Resmed VPAP Adapt SV - for Central Sleep Apnea

[Snoredog]

So gang, if you can rally around again and send in some support, ideas, thoughts

Very interesting. I don't see how you could stand six months of it throwing those changes at you. When I messed around with the VPAP III ST, it was more than just a little annoying to have the E/I pressures changing unexpectedly when I didn't need it.

As much as I like trying different machines and having the nice exhalation relief of the one I use now (BiPAP Auto) if truth be told, straight cpap at 9 or 10 or 11 would treat me fine. Maybe straight cpap -- a simple steady pressure -- would suit you after all, frequen?

Even if it didn't when you first began using "cpap", you've come a long way since then tweaking other "comfort" aspects of using cpap -- trying masks, etc. Perhaps straight cpap at an effective single pressure and an unplugged Swift would do you well now. Might be worth trying.

I'm surprised you are able to use a bipap at all, it would seem to make things worse for you. That is the reason I decided against trying one, I read that study SAG had posted the other day.

That little 420e is dancing around my issues just fine, only used it 2 days now, but so far so good. Turning FL off and dropping the A 10 parameter to A=9 seems to have worked like a charm. Last night I had zero CA events.

I think the lower exhaust rate of the Soyala, that combined with avoidance (via machine) is working for me. I'm so sleep deprived it is going to take a while for me to catch up where I can actually feel it.

[-SWS]

Hey, I have seen one of those specialists:

That picture always cracks me up!! Now there's a guy you don't particularly want to sit next to in a restaurant---when he suddenly manages to see the world clearly that is.

Of course, you know the deal with neurogastroenterology, Snoredog. It's considered a "medical research field" more than a mainstream "medical field of practice". If you saw a specialist in the field of neurogastroenterology, then you were most likely a research subject, rather than an ordinary patient making a routine visit to a sub-boarded gastroenterologist.

Two things strike me about this dual field of medical research: 1) not enough is known yet about this convergent area of research to support a widespread/dedicated field of practice, and 2) this dual-discipline field sustains enough scientific promise to warrant a dedicated branch of medical research.

Snoredog, if you do happen to visit that neurogastroenterology researcher again, be sure to flash that picture and then straighten 'em out for us. Ya just gotta figure those scientific researchers stand only a fifty-fifty chance of catchin' up with our man Snoredog.

[-SWS]

That little 420e is dancing around my issues just fine, only used it 2 days now, but so far so good. Turning FL off and dropping the A 10 parameter to A=9 seems to have worked like a charm. Last night I had zero CA events.

I think the lower exhaust rate of the Soyala, that combined with avoidance (via machine) is working for me. I'm so sleep deprived it is going to take a while for me to catch up where I can actually feel it.

I agree with you, Snoredog. Time is the best test regarding how well the 420e makes you feel by day. I've got my fingers crossed for you, bud. I may even head out to the backyard and do not a rain dance---but a sleep dance! Wait a second... Isn't RLS a sleep dance? But wait! I don't have RLS. Besides, SAG is supposed to do the jokes.

Okay, then... I'll just keep my fingers crossed! Good luck!!!!

[-SWS]

So what about my doctor's interest in the backup rate being 8??
And why does it feel so uncomfortable in the first minutes of use when it is learning my respiration patterns and seems to be forcing the rate and volume then?

I think those are great questions, frequen. Would really love to hear what the Resmed rep says about: 1) that 15 backup respiratory rate being "increasingly" used (if he could define that increasing rate), 2) any baselining and/or settling details to explain your initial sleep-session discomfort, and 3) ASV's technical purpose(s) for mask settings (impedance calculations, leak rate, etc,).

Also, the question comes to mind regarding how well or poorly the ASV reads you (from moment-to-moment) throughout the entirety of any given night. Rested Gal's suggestion gets at the question of whether the ASV platform is suitable or adequate for you. Based on anecdotes in this and other threads, the ASV doesn't seem to come close to being the central apnea panacea the marketing literature describes.

Perhaps I should post some graphs/data.

It will be nice to eventually see that data. Perhaps after debriefing us about what the Resmed rep says? However, it will also be virtually impossible to accurately pinpoint back-up occurrences, when the ASV data set does not even score or display apnea/hypopnea events. Isn't that little data omission frustrating? Where's Snoredog's picture when we really need it!! .

[frequenseeker]

Thanks everyone. I am speaking with the rep in an hour and will be back to you.

