Trilogy AVAPS-AE-Ongoing

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
aytikvjo
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Re: Trilogy AVAPS-AE - Time to Revisit

Post by aytikvjo » Wed Aug 27, 2014 2:27 pm

If your BPM is comfortable then by all means keep that where it is.

You are meeting your target tidal volume correct?

As far as pressure support goes, it is merely the pressure above EPAP
Thus:
EPAP + PS = IPAP

My only concern with the maximum pressure thing is that it was low enough that if you are normally operating at the upper end of your pressure support range it would limit how high the EPAP could go.

One alternative that crossed my mind is to use the dual prescription setting to have one S/T for day and one for night.
If the AVAPS-AE isn't responsive enough / your not getting the efficacy you desire for you therapy during the nights on your back, you could set up a second prescription using your normal S/T mode but tailored to do obstructives during sleep on your back.

If that if the route you wish to go, you could start with EPAP at 12 or so and watch your data / what your husband says.

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Madalot
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Re: Trilogy AVAPS-AE - Time to Revisit

Post by Madalot » Wed Aug 27, 2014 2:50 pm

I use the Trilogy at night ONLY. I have the Primary Prescription set for regular AVAPS (my regular settings) and Secondary Prescription are the AVAPS-AE settings.

My regular AVAPS settings have been keeping my average tidal volume ABOVE target (450ish most nights).

We are having company for dinner so I need to table this (no pun intended) until later this evening. Before I go to sleep, I will read your information and reset the AE settings to what I believe you are talking about. Might post a question or two between 9:00 - 10:00 EST.

Thank you very much for the help.

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Madalot
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Re: Trilogy AVAPS-AE - Time to Revisit

Post by Madalot » Thu Aug 28, 2014 9:36 am

aytikvjo wrote:As far as pressure support goes, it is merely the pressure above EPAP
Thus:
EPAP + PS = IPAP
The above piece of info was incredibly helpful in allowing me to think clearly when doing the settings. But I didn't get to it until late and made the changes I *thought* made sense. I must have screwed something up because hubby said I was NOISIER than the night before. I still slept through as much as possible, but the FOT's seemed more intense and annoying. Plus, I woke up foggy and with a headache.

If this weren't so important, I'd bag it for now because I've got too much else going on to mess with this. But I really need to.

And I know a lot of people are thinking "just sleep in separate bedrooms" but my husband is REFUSING that option. He would rather have me snore like a train and wake him up all night than us sleep apart. And I can FORCE him to change his mind about it. So, I'm trying to figure out a way to me to stop making so much noise.

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Madalot
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Re: Trilogy AVAPS-AE - Time to Revisit

Post by Madalot » Thu Aug 28, 2014 1:48 pm

Okey Dokey --

I've figured something out and it's a problem. The AE settings do not have a Min IPAP. Because my regular AVAPS settings are 18/10, in order to get that starting out with AE, I need to set Pressure Support to 8. But as EPAP goes up, so does the IPAP. I might need the EPAP up to 11 or 12, but that doesn't mean I need my IPAP to be at 19 & 20 accordingly.

The other problem is that I have trouble exhaling if the EPAP gets too high. Last night that was part of the problem. I was laying on my side, trying to fall asleep, and I FELT the EPAP go up (after a few annoying FOTs). I looked and sure enough, I'm suddenly at 19/11, then 19.7 over 11.7 or something alone those lines.

I really only need the varying EPAP when I'm on my back, which I do NOT start out that way. The only way *I* can see is for me to manually go between Primary (regular AVAPS) and Secondary (AVAPS-AE) when I turn to my back. But that would be very difficult considering my mobility issues.

Does this make sense? Anybody have any suggestions here? Am I missing something and/or being very stupid?

WAAAAHHHHH! I think I may be stuck here....

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aytikvjo
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Re: Trilogy AVAPS-AE - Time to Revisit

Post by aytikvjo » Thu Aug 28, 2014 9:47 pm

Madalot wrote:
I've figured something out and it's a problem. The AE settings do not have a Min IPAP. Because my regular AVAPS settings are 18/10, in order to get that starting out with AE, I need to set Pressure Support to 8. But as EPAP goes up, so does the IPAP.
This sounds correct to me.
Madalot wrote: I might need the EPAP up to 11 or 12, but that doesn't mean I need my IPAP to be at 19 & 20 accordingly.
The other problem is that I have trouble exhaling if the EPAP gets too high. Last night that was part of the problem. I was laying on my side, trying to fall asleep, and I FELT the EPAP go up (after a few annoying FOTs). I looked and sure enough, I'm suddenly at 19/11, then 19.7 over 11.7 or something alone those lines.
Your lungs behave kind of like an elastic balloon, which is why BiPAP machines are prescribed for high pressure therapy to make things more comfortable. As long as you have this difference in support pressure (remember PS=IPAP-EPAP), your lungs will _have_ to inflate and deflate with the high and low IPAP and EPAP to maintain surface tension vs strain equilibrium. A larger pressure differential will increase this effect. When the PS is a low number ( think like 2-4 cmh2o), your lungs probably aren't inflating enough for adequate ventilation. The awesome thing about AVAPS is that it's going to adjust this pressure differential to make sure that you are on average receiving adequate ventilation. In your case this number is about 8 cmH2O.

