"Dying" To Find ST-A User to Help Me

[robysue1]

HERE IS TRANSCRIPT OFF FIRST PAGE:

Before optimum pressure was reached I had 170 arousals.
Arousal index was 27.4 per hour.
PLMS 67 for an index of 10.8 per hour.
AHI 20.3 per hour (REM AHI 0.0)
Total of 47 apneas, 79 partial apneas.

There were 126 respiratory events consisting of 30 obstructive, 5 mixed, 12 central. The average event duration was 20.1 seconds, and the maximum duration was 37.0 seconds.

Minimum Sp02 during titration before reaching desired pressure was 87%. Time <88% was 0.3 minutes.

Conclusion: Complex sleep apnea: Poor response to CPAP; Positive esponse to Bipap S/T.
Snoring and associated hypoxia corrected.
Leg movements and occasional PACs noted.
Total sleep time and efficacy are normal. REM and Slow Wave sleep are reduced.

So this explains why you were prescribed a Resmed Aircurve 10 ST-A machine. But it doesn't directly explain why your machine was set up in iVAPS mode. And it doesn't tell us anything about how the therapeutic settings for iVAPS mode were determined.

Do you have a copy of the clinical menu? And do you understand how the iVAPS mode is supposed to work on your machine?

If you don't have the clinical menu, you can get it from https://www.manualslib.com/manual/17743 ... -St-A.html

The relevant information about how your machine should be increasing/decreasing pressure is found on page 6 of the manual and on page 8 of the manual.

And the adjustable (therapeutic) settings for iVAPS mode are shown in page 7 of the manual.

So can you get into the clinical settings and tell us what the following things are set for:

EPAP
min PS
max PS
Target Pt Rate
Target Va
Ti Max
Ti Min
Rise Time
Trigger
Cycle
Height

There may also be a setting for iBR (intelligent back up rate). If so, please list it as well.

Note: Depending on how your iVAPS settings are set up, some of these settings may be disabled and not show up in your clinical settings menu. Just tell me all the settings you do find.

I need this information in order to help you figure out how to help you.

[robysue1]

Below are images from last night.
<much deleted>

FULL NIGHT

<more deleted>

NOT SURE WHAT TO MAKE OF THIS VIEW. DID HAVE AIR LEAK

You had a pretty massive air leak for over 27% of the night: All the areas with gray backgrounds are time periods when you were leaking at a rate that your machine defines as "Large Leak". For Resmed machines, this usually means your (unintentional) leak rate was AT or ABOVE 24 Liters/minute. You didn't include the leak graph so we don't know just how bad all those Large Leaks are, but typically when you've got official Large Leaks for 27% of the night, there's a problem that needs to be addressed.

Next, there are several things you need to do a bit differently to make your data easier to understand.

First, can you organize your data like this:



And your image has the left side bar fonts so small that I can't really read them even when I open up the image in imgur and magnify it. That's why I want you to confirm what your machine's settings are: I can't pick them up from the Oscar data you posted.

Second, I'm less interested in the tidal volume and minute ventilation graphs than I am in the leak and flow limitation graphs. Now, it's just possible that your machine doesn't record a flow limitation graph, but try looking for it. If it's there, it provide a lot of useful information.

Third, please don't try to cram more than the four graphs that I want into the screen shot. If/when it is time to look at the minute ventilation or tidal volume or respiratory rate graphs, I'll let you know.

[robysue1]

AS DECENT SHAPE I CAN FIND?

I don't know. Have you scrolled through the whole night? That's the only way to tell if this is as decent of a shape as you can find in your own data.

That said, your machine seems to be relatively happy with your breathing: Your PS = 6cm, which is closer to your min PS = 5 than it is to your max PS = 15.

Although, with iVAPS, the machine is more worried about your alveolar ventilation and I don't know what your machine thinks the "targets" are supposed to be nor do I really understand how it estimates the current alveolar ventilation. But my best guess is that your machine is using the Height setting along with some of the other settings in the clinical menu to do this.

Just for comparison, here's a snippet of some really good sleep breathing of my own:

[robysue1]

ISSUE WITH SHAPES?

