anyone couldn't bring AHI down (tired) despite all trials???

[williamco]

I am interested if there are people out there who tried everything, for three months or more, from titration to titration, from APAP to BiPAP, from mask to mask..etc and couldn't bring their AHI down, or still feel tired

I am sorry I don't mean to talk about the opposite topic "successful strories" , but what I mean to is try to find out what might be the problem, and what is the size of these problems out there, and talk about possible solutions

one of the thought is that XPAP can't do anything for a tongue that is slacking backward during sleep, XPAP can only push softpalate and soft tissue of the throat open, but can't push the tongue forward. and if XPAP open the throat but the tongue keeps sliding backward into the open throat, XPAP has limited success. it is still needed though but something else is required

other thought is that BiPAP should be the standard not CPAP, even at lower pressure, the reason is exhalation is always passive move (no muscle move is involved but only the chest elasticity that brings chest down again) but at sleep this elasticity is not enough to counter the CPAP pressure so exhalation is not complete

on the other hand if BiPAP is used and pressure goes down in exhalation, by law of physics, the chest has to go down, as there is high pressure inside the chest ( lung) and a lower pressure at the mouth, so it is again a passive move here so exhalation is complete

even if while awake you feel the CPAP pressure is OK to handle, it might not be OK while asleep, when the breathing process is much weaker and done naturally

[sepool]

I would think that exhalation does involve muscles - or else we couldn't blow up a balloon. The pressures that cpap uses are really quite low compared to what we can breathe - for a relatively healthy person. Now being distracted by it is another matter - and of course some people physically need bipap.

[williamco]

exhalation is different than blowing. exhalation for a healthy person doesn't involve muscles if it done naturaly, unless consciously you use your muscles

[millich]

William -
What is your AHI on BiPAP?
How is your leak rate?

[Julie]

If you are sleeping on your back, you will have worse problems, tongue and otherwise, and more apneas do occur that way, so do whatever you can to not sleep that way. You might also consider a full face mask because you very likely could be losing all the good air out of your mouth if it opens when you're asleep, if only as a reaction to Cpap pressure.

[jules]

if you have been using your lab titrated pressure and still are tired, it is time to go back to the doctor or find a new certified sleep doctor - you might not have just "garden variety OSA"

[kteague]

Date of starting successful treatment, not just treatment, is the time one can more realistically start marking how long it has taken to feel the results. There have been some good suggestions. I'd like to add that putting all your study results side by side for comparison may give some clues, along with more machine data as previously mentioned. The info given so far isn't specific enough to venture much but general possibilities, but hopefully as this thread develops it can be more targeted.

There are always those with other contributing factors to their tiredness, but until the OSA treatment is producing acceptable data, it's hard to tell what comes from the OSA or from something else. If you exhaust all other avenues, you may want to look into having an xray to determine if your airway is the "normal" width. There are some whose airway is so compromised structurally that even cpap is not enough. Particularly those with what was once considered a receding chin may actually have a jaw that is inset further rather than being smaller, and sometimes that infringes on the airway. That's a long shot, just something to keep in the back of your mind if more targeted addressing of your continued high AHI doesn't resolve your issues.

[ozij]

if you have been using your lab titrated pressure and still are tired, it is time to go back to the doctor or find a new certified sleep doctor - you might not have just "garden variety OSA"

For example:

Complex Sleep Apnea
CompSA is characterized by the following:

■The persistence or emergence of central apneas or hypopneas upon exposure to CPAP or bilevel when obstructive events have disappeared
■CompSA patients have predominately obstructive or mixed apneas during the diagnostic sleep study, occurring at least 5 times per hour
■With use of a CPAP or bilevel, they show a pattern of central apneas and hypopneas that meets the Centers for Medicare Services (CMS) definition of CSA (described below)

A diagnosis of central sleep apnea (CSA) requires all of the following:

■An apnea index > 5
■Central apneas/hypopneas > 50% of total apneas/hypopneas
■Central apneas or hypopneas occurring at least 5 times per hour
■Symptoms of either excessive sleepiness or disrupted sleep

[williamco]

thanks for the input. here are the my info:

1- nasal mask yes, but I tape my mouth, so the leak is totally under control
2- AHI coudn't go under 4-6 , along with feeling tired all the time
3- tried CPAP straight then AUTO and then BiPAP
4- I wondered across the entire range of pressure from 7-20, spending few days at each 2-3 cm range
5- ozij along with others suggested to go back from the beginning of the range around 10 and start allover
nowadays I am there with BiPAP auto 9-20 with max pressure support of 4 cmh20, machine hanging around 14/11 (IPAP/EPAP) but AHI still around 4-6
6- tried to sleep on my back, only made a difference 1 point not more, also not much on my tiredness
7- overnight oximeter showed only 2 attacks that lasted 10 seconds or more, one with 95% and the other 93%. so I don't think there is problem here about central apnea
do you agree about this statement in red??

