Newbie needs help w/ Respironics S/T

[Sleepy55]

I'm experienced user of the Respironics M Series BiPap Plus w/ Biflex but just received my new Respironics S/T 3 days ago. It came setup w/ my Rx levels of 16/8, BPM 10. At least a dozen times per night the S/T alarm buzzer goes off, waking me, my wife and my dog I reach over and press the silence button, then the reset button, then go back to sleep. On everyone of the alarms, the display always says it was an APNEA ALARM. The owner's manual does not explain much about the alarm. Can someone pls explain why the audible alarm is going off and if I can permanently disable it? Is it supposed to do this every time I have a CSA eposiode?

My wife and my dog both want to send me to the guest room. Pls Help.

[dsm]

Hi Have one of these & you can set the alarms off. Also that gap of 8 CMs is very very large !!!. Do you have any respiratory illness or damaged lungs ?

Am guessing you have severe CAs as that is the only possible explanation for the settings you describe. If not then you need better advice.

Am going to be out of contact for a few days but could assist further if needed.

Good luck

DSM

PS can anyone pm the clin manual here as I am not able at the moment.

[Sleepy55]

I don't know why the big difference between In and Ex pressures. I'm otherwise in very good health with no lung or breathing problems whatsoever. I've seen two doctors in two different clinics over the years and they both tend to set the Ex pressure at half of whatever the In pressure is. I could not tolerate my CPAP, felt like I could not exhale, so they switched me to a bipap, which has worked well for a few years, except I'm stil having the dreaded daytime sleepiness. After a recent overnight test, which showed worsening OSA but only a few "transient" CSAs, they upped my pressures to the current settings (using the M Series bipap plus). However, follow-up overnight oximetry tests show my blood - oxygen levels in the mid-80's several times per night. My doctor does not understand why the low oxygen levels and the continued daytime sleepiness, so he prescribed the BiPap S/T w/ a BPM of 10, in case I am having CSAs that just did not show up on the overnight test. Of course, he recommended another overnight sleep test at the hospital. I don't feel like doing another overnight test and paying all the deductibles. Just want to give the S/T a chance, but have to get rid of the alarm buzzer. I also want to do a lot more reading on this forum and try and tweak the pressures, BPM, rise time, and see how they affect my daytime sleepiness and my blood-oxygen levels. I just ordered the Encore Viewer & will try and buy an pulse oximeter & software to track the effectiveness. Is the BPM of 10 an "average" starting point? Can someone pls send me instructions or the clinical manual so I can silence the alarm buzzer? Thanks in advance.

[DSM (oseas)]

Sleepy55,

I think we can probably help you. Can you get your hands on the software to read the datacard ?.

The Bipap S/T doesn't record detailed AHI only summary AHI for the night but it does give enough other data for us to have an inkling of what is going on. The other very important data is info from a Recording Pulse Oximeter, you can rent one of these very cheaply.

If we can get you set up to extract nightly data from the Bipap & from an SpO2 recorder, I believe we can better tune your machine and attempt to get your Spo2 consistently in the 90+ % range.

DSM (back home next week)

[Sleepy55]

DSM, thanks for the follow-up. I just received my smartcard reader and software. Also just purchased a new recording pulse oximeter w/ software. I'll try and install and use both this weekend, so by Monday I should have printouts of both. Very anxious to see how they look.

[Snoredog]

I agree with DSM and I disagree with your doctor having another PSG "at the hospital", I would go to a dedicated sleep lab, hospitals cut corners to save money and increase profits, that means outdated equipment, inexperienced staff.

With primary disorder being obstructive I too question the 16/8 settings. 12/8 would be more realistic. Your new machine is Spontaneous (like your old bipap) and Timed. Timed mode is only used when you have periodic breathing or central apnea.

I also question if you are having a few centrals why the pressure is so high? I would think if you are having centrals EPAP pressure or the lower one would be much lower possibly in the 6 to 8 cm range.

I would refer back to any CPAP titration for a base EPAP pressure. I would prefer going lower with both pressures, in fact mfg protocol calls for setting IPAP/EPAP within 2 cm of each other maintaining that delta until obstructive apnea subside then increasing IPAP pressure leaving EPAP alone. Some fine tuning of inspiration time. Many times CA will follow a obstructive apnea, not really a problem unless it leads to periodic breathing. Once your spontaneous settings are known, then you duplicate those for the backup or timed mode with a slower BPM, when the machine switches it slows your breathing down (that is what the alarm is indicating). Once your breathing stabilizes machine goes back to the Spontaneous mode.

This will be seen as User initiated breathing in a percent. The higher the User initiated breathing the better (meaning the machine ran in the mechanical timed less if at all).

If they over titrated you, you will have more CA's and irregular breathing. I would call the doctor back and tell him you would like to have the new titration done by an accredited sleep lab who have more experience with your condition, get away from the good-ole-boy network.

