Trilogy - PTB Down - UPDATE

[Madalot]

Okay - as I was fiddling with the settings last night, I realized there are TWO sensitivity settings related to Flow Trigger.

These are the those options and the current settings:

Flow Trigger Sensitivity - 6 l/min
Flow Cycle Sensitivity - 25 %

If the hypothesis that during sleep, I'm not triggering the machine (thus the lower PTB) - which of these would be the best place to start increasing - and recommended increase?

I've been at these settings a LONG time.

[raisedfist]

Okay - as I was fiddling with the settings last night, I realized there are TWO sensitivity settings related to Flow Trigger.

These are the those options and the current settings:

Flow Trigger Sensitivity - 6 l/min
Flow Cycle Sensitivity - 25 %

If the hypothesis that during sleep, I'm not triggering the machine (thus the lower PTB) - which of these would be the best place to start increasing - and recommended increase?

I've been at these settings a LONG time.

I think the flow trigger sensitivity is where you want to start. Triggering is what is related to the patient or machine taking a breath/inhalation. I would just make slight adjustments per night (so make it slightly more sensitive in an increasing fashion) and see if you see any difference in the PTB%. I'm not familiar with flow triggers so I don't know which way you would "turn the dial" in terms of increasing or decreasing sensitivity...

I believe Cycling just controls what percentage of a breath cycle time are for inhalation before it kicks over to EPAP. So, the inhalation phase can be 30% of the breath cycle (usually for obstructive disease) or 40% (usually for restrictive disease). I don't think you need to adjust this value as it seems to be working as is.

[Madalot]

Okay - as I was fiddling with the settings last night, I realized there are TWO sensitivity settings related to Flow Trigger.

These are the those options and the current settings:

Flow Trigger Sensitivity - 6 l/min
Flow Cycle Sensitivity - 25 %

If the hypothesis that during sleep, I'm not triggering the machine (thus the lower PTB) - which of these would be the best place to start increasing - and recommended increase?

I've been at these settings a LONG time.

I think the flow trigger sensitivity is where you want to start. Triggering is what is related to the patient or machine taking a breath/inhalation. I would just make slight adjustments per night (so make it slightly more sensitive in an increasing fashion) and see if you see any difference in the PTB%. I'm not familiar with flow triggers so I don't know which way you would "turn the dial" in terms of increasing or decreasing sensitivity...

I believe Cycling just controls what percentage of a breath cycle time are for inhalation before it kicks over to EPAP. So, the inhalation phase can be 30% of the breath cycle (usually for obstructive disease) or 40% (usually for restrictive disease). I don't think you need to adjust this value as it seems to be working as is.

Got it. The Flow Trigger goes up by a full l/min, meaning the minimum I could increase it would be to 7 l/min. So, we'll give that a shot, give it a few nights, then run a report and see if PTB is any different/better. I won't mess with the other setting, at least for now.

Thanks for this input!

[ajack]

This is off the top of my head as I haven't read the manual....but...Wouldn't the flow sensitivity be a lower number flow, to increase the sensitivity? If it works similar to the s9. I'd get sensitivity that it self triggers too much, then increase the flow rate setting number to decrease the sensitivity a bit. On the least sensitive, I can breathe very gently and not trigger a breath.

you could try this now, put it on 1 and see the trigger response and then put it on 7, it should be obvious which is more sensitive,

[Madalot]

This is off the top of my head as I haven't read the manual....but...Wouldn't the flow sensitivity be a lower number flow, to increase the sensitivity? If it works similar to the s9. I'd get sensitivity that it self triggers too much, then increase the flow rate setting number to decrease the sensitivity a bit. On the least sensitive, I can breathe very gently and not trigger a breath.

Excellent point! Yikes! I'm going to need to research this to be sure which way to go (unless raisedfist or another knowledgeable person comes in on this one). Thanks for pointing that out....

