Resmed VPAP Adapt SV - for Central Sleep Apnea

[dsm]

<snip>


I don't even want to know why you were pulling the heads off your sisters dolls ...and why you remember the smell.....

<snip>

Has to have been ...

1) to work out how the doll closed its eyes when laid down

2) to fix a doll that stopped closing its eyes when laid down

DSM

all very logical

[Bella]

<snip>


I don't even want to know why you were pulling the heads off your sisters dolls ...and why you remember the smell.....

<snip>

Has to have been ...

1) to work out how the doll closed its eyes when laid down

2) to fix a doll that stopped closing its eyes when laid down

DSM

all very logical

And they enjoyed discovering how my Chatty Cathy doll spoke!

[frequenseeker]

Thanks, CQ.
I am giving your comments good consideration.

Regarding the time or two when I woke up with the machine being loud and alot of pressure, I can't think of any logical explanation. It wasn't like anything you have described. Do you think if I was having a massive leak it would do this. But it has an alarm that has quick response (and that can't be disabled) and that was not sounding.

SAG, thanks for your comments. I will follow up with my doctor. I do know I was in ASV mode until they switched me to the bipap.

There was one time the tech came in and it startled me, I kindof jumped into the air for a split second. Wonder if that is the jerk you are talking about. I really had trouble getting back to sleep after waking with the "forced breathing" sense and autonomic symptoms. Do you see anything in the graphs related to the CO2 levels?

frequenseeker

[StillAnotherGuest]

I do know I was in ASV mode until they switched me to the bi~pap.

I don't mean "ASV mode" to mean "using the AdaptSV", I mean ASV Mode as a function of AdaptSV, differentiated from what I refer to as "Spontaneous Mode" noted about a hundred posts ago. If you're on an AdaptSV and it's buzzing along in Spontaneous Mode, it's acting like a basic Bi~PAP. When Minute Ventilation drops below Target, then it goes into ASV Mode.

The "forced breathing" sounds like ASV Mode with asynchrony.

No, that isn't the jerk, comment later.
SAG

[christinequilts]

And they enjoyed discovery how my Chatty Cathy doll spoke!

The worst I did was 'tweeze' one of my dolls eyeLASHES (the brows were painted on ) ...and I melted one dolls hair with a hair dryer (can you tell I picked up a lot things from my older sister, who was in cosmetology school when I was 3-4 years old?)

I'm glad you joined us Bella...and for everyone else, Bella & I got to know each other on a non-sleep related board a couple years ago and then she got DXed with CSA. Talk about strange coincidences.

And yes, in answer to your PM, we need to find out if the Adapt is available in Canada yet...or even the Respironics ASV, which was just approved in the US & isn't on the market yet. You of all people need a try at one of these machine. The good news, at least in the US, is its classed the same as BiPAP ST, so hopefully Canada will do the same which means it should be covered fully like your BiPAP ST is. I know you've been faithfully using your Synchrony, but when you see the difference in how well the Adapt can work, you'll be amazed (...Adapts tag line is "Simply Amazing" after all...and they were not exaggerating one bit ) Its not just that it took care of my breathing brilliantly, but it also significantly reduced my severe Alpha Intrusion and excessive CAP (cyclic alternating pattern). I had more time in stage 3/4 sleep during the Adapt titration then I'd had in previous 4 PSG combined! My biggest 'problem' with the Adapt itself early on was sleeping so sound I didn't move a muscle all night because I was sleeping so soundly, which makes for a sore back. The Synchrony was a great machine for me at the time, especially compared to the alternative, as it let me 'tread water' for 3 years instead of continuing to decline overall health wise. But anyone with as high of a central AHI as you needs a chance to give the ASV technology a try.

Drats! I just checked ResMed's site, but they don't have a choice for Canada (US, Australia, France, UK, Germany, etc) as a separate country...now it'll take some more work to figure this out. Did the DME you obtained your Synchrony from also carry ResMed machines? Maybe you can call them and ask if either the VPAP Adapt SV (US name) or the AutoSet CS2 (name used in some countries) is available. If it is, start bugging your sleep doc. Let us know what you find out.

[rested gal]

Did the DME you obtained your Synchrony from also carry ResMed machines? Maybe you can call them and ask if either the VPAP Adapt SV (US name) or the AutoSet CS2 (name used in some countries) is available. If it is, start bugging your sleep doc. Let us know what you find out.

Bella, if you can't get the resmed machine (by either its US or Australian names) the Respironics ASV machine Christine mentioned is available here:

https://www.cpap.com/productpage-advanced.php?PNum=2471

[christinequilts]

Adapt with you in stable slow wave sleep--everything looks good in slow wave sleep!

Except for all the alpha intrusion.

Is there anyway to tell if the alpha intrusion is an underlying issue or if an xPAP contributes to it? Guess the only way to determine that would be to have recent non-treatment PSG to compare with, isn't it?