So I guess what i'm saying is that you shouldn't feel intimidated by high-ish numbers. I think a while back there was a survey here where it was found that average CPAP (EPAP) pressure were in the area of 10-12 cmH2o. So with your PS of 8, numbers in the 18-20 area aren't too atypical to maintain an airway through exhalation. The high minimum pressure differential, PS, of 8 and the AVAPS algorithm are going to make sure that you are adequately ventilated. After all this machine is a pretty high end piece of kit.

I think you're way more tolerant than I am to have been able to fall asleep in the first place with the FOTS, so I know you are pretty serious about trying to make this work. Your discomfort is a very real thing to you, so we should still try and resolve that.

A couple points come to mind:

Are you having trouble triggering the exhale cycle or is it a case where you are uncomfortable after the exhalation cycle has begun? The distinction may be important.
In the case of the former you could try playing with your triggering settings. Personally I liked the AutoTrak as it compensates on the go and seems to make breathing pretty natural feeling. Definitely worth a try. A flow trigger of 6 L/min might be causing a delayed exhalation effect (which would make it hard to exhale because you would still be at IPAP pressures for a moment until you generate a strong enough backward flow to make the machine switch to EPAP.), which could be a relatively large source of discomfort / disruption of the natural breathing cycle. I think the default's were somewhere around 4 L /min. To make the machine switch from inhale to exhale faster you want to raise the cycle sensitivity. Try 5% at a time until it's more comfortable. Note that if you raise it too much, like in the 50% area, it may start prematurely ending inhalation and switching to exhalation. At least with autoTrak you don't have to worry about it.

In the case where you aren't having any trouble with cycling and it's just difficulty exhaling against the pressure, keep in mind what I was saying earlier about lungs and balloons. It may be the case where you need to get used to having a higher EPAP. I know the learning curve here for new and inexperienced people on normal CPAP can be days to weeks.

Lemme know what you think.

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Madalot
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Re: Trilogy AVAPS-AE - Time to Revisit

Post by Madalot » Fri Aug 29, 2014 5:00 am

aytikvjo wrote:
Madalot wrote:
I've figured something out and it's a problem. The AE settings do not have a Min IPAP. Because my regular AVAPS settings are 18/10, in order to get that starting out with AE, I need to set Pressure Support to 8. But as EPAP goes up, so does the IPAP.
This sounds correct to me.
By George, I think I've got PS figured out. Your simple equation finally registered in my brain. Thank you!
aytikvjo wrote:I think you're way more tolerant than I am to have been able to fall asleep in the first place with the FOTS, so I know you are pretty serious about trying to make this work. Your discomfort is a very real thing to you, so we should still try and resolve that.
I gave up the first time because of the FOTs. There is a lot more at stake this time, plus the supine sleeping was avoidable before. It's not now. I'm even getting a pressure sore on my right ear from sleeping on my right side so much.
aytikvjo wrote:A couple points come to mind:

Are you having trouble triggering the exhale cycle or is it a case where you are uncomfortable after the exhalation cycle has begun? The distinction may be important.
In the case of the former you could try playing with your triggering settings. Personally I liked the AutoTrak as it compensates on the go and seems to make breathing pretty natural feeling. Definitely worth a try. A flow trigger of 6 L/min might be causing a delayed exhalation effect (which would make it hard to exhale because you would still be at IPAP pressures for a moment until you generate a strong enough backward flow to make the machine switch to EPAP.), which could be a relatively large source of discomfort / disruption of the natural breathing cycle. I think the default's were somewhere around 4 L /min. To make the machine switch from inhale to exhale faster you want to raise the cycle sensitivity. Try 5% at a time until it's more comfortable. Note that if you raise it too much, like in the 50% area, it may start prematurely ending inhalation and switching to exhalation. At least with autoTrak you don't have to worry about it.

In the case where you aren't having any trouble with cycling and it's just difficulty exhaling against the pressure, keep in mind what I was saying earlier about lungs and balloons. It may be the case where you need to get used to having a higher EPAP. I know the learning curve here for new and inexperienced people on normal CPAP can be days to weeks.

Lemme know what you think.
I think my triggering settings are okay (although I have to admit I'm tempted to revisit the AutoTrak - it's been a long time since I've tried it). And you're right about having to get used to a higher EPAP. I re-adjusted the settings back to where they were the first night and things were better again. Hubby said I woke him up once and that's it. And I slept better. The only time the FOTs bother me is before I fall asleep or when I am awake during the night. They aren't waking me up a lot so once I get to sleep, I CAN sleep through them.

I think I'm going to leave these settings now for a few nights and check my data. We *might* be going out of town for the weekend and I won't be taking the machine. If that's the case, I won't check until after I've got 3-4 consistent nights under my belt (Sunday - Tuesday or Wednesday most likely). If we don't go, I'll be able to check my data by Sunday.

