BiPAP autoSV User needs help

[Mr Capers]

Hi Everyone,

I thought I was just hitting a plateau in my therapy, but started to see lots and lots of hypopneas plus periodic breathing. Here's a report from last night:


Ideas, comments would be appreciated. My sleep study showed 48% centrals, and while I don't see many apneas, which is encouraging , I just don't get the high number of hypopneas. I'm puzzled, so am submitting my data for the experts to have at it.

Many, many thanks in advance, for your comments
Mr Capers

[DreamOn]

Mr Capers,

I'm bumping this up in the hope that someone can help you interpret your data. Sorry that I don't know enough to help.

Could the hypopneas be related to the leaks (either through mouth or mask)?

~ DreamOn

[Mr Capers]

Hi DreamOn,

Thanks for the bump

If you look at the bottom graph, it shows 0 leaks, so that isn't the culprit. I actually thought the problem was using nasal pillows, switching between Opus 360 and Swift LT, so the night I'm showing I used the ComfortGel Nasal mask. My hypopnea rate with the nasal mask was basically the same as when I used the pillows, so that doesn't seem to be the problem. Mouth breathing doesn't seem to be it, at least I'm not waking with dry mouth.

This is really a puzzle

Where is SWS? How about Kiralynx? Rested Gal? All ideas are welcome

Thanks again,
Mr Capers

[roster]

I suggest you edit the OP and change the subject line to "BiPAP Auto SV User Needs Help".

That might attract some of the techie types who like to help with the more complicated problems.

Good luck.

[-SWS]

I thought I was just hitting a plateau in my therapy...

Would you mind describing what you observed by the way of that therapy "plateau"?

...but started to see lots and lots of hypopneas plus periodic breathing. ... My sleep study showed 48% centrals, and while I don't see many apneas, which is encouraging , I just don't get the high number of hypopneas.

Well, true to your phenotype at least some of those are probably central hypopneas---if not most. I suspect that because your 11% periodic breathing rate above seems somewhat prolific as well---and both are classic presentations of CSDB/CompSAS respiratory dyscontrol. However, there's an underlying obstructive component to CSDB/CompSAS as well. And since your above PB episodes are almost always preceded by hypopneas, it's not inconceivable that slight obstruction by the way of hypopneas might serve as neural stimuli for subsequent episodes of CSDB/CompSAS central dyscontrol.

If we somehow knew those were obstructive hypopneas instead of central hypopneas, then Respironics would suggest that you and your clinicians raise EPAP to address that outstanding obstructive component. Lacking a proper PSG re-titration, I suspect your clinicians might experimentally raise EPAP to the current average IPAP peak value if they suspected obstructive hypopneas. But if they suspected central hypopneas, then they might prefer to experimentally raise IPAP min instead. Once again, the current average IPAP peak value is probably a good experimental value to try for IPAP min in that latter central-hypopnea scenario. As a reminder, I am not a clinician or health-care professional of any kind.

Raising EPAP to address obstructive hypopneas with what would have been your newest/latest CPAP-equivalent pressure, stents the airway for the sake of obstructions. But raising IPAP min to address central hypopneas elevates your machine's per-breath transitional pressure support (PS) for the sake of assisting with ventilation or transitional work of breathing (WOB).


Please tell us a little more about what your data was up to before this recent trend. Also, tell us if you suspect any changes in mask, weight, sleep position, medication, diet, mental or physical stressors, etc. might have triggered this latest episode of unstable breathing during sleep.... Any recent machine-setting changes that might have caused this?

[Mr Capers]

I thought I was just hitting a plateau in my therapy...

Would you mind describing what you observed by the way of that therapy "plateau"?

I wasn't feeling physically better, short-term memory was no longer improving, mental acuity seemed to have leveled off. Blood pressure seemed to be trending down, but blood sugar was creeping up. In other words, the slope of the improvement graph was much less pronounced.

Looking back through my reports, I see the hypopnea numbers started growing around the end of September. So, I had less than two months of unremarkable therapy, then the larger numbers of both Periodic Breathing and hypopneas.

Well, true to your phenotype at least some of those are probably central hypopneas---if not most. I suspect that because your 11% periodic breathing rate above seems somewhat prolific as well---and both are classic presentations of CSDB/CompSAS respiratory dyscontrol. However, there's an underlying obstructive component to CSDB/CompSAS as well. And since your above PB episodes are almost always preceded by hypopneas, it's not inconceivable that slight obstruction by the way of hypopneas might serve as neural stimuli for subsequent episodes of CSDB/CompSAS central dyscontrol.

Looks to me as if the reverse is happening, Periodic Breathing seems to frequently precede the hypopnea events. Should I post some more report dates? I can do so if it would be helpful. Yeah, It looks from your last paragraph it would help, so I'll probably get that done tomorrow. I'm to see a Kaiser RT on the 24th. Remember, they don't seem to think I should even see my data.