[StillAnotherGuest]

Is there anyway to tell if the alpha intrusion is an underlying issue or if an xPAP contributes to it? Guess the only way to determine that would be to have recent non-treatment PSG to compare with, isn't it?

Used to be that the alpha intrusion would be reported out, like on a scale of 1 to something, x% of the epoch, in SWS or throughout all stages, etc. But not only do few people do that (that I've seen, anyway), the assessment is kinda subjective, so if you have different scorers doing the sleep studies you can't make a comparison, so yeah, line 'em up to compare.

But...

Alpha intrusion has been a common thread in the Freqmeister studies for a while. And while alpha intrusion can sometimes be benign, if you have someone with a laundry list of symptomology you really have to give some thought as to how that factors in there.
SAG

[StillAnotherGuest]

AKA "More Stuff Than You Really Care To Know"

So if this is the seminal AdaptSV intolerance example:



then let's spend a moment.

I believe those respiratory "blips" occur independent of the EEG. For the first "blip", the timing is off. The EEG change occurs either prior to (start of alpha) or coincidental with (start of K-complex, note red line at C3) the blip. So the "blip" can't cause the a~rousal.



Alternatively, if the larger amplitude stuff (>75 µV high, the difference between +37.5 and -37.5 µV) in C3 is not artifact, then those areas are not a~rousals, they're delta waves, you're actually going from lighter to deeper sleep, and it's an alpha-delta pattern. Note the comparison to your "stable" SWS with the above 75 µV area:



Regardless, there's no corresponding EEG anything, whether it's a~rousal, alpha intrusion or alpha-delta to the second event, cause all the alpha (green line) occurs much too far away to have any relation.

The AdaptSV ASV Mode is not creating any problem. It is not in ASV mode. When AdaptSV does enter into ASV Mode, it doesn't do just one breath. If anything, the problem with incompatibility with this thing is that once you go into ASV Mode, it take a while to get out as the Target has to readjust (and the "forced breathing" that you felt while awake).

There is no reason (trigger) for the AdaptSV to go into ASV Mode here anyway.

I am somewhat perplexed to see that the flow and pressure outputs from AdaptSV are not included. That makes it impossible to determine what it's doing when (or even if) it does go into ASV Mode.

Can't tell anything about CO2 either, it's not on in the AdaptSV portion, and in the Bi~PAP there's no corresponding grid to track that (there's a read-out on the right there, though, that reads a single point).

The SagMontage monitors this stuff effectively, including all these components (and this is just the bottom half, reprinted from Chapter 5):



This is an outstanding CHF/CSR case. Check out that undulating CO2, level, one of (if not "the") major players in this thing.
SAG

[frequenseeker]

I would think there are more data files than these that were collected. Still waiting for the official study report too..

SAG, your comment

Severely delayed REM (due at least in part to huge WASO).

Please translate WASO..?

you're on an AdaptSV and it's buzzing along in Spontaneous Mode, it's acting like a basic Bi~PAP. When Minute Ventilation drops below Target, then it goes into ASV Mode.

Maybe this is the problem: I have a very low TV 250-350. Perhaps this is what triggers the backup rate?

In one Adapt SV screen your rate is 12, in the other is 15. Neither screen, however, looks to be in ASV Mode, so that rate is entirely you. Therefore, the AdaptSV can do <15, and you can do fine at 15.

You say "neither looks to be in ASV mode. How can you tell accurately? I can tell you I was not doing fine at 15. I was perhaps it could be termed regulated but it was not comfortable once I was awake to notice it, it was regimented. Think of an army marching relentlessly forward in lockstep.
I understand that sometimes we have to do things that are out of our usual in order to function more likenormal, but in this case alot of other indicators were zinging the message that it had become counterproductive.

Another comment to share:

The high RR with the adapt could contribute to low CO2--the fact of the matter is it may be driving your respiratory rate where it doesn't belong. Presumably it is still trying to keep the overall minute ventilation where it belongs but if the resp rate is too high it will then end up providing a minimum increase in inspiratory pressure (which is 3) which still may be too much support. I think with the default back-up and the minimum inspiratory pressure it may just not be able to ventilate appropriately.

The sleep related hypocapnia is indeed an issue outside of the adapt--one the adapt may not be able to deal with for you given its minimum/default settings as it currently exists.

My extremely low VT and/or restrictive lung condition (asthma? emphysema?) maybe sabotage the ASV's "miracle" algorithm

frequenseeker

[rested gal]

Please translate WASO..?

Wake after sleep onset.

[StillAnotherGuest]

I would think there are more data files than these that were collected.

Perhaps.

Please translate WASO..?

Right, the long stretch of wake after that first sleep period.

Maybe this is the problem: I have a very low TV 250-350. Perhaps this is what triggers the backup rate?

Normal spontaneous tidal volume is 5 ml/kg. You look to be normal.

