UARS

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
TooNew

Re: UARS

Post by TooNew » Fri Jul 28, 2017 1:40 pm

Pugsy wrote:
Unless you develop a bunch of centrals with the cpap pressure tonight during the titration sleep study central apnea isn't a factor in your situation.
I don't think it will matter, I already told you the world is ending tonight or early tomorrow morning.

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Re: UARS

Post by Pugsy » Fri Jul 28, 2017 1:46 pm

Dr Krakow is thought of as a bit "out there" by most sleep doctors.
He's a bit controversial. He's probably the only sleep doctor who would promote ASV for UARS...but then he pushes ASV for everything.

ASV for UARS is NOT a commonly thought of first line of therapy in the general/majority of the medical community.

Now that doesn't mean you couldn't get one and use it...but you would have to foot the bill yourself and those puppies are expensive.
I did it but I bought used and bought privately and snapped up killer hot deals. I am using ASV...don't have central apnea issues either.
I don't have time to go into all of it but if you are interested I will share the why later when I have more time.
I don't have UARS either. I have plain jane vanilla OSA.

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Re: UARS

Post by robysue » Fri Jul 28, 2017 1:47 pm

xxyzx wrote: =======
whatever doodette

my congestion blocks the top of my nose so that no air get through when it is bad
my congesstion limits flow when it is not bad

if you want to quibble about where the upper part of UA is then okay
but if you are saying congestion cant do it then you are totally wrong
and it can last for hours or days when it is at its worst
Upper airway resistance syndrome (UARS) is NOT caused by congestion in the nasal passages. Look up the definition of UARS. UARS is a form of sleep disordered breathing, meaning it does NOT happen in the daytime. A person with untreated UARS has trouble breathing every night, all night long for years---until they either treat it OR it gets progressively worse and turns into OSA. Some people with UARS breathe through their mouth while sleeping and they still have RERAs. Other people with UARS are exclusively nasal breathers.

Nasal congestion and allergies CAN and DO lead to serious breathing problems. But nasal congestion and allergies affect both daytime and nighttime breathing. And nasal congestion comes and goes: Head colds last 5-10 days, and during that time it may well be the case that you can't breath at all through your nose---but you can breath just fine through your mouth. Likewise, nasal allergies (both seasonal and nonseasonal) can lead to substantial congestion and breathing problems. But again, the problem is getting air in through the nose, not down the upper airway.

Obstructive sleep disordered breathing, including both OSA and UARS, involves the upper airway repeatedly narrowing during sleep. And the upper airway is the passage that runs from the back of the nose, past the upper palate, through the back of the mouth, past the uvula, and down to the larynx (where the esophagus and trachea come together). The usual spots where the airway becomes narrowed (in UARS) or blocked (in OSA) is where the upper palate juts into the upper airway and where the tongue can fall back into the airway right around the uvula.

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Re: UARS

Post by jnk... » Fri Jul 28, 2017 1:53 pm

Dr. K has an entire team a mile high up in the air who know how to get SOME (at least a few) insurance companies on board with ASV for UARS. But that is generally for people who have already given other forms of PAP the full shot and can be, um, induced to have a few altitude centrals. In my opinion. And I'm actually a fan of the whole concept. It is for a subset of patients who can tolerate and benefit from much higher pressure than needed for other events. It is a way to stabilize the airway far beyond what most patients need, as I understand it. Some swear by it, some swear at it, but it is what it is.

Nasal congestion can increase likelihood of upper airway issues of all sorts. Anything that increases effort to breathe can increase the arousals that can occur with that scenario. If it has the potential to increase negative pressures in the airway, or even create a new variation in pressures in the airway, it has the potential to wreak havoc with a sensitive nervous system with a jumpy throat. Nasal issues can do that for some, according to some ENTs.

But like Pugsy wisely touched on in the other thread, when pain issues and pain treatments get into the mix, using data to figure things out gets problematic. That is why I suggested concentrating on experimenting logically and systematically to see what helps without getting too caught up in definitions and imaginary lines in the diagnostic sand.

But hey, that's just me.

