Dazed and Confused

[grifho]

Hi all, it's been a while, but I've been dealing with labyrinthitis for almost 7 weeks now. It came on me suddenly one day, and has been quite an ordeal since, with balance issues and all. Still dealing with it, and getting vestibular therapy.

In the meantime, I haven't been able to get my AHI scores down. I spoke with a respiratory therapist the other day, and he suggested I get a BiPap machine to replace the CPAP. According to Sleepyhead, my average AHI for the last 30 days is 6.14, with averages of Obstructive of 1.32, Hypopnea of .57, RERA of .36, and Clear Airway of 4.04. From what I've heard, if you're CA is more that 50% of your AHI, then BiPap may be a good idea. Not sure if that standard has any authority. Anyway, okydokey mentioned to me that a high leak rate can lead to false CA events, and my average leak rate has been 8.63 with a 9.28% of time above leak threshold. But when I look at the times of the CA events, they don't seem to correspond with times of high leak. So, perhaps I should consider the BiPap? Or could the CA be for another reason? I'm still using the Mirage FX nasal mask, although I bought an Innomed Hybrid as well, based on a suggestion here. The hybrid leaked loudly once it approached the higher pressures, so I had to put that aside and stick with the FX. Thanks for any feedback.

[lilly747]

I did not read through your long thread, but I am sure it is in there somewhere: Are you using EPR. If so what setting,1,2,3? EPR can cause CAs with some people.

EDIT: If you have not tried running without EPR, I would. Won't hurt anything to give it a try.

[grifho]

I did not read through your long thread, but I am sure it is in there somewhere: Are you using EPR. If so what setting,1,2,3? EPR can cause CAs with some people.

EDIT: If you have not tried running without EPR, I would. Won't hurt anything to give it a try.

Hi Lilly, yes my machine --Resmed AirSense 10 -- has pressure relief, and I have it set to "On" with a setting of 3. So, that can cause CAs, OK. It would be worthless to get a Bipap if the CAs came from the the EPR setting, so I'll have to look into that. Thanks for the info. In looking at Resmed.com, it says "The Airsense 10 AutoSet differentiates between obstructive and central apneas, and also Cheyne-Stokes respiration, so you can be confident that your patients are receiving appropriate therapy and pressure" It makes it sound like it can remedy central apneas, but in reality it can only correct obstructive and hypopnea events (and record central apnea events), given that it's a CPAP. So I don't know what to make of that statement, unless I have some wrong assumption.

[lilly747]

I did not read through your long thread, but I am sure it is in there somewhere: Are you using EPR. If so what setting,1,2,3? EPR can cause CAs with some people.

EDIT: If you have not tried running without EPR, I would. Won't hurt anything to give it a try.

Hi Lilly, yes my machine --Resmed AirSense 10 -- has pressure relief, and I have it set to "On" with a setting of 3. So, that can cause CAs, OK. It would be worthless to get a Bipap if the CAs came from the the EPR setting, so I'll have to look into that. Thanks for the info. In looking at Resmed.com, it says "The Airsense 10 AutoSet differentiates between obstructive and central apneas, and also Cheyne-Stokes respiration, so you can be confident that your patients are receiving appropriate therapy and pressure" It makes it sound like it can remedy central apneas, but in reality it can only correct obstructive and hypopnea events (and record central apnea events), given that it's a CPAP. So I don't know what to make of that statement, unless I have some wrong assumption.

CAs are a funny thing. They can be pressure induced (HIGH pressure or PS/EPR) or a neurological problem or a combo. Mine I think are a little of both. Some people a bilevel helps others it makes worse, that is a regular bilevel. An ASV/bilevel treats centrals. You just have to figure out what causes yours and what helps. I got a bilevel because I was having 17 CAs/hr then found out the PS/EPR was the cause of my problem. Now I use PS of 1 on my bilevel and get away with that.

[yaconsult]

I'm just trying to increase my understanding. So, using EPR is like using a simple bi-level machine but with the limitations that the pressure difference can only be set to one, two, or three and the bi-level can allow for a much wider inhale and exhale pressure difference? Also, the non-bi-level machines can not increase the pressure as high as a bi-level machine - maximum pressure of 20 versus 25.

[Wulfman...]

I'm just trying to increase my understanding. So, using EPR is like using a simple bi-level machine but with the limitations that the pressure difference can only be set to one, two, or three and the bi-level can allow for a much wider inhale and exhale pressure difference? Also, the non-bi-level machines can not increase the pressure as high as a bi-level machine - maximum pressure of 20 versus 25.

That's pretty much "spot on".


Den

.

[grifho]

I did not read through your long thread, but I am sure it is in there somewhere: Are you using EPR. If so what setting,1,2,3? EPR can cause CAs with some people.

EDIT: If you have not tried running without EPR, I would. Won't hurt anything to give it a try.