Yes, there's an obvious issue with the shapes of the inhalations. And yes, the usual interpretation would be there's some significant flow limitation going on in this snippet of breathing.

If you look closely, you can see the machine has increased the PS to something around 8-10 cm for the breaths before 6:21:35. The breaths around 6:21:35 look (to my non-expert eye) like they are an arousal. And you'll notice the PS goes down after 6:21:45 when it looks like normal sleep breathing is starting to resume. So we can conclude the machine was not completely happy with the way you were breathing here.

One thing that I think is important to remember about your Resmed Aircurve 10 ST-A running in iVAPS mode: I believe in this mode there is a fixed EPAP after the ramp period is over. The IPAP can vary (as the PS is increased) in response to the iVAPS algorithm, which is targeted towards maintaining a target alveolar ventilation (according to the manual)

So it's not clear to me what, if anything this machine running in iVAPS mode is supposed to do if/when flow limitations, snoring, hypopneas, or apneas are detected.

[robysue1]

Uh oh! Why are mmy. images showing so large??? Did I do something wrong? I thought these were links to imgur?

The size of the image is just fine: It lets us get an idea of what's going on without having to go back and forth between two tabs.

[Dog Slobber]

Uh oh! Why are mmy. images showing so large??? Did I do something wrong? I thought these were links to imgur?

If the link is to an image and it's surround by the forum's image tags, the image will be displayed in the post.

I prefer just how you've done it.

[robysue1]

NOT SURE WHAT TO MAKE OF THIS VIEW. DID HAVE AIR LEAK

Several things are obviously going on here:

There's some really ragged breathing going on here, and in response, the machine increases the IPAP starting around 8:44:05.

The hypopnea scored at 8:44:15 is most likely based on the data 8:44:00 and 8:44:10: That area of breathing looks pretty much like a hypopnea to my eyes.

That hypopnea might not be a "real" hypopnea: There's a huge inhalation right at the start of this snippet, which could easily be some kind of arousal. And in that case, the H might just be a normal breathing glitch as part of the transition back to sleep. Only we don't see an establishment of normal, regular sleep breathing resuming. In other words, this whole snippet might just be sleep-wake-junk: You might be going back and forth between a very light sleep stage and wake, but for whatever reason, you never get back into a sound sleep. And it's important to understand: Wake breathing and sleep-wake-junk breathing are naturally more varied than normal sleep breathing.

It sure would be useful if Rubicon took a look at that last snippet and said something about it.

Finally, I'll add this: For folks using the more common APAPs and auto-adjusting bilevels (PR BiPAP Autos and Resmed AirCurve VAutos), who have a lot of residual flow limitations and who are not feeling rested, we typically recommend two possible approaches for trying to eliminate the flow limitations:

1) Increase the minimum pressure. In the case of a bilevel machine, that means increasing the minimum EPAP. Since your machine does not adjust EPAP, you could try a very modest increase in the EPAP setting I suppose.

2) Increase the PS setting. That's done by increasing the EPR or Flex on the APAPs, and increasing the (fixed) PS on a Resmed AirCurve VAuto. But your machine already has the ability to increase the PS as needed, and increasing your minimum PS setting just might make things worse since your min PS is already at 5cm.

[Rubicon]

It sure would be useful if Rubicon took a look at that last snippet and said something about it.

IMO your assessment is correct.

BTW I don't believe an S/T machine is going to report F/Ls because the breaths are "tailored" by the machine. The flow waveform you see is manufactured by the machine, not the patient (IOWs, it's hard to claim Inspiratory Flow Limitation if the machine is shoving the breath in).

I'm looking at an S9 Lumis 150 and FL isn't there. IDK if that's true of all S/T machines, but regardless, now you have to really think about the waveforms (is it a T or an S?) instead of relying on the machine interpretation.

[robysue1]

It sure would be useful if Rubicon took a look at that last snippet and said something about it.

IMO your assessment is correct.

Thank you.

BTW I don't believe an S/T machine is going to report F/Ls because the breaths are "tailored" by the machine. The flow waveform you see is manufactured by the machine, not the patient (IOWs, it's hard to claim Inspiratory Flow Limitation if the machine is shoving the breath in).