RG,

Maybe straight cpap -- a simple steady pressure -- would suit you after all, frequen?

While I was waiting to get the ASV I was on straight cpap with the nonvented mask and added deadspace and it was not optimum. I do have the complex type of SDB pattern so just straight pressure to keep the airway open and unobstructed does not address the fact that my brain will be triggering apneas anyway. In other words, keeping the airway open doesn't guarantee respirations will occur and use the air!

Snoredog, great photo! Unfortunately, when I don't get enough info from all the doctors, manuals, reps, DMEs etc and my own observations and inadequate thinking abilities, I feel like I am that guy...it is hard to live a reasonable life and get ahead when you are so stuck in such a position and have to keep fighting without knowing where you are going!

As to your question about my using bipap - ASV is not bipap. It makes pressure adjustments and has ventilatory support but it actually gives more pressure on the expiration (EEP) to assist the readiness to take the next breath. I had been hopeful this would be the little "boost" that I had approximated with other machines/settings that seemed to be promising. I think the backup rate being so fast rushes me along so I can't get its benefit though.

[frequenseeker]

Update: I am waiting to be contacted by ResMed's clinical specialist, thanks to the rep's arrangement. Sounds like the right person for the job.

[rested gal]

Thanks everyone. I am speaking with the rep in an hour and will be back to you.

RG,

Maybe straight cpap -- a simple steady pressure -- would suit you after all, frequen?

While I was waiting to get the ASV I was on straight cpap with the nonvented mask and added deadspace and it was not optimum. I do have the complex type of SDB pattern so just straight pressure to keep the airway open and unobstructed does not address the fact that my brain will be triggering apneas anyway.

Well, actually I was thinking more along the lines of a regular vented mask and no added deadspace. In other words, going back to square one -- perhaps even with a new baseline sleep study and new titration. A night or two at SAG's lab, for instance. Lot closer to you than it was to me. As he's been known to say, "You got to know what you need to treat before you try to treat it" or words to that effect. There are some very savvy people there. Might be worth the trip. Starting from scratch after a new baseline PSG and titrarion might reveal something that's been missed. Just a thought.

Will be very interested to read what the resmed guys tell you about what you're experiencing with the ASV. All of this is fascinating.

[frequenseeker]

Rested,

going back to square one

I do appreciate your brainstorming, I'm unclear what you imply though. Do you think if I went back to plain vanilla everything I would be okay now? My need for CO2 was documented in the Beth Israel study:

First, she was tried on the Adaptive Servo Ventilator using a
vented mask. During non-REM, there was occasional obstructive
hypopneas and intermittent flow limitation, worsening during REM,
though oxygenation remained reasonable, with nadir oxygenation of
97%.

For the final 3 hours of the night, she was trialed on a
non-vented mask and 50 mL EERS, again with Adaptive Servo
ventilator. There were again infrequent obstructive hypopneas
during non-REM, which again increased during REM. However, there
was an overall reduction in respiratory events, relative to the
two earlier REM stages when she had been on the vented mask.

While on the vented mask, she had 82 obstructive hypopneas; AHI
(Medicare criteria) 0, and RDI of 19.9. While on the non-vented
mask and 50 mL EERS, she had 28 obstructive hypopneas, AHI of 0,
and an RDI of 10.7.

End tidal CO2 measurementswere: mask only- 41, 50 mL- 42, 100 mL-
42 to 44, 150 mL- 44. During titration using 50 mL EERS, end
tidal CO2 ranged from 42-49, but there was no clear increase
during REM.

PERIODIC LEG MOVEMENTS: Infrequent leg activity was seen and was
not associated with arousal. This did not appear periodic.

EKG/HEART RATE: Normal sinus rhythm, no arrhythmias.

EEG: Alpha activity level of 10 cps.

IMPRESSION: Improved control of respiratory events utilizing
non-vented mask and 50 mL EERS. The Adaptive Servo Ventilator
conferred reasonable control of respiratory events during
non-REM. Control was less optimal during REM with presumptive
EEP (default setting) 4, but this would not be surprising given
the degree of CPAP that has been previously required to resolve
her SDB. Would begin Adapt SV with EEP initially set at 6,
nonvented mask, EERS 50cc.

Previous to the ASV, I had tried an S8 with the EPR, which I liked in general (so much quieter than the VPAP III) but to get desired results I needed a pressure at a level I could not tolerate without aerophagia (~12) so it was a big reason we went to the ASV titration.