I may be as far left in the field as old what's-his-name, but for pure UARS (if there is such a thing), trying straight PAP (not Auto) with no relief settings and with pressures as high as the person can tolerate can be something to try, whether it can be documented by any home-machine data as treating anything a home machine can measure or not. It is a matter of figuring out which disturbs sleep most for that one person--the unstable airway or what it takes to stabilize it. Maybe that will make the pain/drugs/limb movements more tolerable/workable, and maybe not. But it is still worth trying.
Last edited by jnk... on Fri Jul 28, 2017 2:07 pm, edited 1 time in total.
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Re: UARS

Post by robysue » Fri Jul 28, 2017 1:57 pm

TooNew wrote:
robysue wrote:You don't need an ASV to treat UARS.
That is not the opinion of Dr Krakow, and I thought he was pretty well renowned...
Much as I respect Dr. Krakow's writing on insomnia, I tend to agree with the majority of sleep docs who think he's pretty far out there on a limb thinking that everyone needs an ASV machine.

One fact that's worth remembering: ASV machines are a lot more expensive. As in at least five times as more expensive than a high quality full data APAP. If we're serious about reining in the cost of health care in this country, then we need to think about our own health costs (as well as the health costs of all those others out there in the country); and we ought to be willing to try simpler, cheaper treatments of our own medical conditions first and only insist on moving up the ladder to more expensive treatments if the cheaper ones fail---particularly when all the available scientific data show the cheaper treatment works as well as the more expensive one in many (most) patients.

In my case, I was moved to bi-level after three or four very long months of 100% compliance with CPAP/APAP where I simply could not tolerate the pressure needed to control my apnea AND my sleep was getting worse and worse and worse. I didn't suggest bi-level to my doc; rather the PA told me (at a semi-emergency appointment) that she'd had a conversation with the doc about my very troubling and unexpected reactions to starting CPAP and she and the doc agreed that maybe a trial on bi-level might be worth it.

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TooNew

Re: UARS

Post by TooNew » Fri Jul 28, 2017 1:59 pm

Pugsy wrote:Dr Krakow is thought of as a bit "out there" by most sleep doctors.
He's a bit controversial. He's probably the only sleep doctor who would promote ASV for UARS...but then he pushes ASV for everything.

ASV for UARS is NOT a commonly thought of first line of therapy in the general/majority of the medical community.

Now that doesn't mean you couldn't get one and use it...but you would have to foot the bill yourself and those puppies are expensive.
I did it but I bought used and bought privately and snapped up killer hot deals. I am using ASV...don't have central apnea issues either.
I don't have time to go into all of it but if you are interested I will share the why later when I have more time.
I don't have UARS either. I have plain jane vanilla OSA.
I would be interested in hearing any benefits to ASV over other devices - no matter the disorder.

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Re: UARS

Post by jnk... » Fri Jul 28, 2017 2:14 pm

Pugsy wrote:Dr Krakow is thought of as a bit "out there" by most sleep doctors.
He's a bit controversial. He's probably the only sleep doctor who would promote ASV for UARS...but then he pushes ASV for everything.

ASV for UARS is NOT a commonly thought of first line of therapy in the general/majority of the medical community. . . .
I agree with every single word of that. Well said.

Dr. K. is a guy you go to for experimentation when none of the mainstream stuff works for you. Always try mainstream first. But if none of that works after the full college try, it's good to know there is something else to try.

Assuming, of course, that the world doesn't end according to TooNew's schedule. I'll have my earplugs in, though, so I won't hear it happen. Hopefully someone in the forum will let me know.

I also agree with RobySue that the comfort of bilevel can be the bomb for someone who is sensitive to PAP itself and needs extra comfort to make it work for them. I believe it can cause issues for some with UARS-style problems but that it can relieve issues for others with UARS-type issues. The problem is that only docs experienced with UARS know that and find ways to get insurance on board with that trial of bilevel. Yes, bilevel and to a greater extent ASV ARE more expensive. But that is the fault of the industry, not the patient. That means that it becomes an argument of economics at what point to try them and what percentage of improvement for a particular human's condition makes it cost-effective. That makes it a subjective discussion in which payer, doc, and patient will never be on the same wavelength.