Hi Lilly, yes my machine --Resmed AirSense 10 -- has pressure relief, and I have it set to "On" with a setting of 3. So, that can cause CAs, OK. It would be worthless to get a Bipap if the CAs came from the the EPR setting, so I'll have to look into that. Thanks for the info. In looking at Resmed.com, it says "The Airsense 10 AutoSet differentiates between obstructive and central apneas, and also Cheyne-Stokes respiration, so you can be confident that your patients are receiving appropriate therapy and pressure" It makes it sound like it can remedy central apneas, but in reality it can only correct obstructive and hypopnea events (and record central apnea events), given that it's a CPAP. So I don't know what to make of that statement, unless I have some wrong assumption.

CAs are a funny thing. They can be pressure induced (HIGH pressure or PS/EPR) or a neurological problem or a combo. Mine I think are a little of both. Some people a bilevel helps others it makes worse, that is a regular bilevel. An ASV/bilevel treats centrals. You just have to figure out what causes yours and what helps. I got a bilevel because I was having 17 CAs/hr then found out the PS/EPR was the cause of my problem. Now I use PS of 1 on my bilevel and get away with that.

Thanks lilly, and yaconsult and wulfman too.. Hmm, an ASV/bilevel, I hadn't heard of that. I assume by PS you mean pressure level. Anyway, that would make sense based on your reference to PS/EPR. In regards to figuring out what causes mine, it would seem to make sense for me to reduce my EPR (say, to 1) just for investigative purposes. If I reduce my EPR and it gets worse, then it's likely that getting a Bilevel to raise my EPR even higher than my current 3 would reduce my CAs even more. Or so it seems. Thanks again.

[yaconsult]

Also to be kept in mind is that bi-level machines are MUCH more expensive and there are usually strict insurance requirements before they will pay for one. Usually, the doctor has to certify that you have tried and failed on a regular cpap for a reasonable amount of time and he has to recommend that you get a bi-level instead. And then ASV is yet another level up in function, price, and justification. I found a good write-up about them here: http://www.alaskasleep.com/blog/adaptiv ... leep-apnea

[grifho]

Also to be kept in mind is that bi-level machines are MUCH more expensive and there are usually strict insurance requirements before they will pay for one. Usually, the doctor has to certify that you have tried and failed on a regular cpap for a reasonable amount of time and he has to recommend that you get a bi-level instead. And then ASV is yet another level up in function, price, and justification. I found a good write-up about them here: http://www.alaskasleep.com/blog/adaptiv ... leep-apnea

All the more reason to ensure that my CAs are legitimate CAs before I go the bi-level route, I guess. The respiratory therapist didn't give me the idea they would be much more expensive. He just said something like 'eh, it's just like the CPAP you have but with a different motor". And that link will be helpful information on the ASV, but I hope not to have to get one as that would likely mean other attempts at handling this have failed. Thanks yaconsult

[lilly747]

. Hmm, an ASV/bilevel, I hadn't heard of that. I assume by PS you mean pressure level. Anyway, that would make sense based on your reference to PS/EPR. In regards to figuring out what causes mine, it would seem to make sense for me to reduce my EPR (say, to 1) just for investigative purposes. If I reduce my EPR and it gets worse, then it's likely that getting a Bilevel to raise my EPR even higher than my current 3 would reduce my CAs even more. Or so it seems. Thanks again.

Sounds like you may be a little confused.

PS (Pressure Support) is the difference between EPAP and IPAP, not how high the pressure goes or is.
Just as EPR of 3 drops EPAP By 3 (EPAP set at 8 would drop 3cm, to an EPAP of 5 if you set EPR at 3). However on a bilevel An EPAP at 5 and a PS of 3 = an IPAP of 8' In both cases you get a 3cn difference between inhale and exhale.

In some people this difference makes CAs worse, in others it might make CAs better. Insurance companies will usually make you try a "regular" bilevel BEFORE they will give you an ASV/bilevel that TREATS CAs. NOTE a regular bilevel DOES NOT treat CAs, it's just in some people it will allow the CAs to JUST go away. An AVS is different, it's not just regular PS (Pressure Support) that cause the Cas to go away. An ASV will "Cause/Make" you breath by using High IPAP Blast of pressure.

So if reducing your EPR to 1 does not allow your CAs to go away, you MAY need an ASV but you will most likely have to fail a regular bilevel first. Sometimes lowering pressure or/and eliminating PS/EPR over time will eliminate CAs

[palerider]

....

what she said... +1

[grifho]

. Hmm, an ASV/bilevel, I hadn't heard of that. I assume by PS you mean pressure level. Anyway, that would make sense based on your reference to PS/EPR. In regards to figuring out what causes mine, it would seem to make sense for me to reduce my EPR (say, to 1) just for investigative purposes. If I reduce my EPR and it gets worse, then it's likely that getting a Bilevel to raise my EPR even higher than my current 3 would reduce my CAs even more. Or so it seems. Thanks again.

Sounds like you may be a little confused.

PS (Pressure Support) is the difference between EPAP and IPAP, not how high the pressure goes or is.
Just as EPR of 3 drops EPAP By 3 (EPAP set at 8 would drop 3cm, to an EPAP of 5 if you set EPR at 3). However on a bilevel An EPAP at 5 and a PS of 3 = an IPAP of 8' In both cases you get a 3cn difference between inhale and exhale.

