...or maybe he does and he has a reason for doing things this way.

Changing modes might not hurt anything at all but the history causes me to pause and the lack of more details cements things.
It's not like you don't have a current doctor who is supposed to be watching you.

Does anyone have the ResMed titration guide for the higher end ASV type of machines? I used to have a link but ResMed moved all the good stuff and now my link is broken and I don't think I downloaded it and if I did it's probably on the old laptop hiding in the drawer.

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bonjour
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Re: Why can't I get my AHI down?

Post by bonjour » Tue Jan 24, 2017 7:21 pm

Pugsy is this what you are looking for?

https://www.resmed.com/us/dam/documents ... lo_eng.pdf

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Re: Why can't I get my AHI down?

Post by palerider » Tue Jan 24, 2017 7:25 pm

Pugsy wrote: I have a S9 Adapt which is an ASV machine but it's different than yours and I have never really studied up on just exactly what yours does but maybe PR could hit the high points for me (compare what it can do to what mine does so I can understand better)
the ST-A (iVAPS) and asv both respond to reduced breath effort, and force breaths during central episodes of either reduced, or no breath effort.

the main difference, I believe is that with the asv, it's working to a moving average of 90% of your minute vent, so you can, just get lower and lower and lower ventilation with an asv, trailing off to nothing, if you don't make adequate efforts to breath on your own.

the iVAPS is programmed with a target MV, and it'll work to meet that minimum, no matter what your breathing effort gives.... plus it's more programmable than the ASV, which is almost entirely automatic.

page 25: https://www.resmed.com/us/dam/documents ... lo_eng.pdf

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Re: Why can't I get my AHI down?

Post by Pugsy » Tue Jan 24, 2017 7:27 pm

Yep...thank you ...that's what I think I was thinking of but unfortunately it doesn't go into the ASV titration part of things nearly as deeply as I had hoped. It's mainly a VPAP titration guide for OSA with a tiny bit of ASV thoughts tacked on at the very end. Doesn't really explain what I was looking for.

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Re: Why can't I get my AHI down?

Post by zimm4er » Tue Jan 24, 2017 8:21 pm

My settings came from a sleep titration night. Not sure how savy my doc is with sleep apnea, machines, and settings.

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Re: Why can't I get my AHI down?

Post by Pugsy » Tue Jan 24, 2017 8:51 pm

Do you happen to have a copy of that sleep titration report?
It might explain how these settings came to be chosen. I am sure they had their reasons.

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Re: Why can't I get my AHI down?

Post by palerider » Tue Jan 24, 2017 8:52 pm

Pugsy wrote: I am sure they had their reasons.
I'm more suspicious of that

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Re: Why can't I get my AHI down?

Post by zimm4er » Wed Jan 25, 2017 6:03 am

Initial sleep study was at home: total 51 apneas, 39 obstructive, 2 mixed , 10 central. There were 71 hypopneas. Overall AHI 15.9, aned 19.8 while supine. The titration sleep study: 104 A/H events before tx started. total NREM apneas 68, apnea index 12.7, total central apnea: 65, central apnea index 12.1, total NREM 33, total REM 3, Started on cpap 4, titrated to 12 cpap. Then changed to bilevel 14/10 and further titrated to 19/14 with a rate of 10.
I really want to increase my IPAP to 19. What do you think?
If I were to buy my own machine? Would you recommend the Aircure10 then? or Dreamstation BIPAP?
My endpoint is better #'s and hopefully to feel better, ie more rested.

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Re: Why can't I get my AHI down?

Post by Pugsy » Wed Jan 25, 2017 8:44 am

Sounds like they used these settings more as a bilevel with fixed breathing rate.
Bilevels were really the first line of therapy thought about for centrals and sometimes they worked.
Yeah...I don't blame you for wanting to try more IPAP. I think it it should be okay.
You had some centrals on the initial diagnostic home study so not all your centrals post cpap titration were cpap triggered.