Thing is, a good number of docs consider any doc who believes in using any form of PAP to treat UARS as already having one foot in left field. The payer-aligned docs play that game, anyway. It's just that Dr. K. is considered a little further in left field than the other UARS-treating docs out there.

So that is why I throw up my hands and refuse to classify people as UARS, OSA, or non-SDB. There are two kinds of people in this world: (1) those who can get better sleep with PAP and (2) those who can't. The testing and so-called "diagnostics" of modern medicine just cloud that issue and provide a reason to deny people the right to try PAP, in my opinion.

And just maybe that opinion makes me crazier than Dr. K. and alphabet soup combined.
Last edited by jnk... on Fri Jul 28, 2017 2:29 pm, edited 1 time in total.
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Re: UARS

Post by Pugsy » Fri Jul 28, 2017 2:24 pm

TooNew wrote:I would be interested in hearing any benefits to ASV over other devices - no matter the disorder.
Remind me later. I don't have time to go into my own personal reasons for going down the ASV road right now. Hubby is home for the weekend and we have things to do.

Mainly it was a comfort thing while awake that did it and once you have the titration study tonight I think you will better understand what I am talking about. CPAP/APAP treats my OSA just fine...I first tried plain bilevel and liked it and then a friend tried ASV (he also didn't have centrals) and liked it so he talked me into to trying it. I will explain more later.

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Re: UARS

Post by robysue » Fri Jul 28, 2017 2:41 pm

TooNew wrote: I would be interested in hearing any benefits to ASV over other devices - no matter the disorder.
To answer your question, it helps to understand that ASV was designed with the goal of treating central sleep apnea and complex sleep apnea in mind. And hence it helps to understand what the problem in central sleep apnea is and how ASV fixes it.

When a person has real, genuine central sleep apnea (CSA) or complex sleep apnea (CompSA), one of the problems is that the person has a tough time maintaining the proper CO2 balance in their blood. The amount of CO2 is what actually acts as the trigger for the brain to send the Breathe In Now signal to the diaphragm and lungs that starts the inhalation. The level of CO2 needed to trigger inhalations is reset when we transition from wake into sleep; in sleep breathing, the level of CO2 needed to trigger inhalations is a bit higher than it is during wake breathing.

In CSA and CompSA, the complex balance of O2 and CO2 gets messed up. And when that happens, the patient will often have very, very long chains of central apneas that are part of a cyclical CO2 overshoot/undershoot cycle.

During the CO2 overshoot part of the cycle, the person is essentially hyperventilating: They're breathing too deeply and as such, they blow off too much CO2. So the CO2 concentration in their blood drops, and with it, the respiratory drive slows down. And that starts the CO2 undershoot part of the cycle.

As the respiration slows (because the respiratory drive goes down because there's too little CO2 in the blood), eventually it reaches the point where the brain "forgets" to send the Breathe In Now signal to the lungs and diaphragm altogether, and the result is a central apnea.

As the respiration slows down, and then ceases altogether, the CO2 concentration begins to rise---this is the CO2 undershoot part of the cycle: The CO2 levels are starting to rise because the body is not blowing off enough CO2 for normal respiration. Eventually the CO2 levels in the blood are high enough for the brain to start sending Breathe In Now signals. And respiration typically starts to slowly rebuild in terms of the size of the inhalations. (This is very different from the typical large, recovery breaths at the end of a typical obstructive apnea or even a typical RERA.)

Eventually, however, the body is once again over breathing and blowing off too much CO2 and the cycle starts over again. And again. And again.

Regular CPAP/APAP/bi-level does nothing to help even out the manner in which the body is blowing off the CO2, and in a small group of OSA/UARS patients, the continuous positive air pressure provided by CPAP/APAP/bi-level encourages over breathing to the point where a CO2 overshoot/undershoot cycle can develop. These are the folks who wind up with what are called pressure induced centrals. And if the pressure induced centrals don't manage to resolve themselves within a few weeks of starting xPAP therapy, the person winds up with a diagnosis of complex sleep apnea.