In some people this difference makes CAs worse, in others it might make CAs better. Insurance companies will usually make you try a "regular" bilevel BEFORE they will give you an ASV/bilevel that TREATS CAs. NOTE a regular bilevel DOES NOT treat CAs, it's just in some people it will allow the CAs to JUST go away. An AVS is different, it's not just regular PS (Pressure Support) that cause the Cas to go away. An ASV will "Cause/Make" you breath by using High IPAP Blast of pressure.

So if reducing your EPR to 1 does not allow your CAs to go away, you MAY need an ASV but you will most likely have to fail a regular bilevel first. Sometimes lowering pressure or/and eliminating PS/EPR over time will eliminate CAs

Thanks for the clarification, lilly, and thanks, palerider. I didn't know what PS was, so I thought you were expressing PS/EPR as a ratio, but now I see you were using the "/" to show they are equivalent. I don't understand the mechanism by which a bilevel would "allow" the CAs to go away. All I can think of is that a higher PS would allow for a more complete exhalation given that there is less relative pressure during the exhale. I suppose a high IPAP blast with an ASV would be another way to have less relative pressure during the exhale.

I was actually planning to lower my EPR to 1 to verify that my CAs would go up, thus inferring that a higher PS/EPR than my current 3 would likely reduce the CAs more than they are now. But from what you say, it can work in the opposite way as well, in that reducing PS/EPR could eliminate CAs. If that's the case, then I would certainly have no need for a bilevel unless it was an ASV.

[lilly747]

I don't understand the mechanism by which a bilevel would "allow" the CAs to go away. All I can think of is that a higher PS would allow for a more complete exhalation given that there is less relative pressure during the exhale. I suppose a high IPAP blast with an ASV would be another way to have less relative pressure during the exhale.

CAs are complicated. The problem is they can be caused by MORE THAN ONE reason, and they can be resolved or be made worse by doing the same thangs

Sooo I might be getting in over my head here, if so somebody chime in......

If you have Pressure induced CAs then more PS or higher pressures may make it worse because it BLOWS OFF more of your CO2, I.E. causes over ventilation. So the CAs get worse. If your CAs is say a neuro problem, your brain just does not tell your body to breath, the the stimulation from higher PS or EPR will possibility tell your body to breath. If this does not work then you need a ASV to Cause you to inhale. It has nothing to do with Exhalation.

Also it can take time for CAs to go away if they are Pressure induced.Your body over time adjusts and you stop (EDIT: should be "OVER ventilating") ventilating. For example I have CAs, if I change my PS from 1 to 1.4, my CAs go crazy. And when I put PS back to 1, my CAs take 2 to 4 weeks to go back down. It's like once I get them stirred up, it takes for ever to get them settled back down.

Like I said CAS can drive you crazy...

Here are some threads that might be of interest

viewtopic.php?f=1&t=86516&st=0&sk=t&sd=a

http://www.apneaboard.com/forums/Thread ... tral-apnea

http://www.apneaboard.com/forums/Thread ... SleepyHead

[grifho]

I don't understand the mechanism by which a bilevel would "allow" the CAs to go away. All I can think of is that a higher PS would allow for a more complete exhalation given that there is less relative pressure during the exhale. I suppose a high IPAP blast with an ASV would be another way to have less relative pressure during the exhale.

CAs are complicated. The problem is they can be caused by MORE THAN ONE reason, and they can be resolved or be made worse by doing the same thangs

Sooo I might be getting in over my head here, if so somebody chime in......

If you have Pressure induced CAs then more PS or higher pressures may make it worse because it BLOWS OFF more of your CO2, I.E. causes over ventilation. So the CAs get worse. If your CAs is say a neuro problem, your brain just does not tell your body to breath, the the stimulation from higher PS or EPR will possibility tell your body to breath. If this does not work then you need a ASV to Cause you to inhale. It has nothing to do with Exhalation.

Also it can take time for CAs to go away if they are Pressure induced.Your body over time adjusts and you stop ventilating. For example I have CAs, if I change my PS from 1 to 1.4, my CAs go crazy. And when I put PS back to 1, my CAs take 2 to 4 weeks to go back down. It's like once I get them stirred up, it takes for ever to get them settled back down.

Like I said CAS can drive you crazy...

Here are some threads that might be of interest

viewtopic.php?f=1&t=86516&st=0&sk=t&sd=a

http://www.apneaboard.com/forums/Thread ... tral-apnea

http://www.apneaboard.com/forums/Thread ... SleepyHead

Thanks for the links to the conversations, I've already started reading them. Now I'm really curious if my CAs go down if I reduce my EPR, given your and other's experience. I just may have pressure-induced CA. At least it will be additional information one way or the other if I lower my EPR a little at a time and see what happens. It's good to know all these subtleties as it seems like the sleep doctors/respiratory specialists take a very crude approach to these things, without considering all the variables and individual people's experiences. I see my sleep doctor this Monday, so I'll question her on her certainty over her suggestions, assuming she has an opinion with the idea of a Bipap or not. In any event, I'll know enough to offer my somewhat-informed opinion. Thanks again lilly

[lilly747]

Your body over time adjusts and you stop (EDIT: should be "OVER ventilating") ventilating.

Would not want to stop ventilating....