[ajack]

I did an edit while you were reading and posting
you could try this now, put it on 1 and see the trigger response and then put it on 7, it should be obvious which is more sensitive because it will self trigger while you aren't trying to breathe and before the backup rate kicks in. ,
you could even turn down the backup rate for a few minutes while you do this

[Madalot]

I did an edit while you were reading and posting
you could try this now, put it on 1 and see the trigger response and then put it on 7, it should be obvious which is more sensitive because it will self trigger while you aren't trying to breathe and before the backup rate kicks in. ,
you could even turn down the backup rate for a few minutes while you do this

Thanks for re-posting this. I missed it in the original post. I'll see if I can work it in today to try it. Great idea! Thanks.

[ajack]

I was trying to work out the trigger on the s9 and I was confused which is the setting to go to from the 5 settings, default medium... very high or very low was at either end. This is the way I did it...one you will gently breathe and nothing will happen and the will trigger without trying, simple not breathing with an open throat, still has air flow with me and will trigger on sensitive..

[Madalot]

I ended up doing nothing yesterday. I found myself so tired yesterday afternoon/evening that it was all I could do to stay awake, let alone mess with Trilogy settings. That's kind of the sad part of my life these days. I get a few decent hours in the mornings, but by 1:00 - 2:00, I am about worthless. But this isn't new to me. Been down this road before.

The trial and error on this may have to wait for the weekend, unfortunately.

[ajack]

can you get assistance from your doctor or dme? as has been said there is the Auto-Trak which your 100 model seems to have. I really think you should consider seeking assistance to set it up.
http://www.ahcah.com/Files/Manuals/Tril ... NGLISH.pdf

"A new setting has been added to increase the sensitivity of Auto-Trak.
Sensitive Auto-Trak is an enhancement to the Auto-Trak algorithm that improves patient and machine synchrony
for patients with minimal respiratory effort. Sensitive Auto-Trak refines the baseline trigger sensitivity threshold. The
device can be set to trigger breaths based on automatic flow thresholds or specific flow settings. Select Auto-Trak
[Sensitive], Auto-Trak, or Flow Trigger as the Trigger Type. When Auto-Trak or Auto-Trak [Sensitive] is selected, the
trigger initiates based on automatic flow thresholds. When Trigger Type is set to Flow Trigger, Flow Trigger Sensitivity,
Leak Compensation, and Flow Cycle Sensitivity become active, and the trigger initiates based on the Flow Trigger
Sensitivity setting"

from reading some of it, I really think the sensitive trigger is 1 litre a minute and the insensitive is the high litre a minute to trigger. I think your present setting may be too high. Is there someone you trust who can advise you? A doctor or DME or even a help desk of the manufacturer
"Trigger Type
The device can be set to trigger breaths based on automatic flow
thresholds or specific flow settings. You can select either Auto-Trak
or Flow Trigger as the Trigger Type. When Auto-Trak is selected, the
Auto-Trak trigger initiates based on automatic flow thresholds. When
Trigger Type is set to Flow Trigger, Flow Trigger Sensitivity and Flow
Cycle Sensitivity become active, and the trigger initiates based on the
Flow Trigger Sensitivity setting.
Flow Trigger Sensitivity
If you set the Trigger Type to Flow Trigger, the Flow Trigger Sensitivity
setting displays. You can increase or decrease the setting from 1 to 9
l/min in 1 l/min increments.
The flow trigger initiates when the patient’s inspiratory effort creates
a flow equal to or greater than the flow sensitivity setting.

Flow Cycle Sensitivity
If you set the Trigger Type to Flow Trigger, the Flow Cycle Sensitivity
setting displays. You can increase or decrease the setting from 10 to
90 percent (%) in 1% increments.
As flow begins to decrease during inspiration, if the patient flow is
less than the flow cycle set point, the device will cycle
to expiration. For example: if the flow cycle is set at
75%, when the flow has decreased by 25% of the peak
flow, the device will cycle to the EPAP/PEEP level.
"

[Madalot]

can you get assistance from your doctor or dme? as has been said there is the Auto-Trak which your 100 model seems to have. I really think you should consider seeking assistance to set it up.
http://www.ahcah.com/Files/Manuals/Tril ... NGLISH.pdf