[Sleepy55]

Folks, thanks for your advise and I apologize for my slow response. First a little more background. After an overnight test about five years ago at a major national hospital sleep clinic, diagnosis was OSA and sleep doctor prescribed Bipap at 9/4. Tried that for a couple of years but still had bad daytime sleepiness and could not sleep on my back due to heavy snoring. Dr. raised to 11/9 but still had daytime sleepiness and snoring on my back. I sought a 2nd opinion from a small regional dedicated sleep clinic. After overnight test, diagnosed w/ OSA and prescribed bipap 14/7 and upped a year later to 15/11. Both settings still left me with excessive daytime sleepiness and snoring when on my back. I tried sleeping only on my sides but kept waking up after a while from pain in my hips.

Six months ago I went back to the same major hospital sleep clinic, another overnight test, while laying on my back most of the night. Diagnosis OSA, some “expected” transitional CSA episodes but according to Dr., nowhere near enough to be diagnosed w/ CSA or complex or mixed apnea. AHI was 13.6 & Dr said that they found that 16/8 would allow me to sleep on my back without OSA and with good oxygen saturation. No sign of the higher pressures initiating central apneas.

Snoring stopped for the most part sleeping on my back but two follow-up overnight oximetry tests (one w/ nasal pillows and one w/ full face mask) showed several disturbing dips into the mid-80s during the night, and I was still having daytime sleepiness. Dr. then felt that I might be having CSA episodes at home that did not show up in the overnight test. Unfortunately, my old Goodnight 425 did not have a smartcard I could bring to the Dr. He recommended another overnight test at the hospital with a Bipap S/T or Bipap AutoSV.

I told the Dr that I did not want to have to go through another overnight test but that I was willing to purchase my own Respironics Bipap S/T w/ Smartcard without worrying about insurance. He aid OK and prescribed bilevel at 16/8 w/ backup rate of 10 BPM, I purchased the S/T on auction for less than my deductible would have been for another overnight test. I have been using it now for about a month. I can sleep on my back now with virtually no snoring and I feel much better when I wake up. Daytime sleepiness has subsided significantly, but still not totally gone.

So, my current settings on my Bipap S/T is 16/8 w/ 10BPM. My smartcard shows that my average BPM is 13.5 and my average “patient triggered breaths” is 84%. Avg. Leak rate is 38. Avg. weekly apnea count is 200. I'm not sure if these numbers are good or not. It does not indicate AHI. My Mindray PM-60 handheld oximeter shows I'm consistently averaging 94% saturation throughout the night. I only occasionally dip below 90% for a few seconds.

I know how to get into the setup screen but not sure of all the options & what they mean. I've tried to find or buy a copy of the clinical manual for the S/T but so far no luck anywhere. I think I'd like to tweak the BMP setting and the rise time but not sure. Appreciate any advice.

[dsm]

Sleepy55,

Got your PM & will offer what advice I can. To provide more accurate assist, can you PM me with the info requested back by PM (not for publishing unless you particularly want to).

The base numbers you have mentioned aren't too bad - any desats below 88% are always a worry as to why & what else was happening at the same moment.

I still haven't found my pdf of the clin manual (I have one somewhere plus the hard copy).

Cheers

DSM

[Sleepy55]

OK, here's how last night went:

Respironics Bipap S/T Settings were IPAP 16, EPAP 8, BPM 12 (raised it from previous setting of 10), 1.2Sec Insp. Time, Rise Time 2

Encore Report - Spontaneous BPM 14, Avg. Tital Volume 570ml, 67% Patient Triggered Breaths, Average Peak Inspiratory Flow 30 LPM, Average Leak 40, Aver. Apnea Count 405

Mindray PM-60 Oximeter Report - Average SPO2 95% (dipped to 90% for a few seconds on four occassions during the night).

It appears to me that my % patient triggered breaths dropped and my apnea count increased as a possible result of changing the settings from 10BPM to 12BPM. I think I will drop back to 10BPM this evening.

Appreciate any ideas on how to increase the % patient triggered breaths and on how to reduce the apnea count.

Tks

Sleepy55

[dsm]

Sleepy,

I don't think changing your bpm is going to help.
What are you wanting to achieve ? (I assume you know the Bipap S/T doesn't give details of your AHI through the night (like the other bipaps do) it only gives a summary AHI for the entire night but it does provide info re tidal flow and minute ventilation.

Your Spo2 % is a great aid but you do need data from the machine before anyone can really help.

Good luck

DSM

[Sleepy55]

I would think my goal would be to fine tune machine settings so my oxygen saturation is consistently in the mid-90% (which it currently is), so that my average patient triggered breaths is in the high 90's, and regarding my total apnea count, I'm not quite sure...I would think I'd want to see a reduction in the apnea count, and of course to feel rested when I wake and to eliminate as much as possible the dreaded and dangerous daytime sleepyness. The Encore report on the S/T does not indicate if the apnea count it provides is for OSA's or CA's or a combination. It also does not provide AHI. My post from yesterday I listed all the relevant data from the Encore report, including tidal volume peak flow. I'm not sure I can attach the entire Encore report to my post but I'm willing to email it to anyone interested in taking a look at it.