Please tell us a little more about what your data was up to before this recent trend. Also, tell us if you suspect any changes in mask, weight, sleep position, medication, diet, mental or physical stressors, etc. might have triggered this latest episode of unstable breathing during sleep.... Any recent machine-setting changes that might have caused this?

The "unstable breathing" has been a factor since my sleep study, and, probably, all my life. I may have gained a few more pounds with my most recent foot injury which has confined me to my chair. The PB has remained a factor through mask changes - the most recent from nasal pillows to nasal mask.

I'm trying to absorb your other comments. Can you rephrase for the understanding challenged?

Many thanks for responding. (Did you see the very complimentary - to you - comments on another central apnea patient's thread?)

Happy naps,
Mr Capers

[-SWS]

your above PB episodes are almost always preceded by hypopneas

Looks to me as if the reverse is happening...

Well, your "PB episodes" entail a total of 12 red bars on your data graph. Here's what I did to determine that 10 or 11 of those 12 "PB episodes" commenced when "hypopnea spells" were already under way:

1) I saved the above graph to my computer
2) I opened the above saved graph in ordinary Windows Photo Gallery
3) I used the slider bar to expand the graph size to HUGE, GARGANTUAN, JUMBO, GIANT, COLOSSAL (no wait... I made it even BIGGER)
4) I dropped a vertical line straight down from the very left-most or leading edge of each red PB graphical bar (okay... I cheated with a paper edge)
5) I noted that there were no hypopneas under foot for that very first PB episode---but that there were already hypopneas underfoot for the next 10 PB episodes; then PB episode 12 was a neck-and-neck race with its "hypopnea spell" partner.

That's 10 or 11 "PB episodes" occurring when "hypopnea spells" were already underfoot. By contrast there are no "PB episodes" already in progress for the vast majority of your "hypopnea spell" leading edges. So I wonder if that "hypopnea first" data trend is common to your other nights in which PB and hypopneas are both prolific, Mr. Capers.

Should I post some more report dates? I can do so if it would be helpful.

Well, I'm not sure exactly what this "hypopnea before PB episode" trend tells us regarding whether: 1) you might benefit by raising EPAP to stent an outstanding obstructive component (obstructive hypopneas) or 2) you might benefit by raising IPAP min to better ventilate central undershoot (central hypopneas). If it were me, I would get in the loop with my doctor and propose both experiments. My own doctor is generally amenable to approving my proposed experiments or coming up with better ideas yet.

Should I post some more report dates? I can do so if it would be helpful.

It might be interesting to see some of your charts with prolific PB but not many hypopneas.

Looking back through my reports, I see the hypopnea numbers started growing around the end of September. So, I had less than two months of unremarkable therapy, then the larger numbers of both Periodic Breathing and hypopneas...

I may have gained a few more pounds with my most recent foot injury which has confined me to my chair.

Wondering how the timing of the above two line up. Weight gain can bring on more obstruction and sometimes a need for increased pressure. But sedentary living can sometimes symptomatically exacerbate conditions in which sympathetic tone plays a pivotal role. So I can't help but wonder if a sedentary cardiovascular lifestyle (from a broken foot in your case) can theoretically exacerbate CSDB flareups in at least some cases as well.

Consider getting a waist-up cardiovascular workout almost daily if your foot is not yet healed: sweat flowing and heart pumping for at least 15 or 20 minutes per workout session. It can't hurt if you have an otherwise clean bill of health---so good idea to get a cooperative doctor in the loop.


Regards and...







BUMP for other opinions.

[rested gal]

Where is SWS?

I think you were right to ask for the best person I know of ( - SWS ) to help you work on your rather complicated treatment issues, Mr Capers.

-SWS is the one I'd be asking, too!

[Kiralynx]

Mr. Capers,

I think ~SWS covered everything... the only thing I could have suggested was the comparison of the periodic breathing and the hypopneas in a graphics program, and he did that!

I will be following this thread, so if I can add anything from my limited knowledge I will do so. <grin> Already I learned something relating to my own study of my scans... so I thank you for this thread, and the chance to learn more about the periodic breathing / hypopnea connection.

[Mr Capers]

Hi SWS, Kiralynx, and any other ventilator users,

I've got a good bit of data to insert so let's proceed:


This report from 8-22 shows a nap, not a full night. What was interesting about this one was the fairly complete decoupling of the hypopneas and the periodic breathing. Note the time gap between the events. I suppose you could say this is an example of PB without hypopnea. Or, an example of PB not triggered by hypopneas. Mask was the ResMed Mirage Micro.