But please give any advice/input. I'll be reading & checking and am willing to make changes or try anything, within reason and my doctor's comfort zone, to make this work better.

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Madalot
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Re: Trilogy AVAPS-AE-Figured Out Something

Post by Madalot » Sat Aug 30, 2014 7:09 am

Well, as usually happens with me, the best laid plans shot.

Last night was horrible. Just horrible. Sleeping on my back (only when the pain on my right side became unbearable), I kept waking myself up snoring and making all kinds of stupid noises.

I finally turned carefully onto my bad (left) side. It hurt, but was tolerable and I dozed on and off that way (with no snoring or noises) for about an hour. When it got hurting too much, I just got up. I'm paying the price in back pain and realize it was too soon to attempt to sleep on that side.

So, not sure where this leaves me. It's bad enough to wake up your partner, but I was waking myself up!

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aytikvjo
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Re: Trilogy AVAPS-AE-Figured Out Something

Post by aytikvjo » Sat Aug 30, 2014 10:35 am

Madalot wrote:
Last night was horrible. Just horrible. Sleeping on my back (only when the pain on my right side became unbearable), I kept waking myself up snoring and making all kinds of stupid noises.
What do you think the cause was? Did you data show anything unusual that the other nights didn't?

I with the Trilogy could auto titrate against things like OA / CA / Hypopneas.

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Madalot
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Re: Trilogy AVAPS-AE-Figured Out Something

Post by Madalot » Sat Aug 30, 2014 10:50 am

aytikvjo wrote:
Madalot wrote:
Last night was horrible. Just horrible. Sleeping on my back (only when the pain on my right side became unbearable), I kept waking myself up snoring and making all kinds of stupid noises.
What do you think the cause was? Did you data show anything unusual that the other nights didn't?

I with the Trilogy could auto titrate against things like OA / CA / Hypopneas.
You and me both. The Trilogy data is NOT tailored toward sleep apnea and doesn't provide any info in dealing with that aspect of all this.

I need to look at the data to see if anything appears off or odd. I'll try to look later this afternoon or tomorrow morning. I'll post when I can.

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Madalot
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Re: Trilogy AVAPS-AE-Figured Out Something

Post by Madalot » Sat Aug 30, 2014 11:52 am

I finally had a chance to get the card and download the data. Everything is totally in line with regular AVAPS results other than average EPAP is closer to 11 (was set at 10 on regular AVAPS).

I'm at a loss.

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Re: Trilogy AVAPS-AE-Figured Out Something

Post by Madalot » Sun Aug 31, 2014 10:23 am

As a temporary measure, it occurred to me that replacing the Convoluted Bed Pad on my side *might* give me some relief. We bought one Friday and put it on the bed yesterday. I was more comfortable and could handle side sleeping (one side only) longer. At least last night.

I'm still using AVAPS-AE and the FOTs are becoming less bothersome. I personally find them almost fascinating when I'm awake for them, which isn't often.

Maybe by replacing that pad, I can get a few good nights under my belt and see how this works out.

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aytikvjo
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Re: Trilogy AVAPS-AE-Figured Out Something

Post by aytikvjo » Sun Aug 31, 2014 7:38 pm

Madalot wrote:.

Maybe by replacing that pad, I can get a few good nights under my belt and see how this works out.
Best of luck. Do you feel like any of this tinkering at least has helped?

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Madalot
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Re: Trilogy AVAPS-AE-Figured Out Something

Post by Madalot » Sun Aug 31, 2014 8:32 pm

Absolutely! I am spending a large amount of time on my back. I'm having some better nights without much snoring or noise.

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Re: Trilogy AVAPS-AE-Figured Out Something

Post by Madalot » Mon Sep 01, 2014 7:55 am

Another night under my belt on AVAPS-AE. Hubby said he heard very light snoring ONCE, but it wasn't bad. I felt I had an okay night. Pain was bad, but I was able to sleep reasonably well. FOTs were annoying when awake, but I find that I kind of lay there and count them, waiting for them to stop and go back to normal EPAP. Passes the time and I fall to/back to sleep before I endure more than 2 rounds of FOTs - so it's fast.

At this point, I am sticking with AVAPS-AE for the time being. Even with on/off nights, the data appears to be in line with where I am supposed to be.

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Re: Trilogy AVAPS-AE-Ongoing

Post by Madalot » Fri Sep 05, 2014 8:38 am

I think if the Trilogy had a white flag, it would have been frantically waving it last night. I was having the most vivid dream where I was snoring like a train. It was awful. The dream lasted a little bit (I still remember bits & pieces of it) and the next thing I know, my husband is poking me. May have been a dream, but IRL, I was snoring to beat all and the Trilogy wasn't stopping squat!

Some nights are okay where I don't seem to snore at all. Some my husband reports that I was snoring very softly and not bothering him. And some are like last night where it seems the Trilogy doesn't have a prayer of stopping it.

I'm not sure if I should keep tweaking or just accept that nights are going to be HORRIBLE.

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