[dsm]

I would think my goal would be to fine tune machine settings so my oxygen saturation is consistently in the mid-90% (which it currently is), so that my average patient triggered breaths is in the high 90's, and regarding my total apnea count, I'm not quite sure...I would think I'd want to see a reduction in the apnea count, and of course to feel rested when I wake and to eliminate as much as possible the dreaded and dangerous daytime sleepyness. The Encore report on the S/T does not indicate if the apnea count it provides is for OSA's or CA's or a combination. It also does not provide AHI. My post from yesterday I listed all the relevant data from the Encore report, including tidal volume peak flow. I'm not sure I can attach the entire Encore report to my post but I'm willing to email it to anyone interested in taking a look at it.

PM sent.

Cheers

DSM

[rested gal]

I'm really puzzled by this statement by the doctor (is he a board certified "sleep" doctor or is he your primary care physician who happened to refer you for a sleep study?) --

I put in bold the part that puzzled me:
My doctor does not understand why the low oxygen levels and the continued daytime sleepiness, so he prescribed the BiPap S/T w/ a BPM of 10, in case I am having CSAs that just did not show up on the overnight test.

In any full PSG sleep study done even halfway right at a decent sleep lab, "CSAs" (central apneas) ARE going to show up. I cannot imagine a doctor prescribing an S/T machine with a back up rate because he thinks there's a possibility that the study had missed seeing central apneas.

My experience using a bilevel S/T machine and setting various backup rates (just for the heck of trying that kind of machine for a couple of weeks) was that having EPAP/IPAP switching on their own was MOST annoying. Cutting off in the midst of inhaling, or pushing more pressure in the midst of exhaling. If that kind of unexpected switching back and forth is not really needed for a person, it is simply aggravating. And could even be disturbing to sleep, I would think.

I'd set the machine for regular bilevel operation... spontaneous only. I'd not use a timed backup rate at all. But that's me. You might want to do what your doctor has prescribed.

Those overnight oximeter reports that showed some dips into the mid-eighties. Is there a possibility that the finger probe was dislodged occasionally? Or that leaks (mask, or mouth if not wearing a Full Face mask) were interfering with optimum positive air pressure therapy at times? I'd want to know more about the leak graph from the cpap machine reports...IF the machine being used was capable of recording full data.... before I'd go to a conclusion that the SpO2 drops into mid-eighties indicated that a PSG sleep study had "missed centrals" and that a person should be using a backup rate for breaths per minute.

Unfortunately, the BiPAP Plus you were using (before the doctor took a leap to bilevel S/T) doesn't record full data. There would be no leak info from the Plus. If I were the doctor, I'd have prescribed a BiPAP Auto set for bilevel mode (if he didn't want to turn on autotitrating) and gather some AHI and leak info. But I'm not a doctor, and I wouldn't like a "timed back up rate" if I didn't truly need it.

[rested gal]

P.S. The lower you set the BPM, the higher percentage of "patient triggered breaths" I'll bet you'll see.

To reduce the total number of apneas, I'd raise the EPAP. Like to 10, if it EPAP is set for 8. But...as I say again and again, I'm not a doctor.

During my playing around with an S/T machine, setting the BPM as low as it would go (4 breaths per minute, as best I can recall...it's been over a year ago) was the only way I could keep from having my nice normal blood pressure rise, just from the annoyance of having the machine (instead of me) occasionally decide when I should inhale and exhale.

Bear in mind, I don't need a timed back up rate at all. Maybe you do. But I'm betting you don't. I think there could have been other reasons for the drop to mid-eighties on the previous overnight pulse oxi. The brief drop to 90 on your most recent one, could very well have been from too low an EPAP letting too many apneas through.

[Sleepy55]

Rested GAl, I don't know if he's board certified or not but he's a very senior MD psychiatrist that specializes in sleep disorders at the sleep clinic of a major hospital. He sounded like he knew what he was talking about, but heck, how would I know! Either way, I'm not going back in for another overnight test. At least not until I get done tweaking the equipment I have and see if I'm satisfied witht he results.

The finger probe was not loose, I used tape to make sure. I did use nasal pillows and I very likely wound up mouth breathing, causing the dip in the mid-80's. I now use a full face mask (under the chin type) and mouth breathing is no longer an issue.

I agree re the BPM, leaving the pressures alone, when I raised the BPM from 10 to 12 for one night, my percentage of "user initiated breaths" went down drastically, from an average of 83% to 67%. I then lowered the BPM from 12 to 9 for one night and the percent went up to 93%. I'll try lowering it to 8 for one night and see what happens. Hopefully it will keep going up. Once I find a BPM setting that will get my "user intiated breaths" up to the high 90%, I'll try and adjust the EPAP up to 9 or 10 to see if it lowers my total number of apneas. Of course, I'll continue to monitor my SPO2 to make sure these changes don't affect it. I'll also turn off the backup rate one night and take a look at the results. Maybe I don't even need a backup rate! I'll post the results.

Yes, tweaking is being made more dificult because neither my S/T or Bipap Plus record all the data that needed. Maybe I'll sell the Bipap Plus and buy me a Biapap Auto M. Anyone have a one for sale? PM me if you do.

Thanks for taking the time to provide your input