"A new setting has been added to increase the sensitivity of Auto-Trak.
Sensitive Auto-Trak is an enhancement to the Auto-Trak algorithm that improves patient and machine synchrony
for patients with minimal respiratory effort. Sensitive Auto-Trak refines the baseline trigger sensitivity threshold. The
device can be set to trigger breaths based on automatic flow thresholds or specific flow settings. Select Auto-Trak
[Sensitive], Auto-Trak, or Flow Trigger as the Trigger Type. When Auto-Trak or Auto-Trak [Sensitive] is selected, the
trigger initiates based on automatic flow thresholds. When Trigger Type is set to Flow Trigger, Flow Trigger Sensitivity,
Leak Compensation, and Flow Cycle Sensitivity become active, and the trigger initiates based on the Flow Trigger
Sensitivity setting"

from reading some of it, I really think the sensitive trigger is 1 litre a minute and the insensitive is the high litre a minute to trigger. I think your present setting may be too high. Is there someone you trust who can advise you? A doctor or DME or even a help desk of the manufacturer
"Trigger Type
The device can be set to trigger breaths based on automatic flow
thresholds or specific flow settings. You can select either Auto-Trak
or Flow Trigger as the Trigger Type. When Auto-Trak is selected, the
Auto-Trak trigger initiates based on automatic flow thresholds. When
Trigger Type is set to Flow Trigger, Flow Trigger Sensitivity and Flow
Cycle Sensitivity become active, and the trigger initiates based on the
Flow Trigger Sensitivity setting.
Flow Trigger Sensitivity
If you set the Trigger Type to Flow Trigger, the Flow Trigger Sensitivity
setting displays. You can increase or decrease the setting from 1 to 9
l/min in 1 l/min increments.
The flow trigger initiates when the patient’s inspiratory effort creates
a flow equal to or greater than the flow sensitivity setting.

Flow Cycle Sensitivity
If you set the Trigger Type to Flow Trigger, the Flow Cycle Sensitivity
setting displays. You can increase or decrease the setting from 10 to
90 percent (%) in 1% increments.
As flow begins to decrease during inspiration, if the patient flow is
less than the flow cycle set point, the device will cycle
to expiration. For example: if the flow cycle is set at
75%, when the flow has decreased by 25% of the peak
flow, the device will cycle to the EPAP/PEEP level.
"

As far as getting assistance, that's highly unlikely. My DME seems to have lost it's RT (again) and I have never seen my new doctor. But, all is not lost...

The information you provided is excellent, but I admit I need to read, study and check MY Trilogy to see if it's got these features and truthfully, for me to grasp all this. It's 1:00 here and I'm running out of steam for the day, but I will look all this over and try to digest it so I understand - and go from there.

Thank you so much for sharing this. Now all I have to do is understand it! LOL

[ajack]

This is my point, if you are exhausted, you cognitive ability is greatly reduced. You have had the trilogy for a number of years and a search shows it's been widely talked about with you. After all this time, I think you need to accept that it is too difficult for you to drive. I think the adjustments you have made has only decreased the machines function. To the point where you now find yourself.

I would want a sleep study using the trilogy and getting them to set it up. I read that with your last sleep study, this didn't happen. Most sleep techs rarely come across hard cases and 99% is garden variety apnea. You may even need a hospital admission. Adjusted over a few days by an ICU respiratorist who would know this stuff.

what you have been doing over the last few years isn't working and hasn't worked, I think you need a full review.

When I was setting up my ST, I found the forums a desert on ventilation stuff

[Madalot]

This is my point, if you are exhausted, you cognitive ability is greatly reduced. You have had the trilogy for a number of years and a search shows it's been widely talked about with you. After all this time, I think you need to accept that it is too difficult for you to drive. I think the adjustments you have made has only decreased the machines function. To the point where you now find yourself.