I have not used either the latest ResMed or latest Respironics but I have used both in the slightly older models. I prefer the ResMed.
It's a bit more aggressive in how it does things. Works well for me but it might not be what someone else likes. It responds faster to my obstructives. This lets me use a lower pressure for the parts of the night where I don't need as much which is especially at the beginning of the night while awake and that's simply more comfortable and I am all about comfort.

Given what we now know....I would say AirCurve 10 ASV. Respironics doesn't have a similar model in the DreamStation line yet.
The ASV does do a breathing rate but it's an auto rate meaning the machine figures out your normal rate and then when you need help it steps up but otherwise it let's you do the initiation of the breathing.
Essentially the ASV is a bilevel that auto adjusts and will breathe for you if needed. What you are doing now is pretty much the machine keeping you at the rate it is set for no matter whether you need the machine to do it or not. Doesn't really hurt anything to do it this way.
The advantage of the AirCurve 10 ASV over the S9 Adapt (which is the same model)...mainly the CSR breathing pattern (should it happen). Otherwise the algorithms are the same. ResMed didn't change the algorithm with the new model line. They just changed the packaging. CSR can be spotted on the S9 flow rate but a person has to go looking for it and know what to look for. With the AirCurve (or AirSense for that matter) the machine actually flags it and takes the work out of looking for it.
Respironics calls it Periodic Breathing on some models. Even without the ResMed breaking down the apneas into central or obstructive in the ASV model line I still prefer it.

Your current machine will do more than it is set to do at this time but it seems to be working well for you so there's no urgent need to have it be more "auto adjusting".
Finding an AirCurve 10 ASV that is affordable on your own is going to be tough. I would love to try one myself but I can't find one within my price range. You might find a S9 Adapt like mine at some place like. If you want to look at those send me a private message because there are 2 S9 Adapt models and I think the 36037 model might be a slightly better option in the S9 models.

I do think you want to look at something that will breathe for you (if you need it) and the regular bilevel machines can't do it.
I don't know that you really need the breathing rate built in but it would be nice to have it just in case.
The ST-A model...actually is a more expensive machine than the ASV. But I don't know that you necessarily need the features that make it cost more.
Your ST-A has been dumbed down so that it's working more like a fixed bilevel but it has the breathing rate built in. I would need to study the machine manual to see what other options in terms of settings it might offer. Since we don't get many people using the ST-A model and I haven't seen one I really am not all that up to speed on how it differs. It's especially useful when people have some sort of lung issue where the breathing rate is critical and a target volume is critical. With people who have maybe really bad COPD or some other restrictive lung condition.

You might do okay with your centrals with a regular bilevel without a built in breathing rate (like the AirCurve 10 VAuto) but I don't think I would want to risk it with the history of the centrals. I would want a machine that could breathe for me IF I needed help.

The normal progression of titration when centrals are present in the titration is
cpap mode first...hey sometimes they go away with simple and easy
if they don't then regular bilevel is tried because sometimes that works
if regular bilevel doesn't work then they try something with a back up rate or ASV bilevel.

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palerider
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Re: Why can't I get my AHI down?

Post by palerider » Wed Jan 25, 2017 1:55 pm

zimm4er wrote:Initial sleep study was at home: total 51 apneas, 39 obstructive, 2 mixed , 10 central. There were 71 hypopneas. Overall AHI 15.9, aned 19.8 while supine. The titration sleep study: 104 A/H events before tx started. total NREM apneas 68, apnea index 12.7, total central apnea: 65, central apnea index 12.1, total NREM 33, total REM 3, Started on cpap 4, titrated to 12 cpap. Then changed to bilevel 14/10 and further titrated to 19/14 with a rate of 10.
I really want to increase my IPAP to 19. What do you think?
If I were to buy my own machine? Would you recommend the Aircure10 then? or Dreamstation BIPAP?
My endpoint is better #'s and hopefully to feel better, ie more rested.
my strong favorite is the aircurve, it's more responsive, other people have other views

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