A night or two at SAG's lab, for instance

Hey, I am game for any good research opportunity...SAG? what say you?

I am scheduled for another study at Beth Israel on April 3. Can bring all suggestions there as well.

Thanks again.
f/

[rested gal]

I do appreciate your brainstorming, I'm unclear what you imply though. Do you think if I went back to plain vanilla everything I would be okay now? My need for CO2 was documented in the Beth Israel study:

First, she was tried on the Adaptive Servo Ventilator using a
vented mask.

---

For the final 3 hours of the night, she was trialed on a
non-vented mask and 50 mL EERS, again with Adaptive Servo
ventilator.

That was using the ASV. I'm talking about getting another "regular" PSG study, as if you were having a regular sleep study done for the first time ever. A full night for baseline study. Then a full night for titration. Literally starting from scratch, but at a different lab than the ones you've gone to before.

SAG's lab came to my mind because he's followed your trials pretty closely and might have additional insight into what's going on. At any rate, it might provide you with additional information if a regular study were done there and scored and analyzed with a new set of expert eyes.

[dsm]

WOW,

Go away for a few days & things can change !!!

So here we have those among us who can't wait to tear the VPAP Adapt apart

It is just an air pump

Love it

DSM

[dsm]

<obscene pic snipped >

That picture always cracks me up!! Now there's a guy you don't particularly want to sit next to in a restaurant---when he suddenly manages to see the world clearly that is.
<snip>

SWS,

As much as I respect your opinions on cpap matters, cant go along with you on this comment

That pic is offensive - sometimes I suspect it says more about the people who promote it than the the target of it.

This is just my humble opinion but I suspect a few other share it. It is simply rude & vulgar !.

Cheers

Doug

[-SWS]

As much as I respect your opinions on cpap matters, cant go along with you on this comment

That pic is offensive - sometimes I suspect it says more about the people who promote it than the the target of it.

This is just my humble opinion but I suspect a few other share it. ...

Doug, I think yours is a very valid opinion, and I'm positive it's shared by others. That picture doesn't come close to offending me. But I also happen to have a fair amount of undergraduate study specializing in deviant social behavior of all things. Needless to say it really does take a whole lot more than that picture to offend me. I've seen that particular picture posted so many times on this message board that I've come to think of it as "the well-dressed yoga master who went a little too far".

However, I think people's values and sensitivities, on any international message board, are virtually guaranteed to be all over the map (pun intended). I also think part of the challenge of coming to a public forum entails learning to tolerate the expressions of others, but also learning to accommodate the diverse social expectations of others as well.

That's quite a balancing act when you think about it: to tolerate the culturally (and even sub-culturally) diverse expressions of others when we listen, but to somehow also accommodate a broad variety of social expectations when we speak. I think that is one incredibly tough balancing act for members of any international message board to collectively nail every time. So my personal apologies to Doug or anyone who finds my own views or humor to be insensitive at times. And, of course, I can't or won't apologize for the views of others. I can only suggest that we learn to tolerate and even ignore that which we take exception to. And to politely mention that which offends us, as Doug has, is fair game too in my opinion. The challenge is in making sure that polite and public airing is in no way inflammatory.

My very best regards, Doug!

[-SWS]

So here we have those among us who can't wait to tear the VPAP Adapt apart

I personally expect Resmed's ASV machine to very nicely handle certain problems in physiology. But I personally don't expect (and never have expected) the PAV functionality of that machine to suit everybody. And I do suspect that adaptive-servo's rotational precision (not to be confused with ASV's PAV) will eventually find its way to more xPAP therapy platforms, when production volume for highly precise adaptive-servo motors goes up and relative cost goes way down. I personally think that BiLevel machines, and particularly auto-adjusting BiLevel machines, will stand to gain some functional benefits from greater rotational precision. However, with PAV machines, that rotational precision offered by adaptive-servo motor design is virtually indispensable. I say that not only because of the avoidance of ventilatory overshoot itself, but also because I personally suspect that a "physiologically defensive" pressure sensitivity just may exist in some patients (related to pressure slope, amplitude, and phase-lag itself). Right now adaptive-servo motor production is comparatively expensive, and understandably targeted for the PAV type machines where that rotational precision is essential.