I would want a sleep study using the trilogy and getting them to set it up. I read that with your last sleep study, this didn't happen. Most sleep techs rarely come across hard cases and 99% is garden variety apnea. You may even need a hospital admission. Adjusted over a few days by an ICU respiratorist who would know this stuff.

what you have been doing over the last few years isn't working and hasn't worked, I think you need a full review.

When I was setting up my ST, I found the forums a desert on ventilation stuff

With all due respect, it took a lot of time, sweat and effort to get myself to the point where it WAS working very well, for YEARS. Much of the insight came from people here. It has only been in the last 6-12 months that I've noticed issues with serious awakenings (and the lower PTB) but there ARE other things going on (working part time) that MAY be contributing.

While I agree that some of the Trilogy's functions are complicated and some are difficult for me to grasp (I do not have a science mind) - I "get" a lot more than most Trilogy patients and understand a ton of what is going on and what the functions do. My comment that I need to read and digest your last post with detailed information should indicate that I am being cautious and careful and won't make changes until I understand them. Your comment about the Trilogy being "too difficult for you to drive" is a little hurtful.

I have been tired by afternoon my entire life. In the mornings, usually, I am fresh and my cognitive abilities are good. I have been working part time, I do paperwork, our bills, handle my husband's business, etc. Yes, by afternoon, I am getting very tired and I agree that my cognitive abilities are diminished, but in the mornings, they are not. It's the nature of my existence and I accept it. I simply have to leave tasks that require concentration for the mornings.

As far as a sleep study - I can tell you right now that it won't happen. Even if I could get a sleep study (which is questionable), being able to get one on the Trilogy? Don't hold your breath. My last sleep study was the most horrendous and stressful endeavor BEFORE it ever happened. It also took me months of screaming and clawing and still couldn't get it on the Trilogy.

When I see my new Pulmo in December (and I just cannot go before then) - if HE wants to do a study, we'll discuss it then. But on the Trilogy? Unless the clinic already has a Trilogy (again, doubtful) they won't get one just for my study and they won't use mine. Believe me, I fought that battle the last time and lost. I even had Respironics offer to LOAN the clinic a Trilogy for my study and they still refused.

All this being said - I do appreciate the input and still plan on reviewing the information and figuring out what I might be able to try to make things better. Today is my last day of working so I'll have more time in the mornings to read, think and see what I can do.

[raisedfist]

I suggest we just slow down and work on one thing at a time. It's not always easy to get to the lab, especially with mobility issues. And it's rare a lab has a Trilogy, let alone your Doctor even knowing what one is.

Madalalot has had the Trilogy for a long time now; it was working before; it still works now - in the sense that her oxygen saturation is maintained and the same tidal volume target is still met - without her sitting at max IPAP/pressure support all night. (She said her lower IPAP is 18cmh2o and the average for a night of sleep is around 19). Of course she may need to "tune it" to readjust considering her likely progression of her NMD causing these new issues.

Let's wait until the weekend and have Madalot change the flow trigger sensitivity 1 notch towards more sensitive and get some feedback. Let's get some evidence that we are going in the right direction. Not being able to breathe properly or do the things you want daily is incredibly stressful; let's not add to that.

[Pugsy]

Hi Maddie...just wanted to say that as usual I am following your struggles but as we have discussed in the past....you know more about your machine and your issues than I could ever possibly know and while I don't say much in this type of threads...doesn't mean I don't care and I am still here for moral support.
Oh...and you probably know this already but Palerider is in the same boat with me. That's why he doesn't say much. He cares too but doesn't know what to offer. Wishes he did but like me why out of our own comfort zone and like I have always said...messing with stuff on a cpap or apap or bilevel is one thing but it's a whole other thing to be messing with stuff on a person who is using a ventilator.

Raisedfist has some good ideas...goes along with what I have always said...careful and well thought out and planned experiments. Do them at your own pace. You know yourself better than anyone else.
I remember your last fight to try to get an in lab sleep study with the Trilogy...you are right...snowball's chance in hell of ever happening.

Hugs...