Help with therapy on Dreamstation BiLevel S/T

[halokittie]

I'm stuck with an ST for at least a month (thank you doctor) and with the Dreamstation line (thank you poverty and the local Medicare DMEs). No diss on Dreamstation, but I wanted ResMed.

I'm miserable. It's set at 26/16 with back up rate of 10. I have to keep using the max ramp feature to get to sleep, then I wake up at midnight and can't get back to sleep because it tries to prompt a breath too soon, way before any person would take a normal breath. Then I start hitting ramp again, and trying to get back to sleep, hit ramp again, repeat until I give up and rip off the mask.

Anxiety has taken hold and my old breathing problem has come back - I have a hard time getting a deep breath. My GP years ago described it as little panic attacks, the muscles in my torso just tighten. I have to really concentrate, close my eyes and breathe slowly and gently through my nose while relaxing my body to get that deep breath (rinse&repeat), which is impossible with a CPAP blowing in your face.

My hope was to come back to my doctor after 4 weeks, with OSCAR reports and Philips own materials directing central apnea patients to ASV. I've already talked with DME and they would take back the ST and order an ASV with the doctor's prescription since it's under the same code, no problem. But I'm not sure that I'm even going to make Medicare compliance for the first month and they take back the ST and I'm back to my comfortable, but ineffective Apap.

Thanks for making it this far. Any ideas? How do I set the prompt so the 'breath' doesn't start so quickly? I do know how to change settings. How do I get through this month comiance wise. What do I say to the doctor?

I didn't attach the OSCAR screenshots because they are just crap - 2 to 4 hours of leaks and ramp. If you think they would have any value let me know.

Thanks,
HK

[ajack]

If you are heading for an ASV. These are the pressures you need to get use to. You will get use to it.
The largest epap you can have is 15 on most machines. Reducing the epap by 1cm really wouldn't be noticeable.

They have a PS10 or 26 ipap to inflate your lungs, when you CA

It seems that you need 16 to clear obstructive events. This would be around your 95% pressure on apap.if this isn't the case you could lower the epap to this number. You would keep the 10cm difference with the ipap.
A need for 16 epap may suggest there are some positional apnea, like chin to chest, obstructing the airway. Some find a different pillow or a foam curvical collar helps.

[Pugsy]

OMG....excuse me while I go throw up.

Did they actually do a sleep study with you using this machine and that's how they came up with these settings or did they just look at the magic eight ball for what to try?

Your sleep was already horribly fragile and now they want you to get used to this crap. Sigh.
Have I mentioned lately how much I hate S/T machines??

Look back through your apap reports and pick the best one recently in terms of both sleep and AHI. I know it won't be pretty but I need a decent baseline to think on...and PR and I will probably have to put our heads together.

First thing you need to do right now is reduce that PS....You won't get any sleep this way and having it happen with every friggin breath you take is pretty much going to hyper ventilate you and likely cause centrals.

And yes...give me a crappy 2 hour SleepyHead/OSCAR report to look at. It's better than nothing. Even 30 minutes of actual sleep would be better than nothing. If you simply never slept...we gotta get you to sleeping with it. Maybe reduce PS to something more comfortable and work your way up to the higher PS IF you actually need it.

Whatever ajack said...take it with a grain of salt. He doesn't know nearly as much about this stuff as he thinks he knows.

So....the best apap report you had recently and the best you can come up with from this damned machine. Have I mentioned how much I hate these machines for treating both OSA and centrals? Be prepared to hear it often.

The settings you are using now would be maybe appropriate if all you had was central apnea...and that's a big maybe at that.
Or if you had some sort of respiratory/lung issue where you needed forced ventilation of some sort.

[Pugsy]

SleepyHead may not play nice with this model machine.
You may need to get OSCAR.
https://www.sleepfiles.com/OSCAR/

[raisedfist]

If you don't have severe lung disease or diaphragmatic failure, reduce that pressure support immediately. A static PS of 10 on a normocapnic person is honestly dangerous and whatever technician arrived at those pressures really needs to find another career.

While with an ASV machine, the machine MAY go to a PS of 10 or even 20 at some point in the night, you would always want the min and max PS to be on a wide range so that the algorithm can do it's job. You would never set a min PS of 10 on an ASV. ASV is meant to REGULATE ventilation, not augment it.

With central apnea not due to respiratory failure, and due to complex sleep apnea, the set PS is adding on to the existing problem and not helping it in any way.

[palerider]

back up rate of 10. ...How do I set the prompt so the 'breath' doesn't start so quickly?

Set the backup rate lower. right now, it's forcing a breath after 6 seconds. .... which, honestly, is fairly low.

[ajack]

You need to excuse the drama and hand wringing over PS10. It is within the normal range for a backup breath. Contact your provider, they can check on the settings and the results. If I were to question anything, it would be if the epap 16 needs to be this high. I assume Oscar doesn't display your machine.

I can post charts of my ivaps showing PS of 18 used during parts of the night.
As is the 10 breaths per minute. If you get a few CA in a row, you need the 10 backup. It can also be set to 2 under your normal breath rate.

Your asv will behave like this too, the difference is that the max PS with probably be set to the default ps15. But it doesn't use it all the time. The backup breath will trigger if you don't breathe steady and likely quicker than 10 per minute

[palerider]

You need to just ignore ajack...

He doesn't know anywhere near as much as he thinks he does, and also has admitted to posting while drinking heavily.

[raisedfist]

You need to excuse the drama and hand wringing over PS10. It is within the normal range for a backup breath.