Yet technical design objectives coupled with medical theory are but one untested ball of wax. Achieving those objectives in the real world are another thing entirely. So in theory Resmed wants to algorithmically drive that adaptive servo motor so that it mirrors patient respiration---as two well-synchronized figure skaters might perfectly mirror each other's moves. To suspect that always or even usually happens in the real world, without at least some form of empirical validation, would be merely unfounded expectations in my own opinion.

Then, of course, there's that medical theory that Resmed's ASV can correct all central apneas. Doug, much earlier in this thread you already expressed that you didn't believe that was even possible. And much earlier in this thread, when I related a clinically-conveyed ASV anecdote about "too much residual disease" I personally came to believe that Resmed's marketing claims about this machine were intentionally or unintentionally confusing/inaccurate. So when you get to the point of believing that Resmed's ASV is not suitable for everyone, then you must start rhetorically questioning and analyzing whether that platform is suitable for anyone who achieves less than desirable results. However, in my opinion we should always question efficacy achieved by any apnea therapy or xPAP platform---not just ASV.

[-SWS]

I continued to have REM related apneas with the back pain and intestinal upset syndrome that would follow, locking everything up in spasm right before dawn.

Frequen, I know you've tried CPAP, APAP, BiLevel, and now the ASV platform. Which xPAP platforms did you happen to notice those pre-dawn gastrointestinal problems? Did any xPAP platforms seem to be better or worse for you in this respect?

I personally suspect your gastrointestinal symptoms are unrelated to xPAP platform. But I just had to ask! However, the pre-dawn timing of your gastrointestinal symptoms may not be entirely unrelated to sleep:

Until relatively recently, people thought that the gut's muscles and sensory nerves were wired directly to the brain and that the brain controlled the gut through two pathways that increased or decreased rates of activity, Dr. Wingate said. The gut was simply a tube with simple reflexes. Trouble is, no one bothered to count the nerve fibers in the gut. When they did, he said, they were surprised to find that the gut contains 100 million neurons -- more than the spinal cord has. Yet the vagus nerve only sends a couple of thousand nerve fibers to the gut.

The brain sends signals to the gut by talking to a small number of "command neurons," which in turn send signals to gut interneurons that carry messages up and down the pike, Dr. Gershon said. Both command neurons and interneurons are spread throughout two layers of gut tissue called the myenteric plexus and the submuscosal plexus. ("Solar plexus" is actually a boxing term that refers simply to nerves in the abdomen.) Command neurons control the pattern of activity in the gut, Dr. Gershon said. The vagus nerve only alters the volume by changing its rates of firing...

...During sleep, the head's brain produces 90-minute cycles of slow wave sleep punctuated by periods of rapid eye movement sleep in which dreams occur. During the night, when it has no food, the gut's brain produces 90-minute cycles of slow wave muscle contractions punctuated by short bursts of rapid muscle movements

The Above NY Times Article Can Be Found By Clicking Here

Pressure-related vagal stimulation is supposedly thought to be a beneficial by-product of certain PAP therapies. Resmed does at least claim that their ASV machine provides beneficial vagal stimulation. If PAP-based vagal stimulation does occur, then I would have to at least wonder if there are ever counter-productive cases as well as productive cases of vagal stimulation. Of course, whether any PAP-based "beneficial vagal stimulation" claim is widely proven or even accepted within the medical community is another thing entirely.

[dsm]

[quote="-SWS"]
<snip>
That picture doesn't come close to offending me. But I also happen to have a fair amount of undergraduate study specializing in deviant social behavior of all things. Needless to say it really does take a whole lot more than that picture to offend me. I've seen that particular picture posted so many times on this message board that I've come to think of it as "the well-dressed yoga master who went a little too far".

However, I think people's values and sensitivities, on any international message board, are virtually guaranteed to be all over the map (pun intended). I also think part of the challenge of coming to a public forum entails learning to tolerate the expressions of others, but also learning to accommodate the diverse social expectations of others as well.

That's quite a balancing act when you think about it: to tolerate the culturally (and even sub-culturally) diverse expressions of others when we listen, but to somehow also accommodate a broad variety of social expectations when we speak. I think that is one incredibly tough balancing act for members of any international message board to collectively nail every time. So my personal apologies to Doug or anyone who finds my own views or humor to be insensitive at times. And, of course, I can't or won't apologize for the views of others. I can only suggest that we learn to tolerate and even ignore that which we take exception to. And to politely mention that which offends us, as Doug has, is fair game too in my opinion. The challenge is in making sure that polite and public airing is in no way inflammatory.

My very best regards, Doug!