I'm looking at an S9 Lumis 150 and FL isn't there. IDK if that's true of all S/T machines, but regardless, now you have to really think about the waveforms (is it a T or an S?) instead of relying on the machine interpretation.

Thank you for pointing these things out. Those of us who are just well read patients don't have that kind of info at our fingertips. And I certainly couldn't find anything in either the AirCurve ST-A's clinical manual or my AirCurve 10 VAuto's clinical manual about what kind of detailed data is (or is not) recorded.

I do have one question: When you say, "The flow waveform you see is manufactured by the machine, not the patient (IOWs, it's hard to claim Inspiratory Flow Limitation if the machine is shoving the breath in)," why does the inspiratory part of the flow waveform sometimes still have really ragged shapes that would be considered a flow limitation if the machine weren't trying to shove the breath in?

[Rubicon]

why does the inspiratory part of the flow waveform sometimes still have really ragged shapes that would be considered a flow limitation if the machine weren't trying to shove the breath in?

Circle the ones you're referring to.

[Notgivingupagain]

Oh my! So much information. It will take a while to process all the questions and pointers. (BTW, what is the proper way to quote someone in this forum? I tried to search for an answer but could not find it).

Regarding my settings:

Therapy Mode: IVAPS
Height: 62 Inches
Target Pt Rate: 12
Target Va: 5.2L/min
MV: 6.2 L/min (Can't be changed)
VT: 523 (Can't be changed)
VT/kg: 10.3 ML/kg IBW (Can't be changed)
EPAP: 15.00 TRYING 12 TONIGHT FOR MY OWN REASONS
Min PS: 5.0
Max PS: 15.0
Ti Max: 2.0s
Ti Min: 0.3s
Rise Time: Min
Trigger: Med
Cycle: Med
Start EPAP 7.0

I'm not sure why the doctor has me on IVAPS but I have the individual pages of the titration if those would be helpful. Only problem is when I try to post them via Imgur, you can't see the writing. I tried to post them as pdf instead of png but you can't post pdf on Imgur.

[zonker]

Oh my! So much information. It will take a while to process all the questions and pointers. (BTW, what is the proper way to quote someone in this forum? I tried to search for an answer but could not find it).

see the overly large quotation marks at the top right hand side of my post?

hit that.

that will quote back everything i'm typing now.

good luck!

[Notgivingupagain]

Here are the OSCAR charts from last night in the STANDARD ORDER. Sorry, TIDAL VOLUME is part of the STANDARD view:


Here, for comparison are the charts for the night before:

[ozij]

Here's what happens if the linked image BBC code is used. If you click on it it's a little less indistinct. No ads.

And, after the image opens in imgur, you can usually right click on the (enlarged) image, ask for it to be opened in a new tab, and then you can see it even clearer - sometimes I find that very helpful.

[Notgivingupagain]

Good Morning.

(I tried to resize the image smaller from the original, but had difficulty. This image might be too small, please let me know).

Last night I decreased the EPAP from 15 to 12 to see what would happen. I only awoke one time that I am aware of and I believe it was due to leaks. My machine has a leak alarm, I think I will turn it on tonight. I just hope it won't annoy my husband My AHI is a tiny bit higher, could be from lowering my EPAP from 15 to 12. I had two hypopnea during the second portion of my sleep and one unclassified apnea. These were all near periods of short air leakage. I feel tired but not devastatingly so. If I could just get MORE sleep it sure would help I think, but unsure of how much because of the issues with my breathing patterns/waves? If zoom shots are requested I will be happy to oblige).

(I did watch suggested video on mask fitting. At first it felt more comfortable, except for the silicone area almost being in my eyes. But I thought I could live with that. I had learned that the top of the mask should be placed just near to below the eyebrow area and the bottom in the crease of the chin. (Chin crease I knew). The video also mentioned tightening the straps so you take out the slack. Unfortunately, these steps resulted in quite a bit of air leak. I stopped the machine and tightened my straps. After starting the machine again I seemed to sleep straight through until about 5am with three episodes of unnoticed air leakage. This morning I do feel residual discomfort from the mask, but not as bad as last night. I am using a small mask because I do have a small face and this is what the fit guide and tech said I should use. The medium just seemed too big during titration. I might take another gander at this though.)