As I said earlier, ASV machines are designed specifically to treat CSA and CompSA by stepping in at the first sign of a CO2 overshoot/undershoot cycle developing. ASV does this by using a highly variable IPAP (inhalation pressure) that can be increased substantially in the course of a very small number of breaths. APAPs and Auto bi-levels can increase the pressure, but they do it much slower and they don't make the decision to increase the IPAP on a breath-by-breath basis.

Basically when an ASV machine sees that the volume of the last few inhalations is starting to go down (i.e. is less than 90% of average inhalation during the last few minutes of breathing), the machine steps in and starts increasing the IPAP quite quickly in order to stabilize the amount of air being inhaled in each breath. As the person's respiration settles back down, the machine decreases the IPAP rather quickly so as to not trigger a CO2 overshoot.

For a person with CSA or with CompSA, there's a lot of benefit: ASVs are the only machine that can actually reduce the number of central apneas that occur during the night.

For people without CSA or CompSA, there's no clear benefit of having an ASV. Yes, it will treat ordinary old OSA just as well as any xPAP. But whether there's any additional benefit for a person with regular old OSA or UARS using an ASV is somewhat controversial.

Krakow's claim is that with an appropriate ASV titration (in his lab), the patient's wave form becomes darn near perfect, and Krakow contends that a perfect wave form must mean the sleep is somehow "better" than a decent, but not perfect wave form that a patient is apt to get from a properly set up CPAP/APAP/bi-level. But there used to be a sleep tech who posted around here under a variety of names (Sludge was one of his later names) who put it this way when he was working with people who were having trouble adjusting to their ASV machines: An ASV can be tweaked to fix the flow rate, but that's no guarantee the sleep will be any good.

Sludge would bring up the following things about ASV:
  • If a person had CSA or CompSA, then ASV really was the way to go since nothing else eliminates CAs.
  • ASV is not the easiest thing to sleep with, particularly if the settings are wrong.
  • ASV users can often have serious leak problems that are caused by the sudden increases in IPAP and that can be disruptive to sleep---even when the wave flow looks darn near perfect
On the other hand, as Pugsy will tell you, some people have no trouble adjusting to ASV. And in Pugsy's case, using ASV means that she can get away with using a lower min EPAP setting and a lower min IPAP than she could back when she was using APAP and Auto BiPAP. She's got sleep apnea that is very mild except in REM, but in REM her pressure needs jump up substantially. The ASV can make those huge jumps in pressure fast enough to break up her REM pressure with lower minimum pressure settings because it is so fast to responde.

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Re: UARS

Post by robysue » Fri Jul 28, 2017 10:49 pm

xxyzx wrote:
TooNew wrote:
robysue wrote:You don't need an ASV to treat UARS.
That is not the opinion of Dr Krakow, and I thought he was pretty well renowned...
=====
logical fallacy

ASV is intended for CA and related problems

but it is good for QOL which insurance does not count at all
they would have you suffer although technically treated with some cheaper device
For people who have documented problems with central apneas, CPAP/APAP won't fix the sleep problem and ASV will. Hence for people with central sleep apnea, an ASV will improve the quality of sleep and hence the quality of life as compared to CPAP/APAP or ordinary bilevel. Why a particular insurance company insists on making a person with a documented central sleep apnea problem fail on CPAP/APAP and then on bilevel and bilevel ST is something to ask your insurance company. We don't make those rules up and we have no effective way to change those rules.

For people (like TooNew) who have UARS or OSA but NO problem with centrals (i.e. no CSA and no CompSA), it's a whole different can of worms: If ASV doesn't improve the sleep quality as compared to CPAP for a person with UARS or OSA, then ASV doesn't improve the QOL as compared to CPAP either.

And that's the issue: Krakow contends that when a UARS or OSA patient without central apnea is titrated on an ASV machine, the ASV can improve sleep quality (and hence QOL) more than CPAP/APAP simply because the ASV can be tweaked to create a near perfect wave flow. Most other sleep docs think that if central apneas are not a problem, then the sleep quality (and QOL) with ASV is the same as the sleep quality (and QOL) with CPAP/APAP if both machines are correctly titrated. In other words, other sleep docs do not believe there is any scientific proof that an ASV improves the quality of sleep (or QOL) more than a CPAP/APAP does when you are dealing with people who have simple UARS or OSA and no central apnea .