Here is a different example from just over a month later:

On this report date the PB seems incidental to the hypopneas. Apneas are 0, AHI 1.0. Large leaks are excessive - restless night?? Mask was the ResMed Mirage Micro.

Next, we skip ahead to November 5:

Here, the hypopneas are taking over! I have some reports with even more hypopneas than this. Yet, with all these hypopneas, periodic breathing is not a prominent factor. I tried as you suggested SWS, to find a report with lavish PB and low hypopneas, but I don't seem to generate that rare a bird. I do, however, recently produce loads of hypopneas with some PB.

My final exhibit is for the night of November 9, the night before my first report, above, which started this whole conversation:

This report shows some clear hypopnea clusters upon first donning re-donning the mask, which in this case is the Swift LT nasal pillows.

I'm thinking my brain doesn't reset for the right amount of CO2 when I'm dozing off, or some other part of that complex mechanism isn't working properly.

So, you now have four reports from fairly early to pretty recent. Hopefully this will allow for a more complete view than the single data point in my first message. To round this out, here is some data I extracted from my original sleep report.

I am sorry, but it is very hard to get everything to line up when you do a spreadsheet. A little study should reveal what everything means. Questions? Ask away, and I'll try to answer. Oh yes, this was an "at home" sleep study, not a full sleep study done in a lab.

I get to see one of the RTs at Kaiser on the 24th. I am to get a pulse oximeter for one night to see what my O2 saturation levels are doing. Since I was never titrated on my ventilator, she may be willing to reset some parameters. SWS, your suggestions will certainly play a part in our conversation. I think she is expecting to download my smart card and get the standard seven days of data. What will she say when she sees my notebook with reports for almost every night and nap since I started in August?

Let me know what you think of all this data. Of course, if there is anything else that will help, let me know and I'll try to provide it.

Thank you in advance, and

Happy Naps,
Mr Capers

[Guest]

I would like to know what idiot setup your current parameters at EPAP = IPAP Min 5cmH20?

Banned

[-SWS]

I would like to know what idiot setup your current parameters at EPAP = IPAP Min 5cmH20?

Setting EPAP=IPAP min is a perfectly viable setting according to Respironics. In fact, Respironics repeatedly recommends setting EPAP = IPAP min (that's CPAP modality as base)...

But I don't yet see any basis for that 5 cm setting either, Banned. I wonder if Kaiser thinks the BiPAP AutoSV can automatically titrate an obstructive component. Respironics is very clear that the BiPAP autoSV cannot do that. Respironics is clear that first the obstructive component must be manually titrated. Then that obstructive-addressing CPAP pressure value or even BiPAP pair of pressures can be used in tandem with an IPAP max setting that is 10 cm higher than the obstructive-addressing EPAP.

Since I was never titrated on my ventilator, she may be willing to reset some parameters.

I'm also extremely disappointed to read that you were never manually titrated on your BiPAP AutoSV, Mr Capers. By the way, below is the Respironics suggested BiPAP AutoSV titration protocol:
http://global.respironics.com/UserGuide ... 042977.pdf

[-SWS]

And we might as well add the following spread sheet for easy viewing in this thread as well:


viewtopic.php?f=1&t=44444&p=396674#p397085

By the way, below is the Respironics suggested BiPAP AutoSV titration protocol:
http://global.respironics.com/UserGuide ... 042977.pdf

Notice that if central dysregulation persists after trying everything else, the Respironics titration protocol has the clinician: 1) turn off auto backup rate, 2) set machine BPM to spontaneous rate minus 2, and 3) start I time ("inspiratory time") at 1.2 seconds. So if all else fails, your clinicians might want to eventually try a manual backup rate of 10 BPM and an "inspriatory time" setting of 1.2 seconds. Ideally all of that is performed during a PSG titration, though.

[Guest]

I have no issue with EPAP=IPAP Min. What I take exception to is EPAP=IPAP Min at 5cmH20. 5cmH20 is a non(sense) setting. 5cmH20 is BS. No wonder this guy is having trouble.

Banned

[Guest]

How did Caper ever get scribed a BiPAP Auto SV?

I wouldn't suggest he go back to Kaiser if they were the ones who scribed a BiPAP Auto SV at 5cmH20 because they clearly do not understand sleep medicine.

Since Caper is using the data he should titrate himself by setting EPAP 9cm, IPAP Min 13cm and IPAP Max at 20cm. Any necessary adjustments can be made from that very conservative starting point.

I don't think "Auto" is the culprit, although with my BiPAP Auto SV I do prefer a manual Backup Rate of 10 BPM; Inspiration Time of 1.7sec; Rise Time of .4sec; for a Total Inspiration Time of 2.1sec. (Remember Inspiration Time and Rise Time are additive for Total Inspiration time).

God, I still love on-line titrations with any SV!

Banned