The person is using a BiPAP S/T - which is not an auto adjusting machine. A set PS of 10 aggravates the CSA instead of helping it. A set PS of 10, in the case of a normocapnic individual, washes out too much CO2 and depresses the drive to breath spontaneously. A set PS of 10 is useful for a respiratory failure patient because it augments their ventilation, which is lower than it should be, helping to normalize it.

ResMed's own titration guide tells you to look at the origin of the Central Apnea - and if it's due to CSA or neurological - skip to ASV. And if it's due to muscle weakness/respiratory failure/hypoventilation - skip to iVAPS or Bi-level S/T. You will never see someone on an ASV with a PS min of 10. The algorithm must be able to swing for low to high PS depending on what is happening, to prevent over and undershoots on minute ventilation.

Hypoventilation is simple to spot with sleep data. If they are ventilating normal, and still have CA, why would you hyperventilate them and create more CA.

There is nothing dramatic about advising what ResMed, Philips Respironics and the AASM tell you to do based on evidence. The fact that most sleep technicians didn't pay attention in class is the reason why people join forums to get help.

I can post charts of my ivaps showing PS of 18 used during parts of the night.

iVAPS and ASV algorithms have entirely different purposes. You already know this.

You put a CSA patient on iVAPS and their CSA problem becomes worse. You put a respiratory failure patient on ASV and you create continuous hypoventilation and give them a nasty CO2 headache to wake up to.

[palerider]

I can post charts of my ivaps showing PS of 18 used during parts of the night.

iVAPS and ASV algorithms have entirely different purposes.

And ST machines are ancient tech by comparison.

You already know this.

You're assuming facts not in evidence.

[Pugsy]

And ST machines are ancient tech by comparison.

All they are is a glorified regular bilevel fixed pressure with a back up rate.
I hate them for people who have OSA and pressure needs vary and centrals aren't the primary consistent problem.
Well....actually I hate them for just about anybody.

To Halokittie
Yes, ASV will go higher with the PS IF (big if) a person needs it...if they don't need it then it won't do it.
The machine you have now is giving you huge PS with every single breath ...even if you aren't having any centrals...and unless you have some very special respiratory problems...having that much PS with every single breath is likely causing even more centrals.

[halokittie]

Thanks for the spirited discussion all!

I've got a few nights of OSCAR data. Sleepyhead does not support this machine.

Which of the following graphs would be most useful for viewing? I can prob fit about five. Leaks are atrocious - time over leak redline was 106.4% last night

Event Flag
Flow Rate
Pressure
Leak Rate
Resp. Rate
Tidal Volume
Pat. Trig. Breaths
Insp. Time
Exp. Time
Test #1
AHI
Time at Pressure

[Pugsy]

The time over red line statistic could possibly from the software using the ResMed red line and not the Respironics red line.
So we can fix that later....really need to see just how much LL the machine itself flagged up on the Events graph before worrying about that statistic.

So the usual stuff on the left (hide the calendar and turn off the pie chart) so the AHI stuff and statistics will all show...and on the right side graphs...just these 4
Events
Flow rate
Pressure leak

don't need any of the others right now.

[Pugsy]

Oh...can you do an awake experiment for me. Just to test comfort and ease of breathing with the machine for right now.
Set PS to 4. Try it for about 10 minutes just to see how it feels and if you can tolerate it well enough.
No other changes.

[ajack]

You need to excuse the drama and hand wringing over PS10. It is within the normal range for a backup breath.

The person is using a BiPAP S/T - which is not an auto adjusting machine. A set PS of 10 aggravates the CSA instead of helping it. A set PS of 10, in the case of a normocapnic individual, washes out too much CO2 and depresses the drive to breath spontaneously. A set PS of 10 is useful for a respiratory failure patient because it augments their ventilation, which is lower than it should be, helping to normalize it.

ResMed's own titration guide tells you to look at the origin of the Central Apnea - and if it's due to CSA or neurological - skip to ASV. And if it's due to muscle weakness/respiratory failure/hypoventilation - skip to iVAPS or Bi-level S/T. You will never see someone on an ASV with a PS min of 10. The algorithm must be able to swing for low to high PS depending on what is happening, to prevent over and undershoots on minute ventilation.

Hypoventilation is simple to spot with sleep data. If they are ventilating normal, and still have CA, why would you hyperventilate them and create more CA.

There is nothing dramatic about advising what ResMed, Philips Respironics and the AASM tell you to do based on evidence. The fact that most sleep technicians didn't pay attention in class is the reason why people join forums to get help.

I can post charts of my ivaps showing PS of 18 used during parts of the night.

iVAPS and ASV algorithms have entirely different purposes. You already know this.

You put a CSA patient on iVAPS and their CSA problem becomes worse. You put a respiratory failure patient on ASV and you create continuous hypoventilation and give them a nasty CO2 headache to wake up to.

ST was the treatment that was used to treat CA, until recently times when ASV mode was invented. The treatment is perfectly sound. It isn't as good as asv, because it has a higher apnea index.

Thank you for your post. Yes it is a ST and has a fixed epap and ipap. There is the PS 10, that is needed to inflate the lung, when no effort is there because of CA. To do this, it needs to have PS 10 on every breath, according to the doctor who wrote the script. It isn't the best mode for CA, but is on the path for ASV. The backup rate of 10 is considered low and wouldn't normally need to be lowered. It normally would be set 2 under the breath rate, so it is often higher

No directed to you but.
Anyone suggesting lowering this PS to 4 is misguided. It isn't the first time misinformation on ST is advised. It would be best to contact his doctor who prescribed the settings.

The settings on PS for ASV in normally default min PS3 max ps15. Unless otherwise indicated. The largest min is ps6. The max PS is often recommend, as high as the machine will allow. as per lanky, to be set at the max available.