Other than Krakow and his high altitude lab, no one else that I'm aware of has been able to document that a typical OSA/UARS sufferer sleeps any better with an ASV than they do with a CPAP or APAP.

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Re: UARS

Post by robysue » Sun Jul 30, 2017 1:51 am

xxyzx wrote: i agree that the ASV will improve QOL because it is a kinder gentler form of xpap
Gentler in what sense? An ASV can increase the IPAP by 5-10 cm in just a few breaths. Not everyone can sleep through that kind of a rapid pressure increase, particularly if they don't have CAs. And when that ASV algorithm kicks in, the PS can go from 3 or 4cm to 8-10cm in just a few breaths. And that too can cause some people to arouse. It can also cause leaks which can be disturbing to the sleep.

Not everyone handles varying pressures very well. There are, in fact, a few people on this board who do best with straight fixed pressure and NO exhale relief because they are so sensitive to changes in pressure.
titration is a laugh
ONE SIZE FITS NOBODY
A titration study is a study that focuses on ONE individual's needs in real time with an actual person looking at the data and deciding what it means and what should be done.
even auto with EPR is not as gentle as an ASV
Again, what do you mean by gentle? An ASV has much more rapid (and extreme) changes in IPAP pressure and PS than an AutoSet with EPR set to 3. Not everyone handles varying pressures very well. There are, in fact, people on this board who do best with straight fixed pressure and NO exhale relief because they are so sensitive to changes in pressure.
pugsy bought her own for that reason
Pugsy is an experimenter by nature and a collector of machines. She also sleeps well even when there are large jumps in pressure. Not every body can handle large jumps in pressure; some of us wake up if the pressure increases too fast or beyond a certain level for any amount of time.

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Re: UARS

Post by Julie » Sun Jul 30, 2017 3:28 am

You are such a rational person... why are you trying to reason with an irrational one?

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Re: UARS

Post by robysue » Sun Jul 30, 2017 10:26 am

Julie wrote:You are such a rational person... why are you trying to reason with an irrational one?
Julie,

I am not actually trying to reason with xxyzx. I am, however, wanting to make sure that any future newbie who stumbles on xxyzx's claims doesn't make the mistake of thinking he's posted something accurate, particularly when his disinformation has the potential cause real harm to some future newbie. In this case, a person who needs to be on AVAPS and is persuaded by xxyzx's unanswered posts that there is no difference between ASV and AVAPS could set themselves up for serious harm. Hence I continue to post factual information about ASV and AVAPS whenever xxyzx claims ASV and AVAPS are the same thing.

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Re: UARS

Post by robysue » Sun Jul 30, 2017 3:47 pm

xxyzx wrote:
robysue wrote:
Julie wrote:You are such a rational person... why are you trying to reason with an irrational one?
Julie,

I am not actually trying to reason with xxyzx. I am, however, wanting to make sure that any future newbie who stumbles on xxyzx's claims doesn't make the mistake of thinking he's posted something accurate, particularly when his disinformation has the potential cause real harm to some future newbie. In this case, a person who needs to be on AVAPS and is persuaded by xxyzx's unanswered posts that there is no difference between ASV and AVAPS could set themselves up for serious harm. Hence I continue to post factual information about ASV and AVAPS whenever xxyzx claims ASV and AVAPS are the same thing.
======

i said that makers and sellers say they do the same thing
although avaps may have higher pressure max and other features
READ the links in my post at viewtopic.php?f=1&t=155982&p=1186248#p1186248.

Those links show that Resmed, one of the makers of ASV and AVAPS/iVAPS machines, does NOT say they do the same thing. Resmed specifically says that ASV and AVAPS do different things because they treat different kinds of respiratory problems.

Similar information can be found on the PR webpages that shows that PR specifically says their ASV and AVAPS machines do different things because they treat different kinds of respiratory problems.

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