[ozij]

thanks for the input. here are the my info:

1- nasal mask yes, but I tape my mouth, so the leak is totally under control
2- AHI coudn't go under 4-6 , along with feeling tired all the time
3- tried CPAP straight then AUTO and then BiPAP
4- I wondered across the entire range of pressure from 7-20, spending few days at each 2-3 cm range
5- ozij along with others suggested to go back from the beginning of the range around 10 and start allover
nowadays I am there with BiPAP auto 9-20 with max pressure support of 4 cmh20, machine hanging around 14/11 (IPAP/EPAP) but AHI still around 4-6
6- tried to sleep on my back, only made a difference 1 point not more, also not much on my tiredness
7- overnight oximeter showed only 2 attacks that lasted 10 seconds or more, one with 95% and the other 93%. so I don't think there is problem here about central apnea
do you agree about this statement in red??

Of course not.

http://www.chestnet.org/education/onlin ... rint10.php

Lesson 10 — Complex Sleep Apnea
By Akram Khan, MD; and Peter C. Gay, MD, FCCP
Clinical Consequences of CompSAS
In patients with CompSAS, PAP therapy for the airway obstruction may help eliminate flow limitation and improve sleep unless residual respiratory controller dysfunction persists, characterized by periodic breathing and arousals. Increase in pressure leads to worsening of the periodic breathing, and a reduction of pressure results in return of obstruction.8 These patients cannot be adequately treated with CPAP, as symptoms (fatigue, sleepiness, and depressed mood) remain unresolved and adherence to CPAP therapy can be poor. Oxygen therapy often is not very helpful in CompSAS because, by the later stage of titration when patients can develop periodic breathing, saturation percentages are usually in the high 90s, and further improvements in oxygenation have very little effect in treating the disorder.8 In one particular study,7 patients with CompSAS required more frequent follow-up and had a higher incidence of interface problems, such as mask removal, air hunger, or dyspnea, reflecting difficulty in adapting to CPAP therapy.

My emphasis.

O.

[tonycog]

From http://www.chestnet.org/education/onlin ... rint10.php :

BPAP and ASV are the only consistently well-documented forms of therapy. Both may be equally effective, but ASV appears to be better tolerated by patients.

The quote above is from the conclusions of the study. What is "ASV"? My Bi-PAP is called a Bi-PAP Auto SV, for Auto Servo-Ventilation. Is this the same thing? What is the difference between Bi-PAP and ASV?

Thanks,
Tony

[blarg]

What is the difference between Bi-PAP and ASV?

A standard Bi-PAP switches between two pressures when you breathe. One for inhale and one for exhale.

The ASV includes an algorithm that attempts to determine when you are experiencing a central apnoea, and it initiates a breath for you.

http://bipapautosv.respironics.com

[ozij]

From http://www.chestnet.org/education/onlin ... rint10.php :

BPAP and ASV are the only consistently well-documented forms of therapy. Both may be equally effective, but ASV appears to be better tolerated by patients.

The quote above is from the conclusions of the study. What is "ASV"? My Bi-PAP is called a Bi-PAP Auto SV, for Auto Servo-Ventilation. Is this the same thing? What is the difference between Bi-PAP and ASV?

Thanks,
Tony

Edit: I think what ASV stands for depepend on the company. Since ResMed's machine is called Adapt SV, Respirionics, is (naturally...)Auto SV. Both adapt automatically... and despine the "Auto" in its name, Resprionics says:
http://bipapautosv.respironics.com/faq.aspx

The device does not have an auto-titrating algorithm to alleviate obstructive events. The innovative algorithm was designed to treat complex apnea and periodic breathing. The obstructive component of SDB is treated utilizing a clinician adjustable CPAP or BiPAP pressure level.

An ASV machine (by either company) can change your inhale pressure speedily, on a breath by breath basis. It assumes your obstrucive events are controled by your EPAP, and jumps in to ventilate you while your lying there doing nothing with your airway wide open. It blows the IPAP pressure into you for one breath, and lets go. An automatic BIPAP isn't capable of that kind of "pressure change per breath" response.

An automatic BIPAP will adjust pressure according to what happens during a number of breaths, and will maintain that change for a number of breaths.

http://chestjournal.chestpubs.org/conte ... /1839.full

Adaptive servoventilation (ASV) uses an automatic, minute ventilation-targeted device (VPAP Adapt; ResMed; Poway, CA) that performs breath-to-breath analysis and adjusts its settings accordingly.8 Depending on breathing effort, the device will automatically adjust the amount of airflow it delivers in order to maintain a steady minute ventilation.

Resmed:
http://www.resmed.com/us/documents/1010 ... -sheet.pdf

Ventilation to a moving target To determine the degree of pressure support needed, the adaptive servo-ventilation algorithm continuously calculates a target ventilation. Based on respiratory rate and tidal volume, the target is 90% of the patient’s recent average ventilation—that means that ventilation can vary gradually and naturally over the course of the night.

Respironics:
http://bipapautosv.respironics.com/faq.aspx
The algorithm is based on flow. Using proven RI technologies such as Digital Auto-Trak, the flow signal is analyzed and a target flow is calculated. If the patient reaches the flow target, the device does not offer any additional pressure support. If the patient does not reach the flow target the device will dynamically change pressure support breath to breath

O.

[millich]

William - how many hours of sleep are you getting at night?