You say "neither looks to be in ASV mode. How can you tell accurately?

Superior skill and intellect.

I can tell you I was not doing fine at 15.

You were sleeping like a rock. That is technically "fine."

Another comment to share:

The high RR with the adapt could contribute to low CO2--the fact of the matter is it may be driving your respiratory rate where it doesn't belong. Presumably it is still trying to keep the overall minute ventilation where it belongs but if the resp rate is too high it will then end up providing a minimum increase in inspiratory pressure (which is 3) which still may be too much support. I think with the default back-up and the minimum inspiratory pressure it may just not be able to ventilate appropriately.

The sleep related hypocapnia is indeed an issue outside of the adapt--one the adapt may not be able to deal with for you given its minimum/default settings as it currently exists.

LOL! SAG knows a



when he sees one!

However, christine and I have tried to explain this concept numerous times, and this is academic in that you never had the criteria for AdaptSV in the first place.
SAG

[-SWS]

More on the subject of that Adapt SV backup rate. In one of my previous posts I quoted the multifactorial decision-making rules associated with that back up rate. That back up rate is not at all fixed at 15 as we have said all along. But the Resmed medical director mentioned that this back up rate of 15 "permeated" throughout the night.

Why and when will that Adapt SV back up rate of 15 "permeate" throughout the night?

...but to the extent that the respiratory airflow signal is of poor quality and it is difficult to synchronize reliably with the patient's efforts, or to know if the patient's efforts are adequate, ventilatory support will be provided in an orderly manner at a predetermined fixed rate.

The bold font above is my own emphasis. The patent text clearly says that if the airflow signal is of "poor quality" then a predetermined fixed rate of ventilatory assistance will be provided (i.e. that "permeating 15" back up rate) .

So how might that airflow signal be of poor quality? Perhaps a mask that can't even pass the Adapt SV's LC. Excessive leaks are another possibility. Generate a poor-quality airflow signal or even present a hard-to-baseline or difficult-to-characterize signal, and that back up rate of 15 is certainly going to "permeate".

[frequenseeker]

SAG, thanks for your responses.

the long stretch of wake after that first sleep period

yes, that is where I woke breathing too fast and tried for a long time but couldn't go back to sleep, the "wired cat" feeling as someone described it. Finally called in the tech and changes were made then.

You were sleeping like a rock. That is technically "fine."

Ok, fine by a technical standard, but it resulted in the autonomic reactions of anxiety, chills, shivering, GI motility that woke me and kept me from going back to sleep. I did not feel well. Maybe it is possible to get to and be in deep levels of sleep despite things that are not good for one's well being, or simply that we learn to submit to or comply with.
Many of us sleep like a rock despite the noise and other experiences of pap that we accommodate to and accept and even want (knowing it means survival). If we were to encounter the same decibels and interferences in a different context for the first time we probably wouldn't be able to sleep very well. People have been known to sleep through nearby bombings when necessary.

All the data records from my year and a half of VPAP III indicated RR of 10-12.

you never had the criteria for AdaptSV in the first place.

I agree that matching patient to machine is essential. I would hope we all agree that the machines cannot be all things to all people and there is still a lack of really good solutions for many.
My initial study showed complex problems including cyclic patterns. The EERS for the CO2 needs made a big difference in how I feel and function. It was monitored and provided for in the sleep studies. I understand that it can be sensitive to alot of influences. Right now it seems to fit as a help for me.
My problem also involves the two different types of apnea I have. The search is for a machine that could make responses to address the REM related ones as the others are more easily dealt with. The ASV was a hope for me (and maybe my understanding of it was limited) in that it might be able to respond. Maybe the discussion here could explore possible other options. It is amazing how I can just seize up in apnea over and over when I dream in the early am (no seizures were noted in my neuro workup/sleep study though).

-SWS:

The patent text clearly says that if the airflow signal is of "poor quality" then a predetermined fixed rate of ventilatory assistance will be provided (i.e. that "permeating 15" back up rate) .

My PFTs indicate inflexibility in my lungs. Just putting aside the Swift question for a moment, might there be an influence from the quality of my respiratory response?

frequenseeker

[christinequilts]

The patent text clearly says that if the airflow signal is of "poor quality" then a predetermined fixed rate of ventilatory assistance will be provided (i.e. that "permeating 15" back up rate) .

My PFTs indicate inflexibility in my lungs. Just putting aside the Swift question for a moment, might there be an influence from the quality of my respiratory response?

I thought your other respiratory issues had cleared up by what you posted back when you requested a BiPAP ST, or even if they are not, I would expect one would need very advanced lung disease before it could possible affect the Adapt more so then a non-compatible mask.

I was hoping for a VPAP III ST because I seemed to get great results for my hypopneas with the timed respiration when I tried it. But my pulmonologist sleep doctor won't prescribe it now, not having enough medical necessity. There is a big danger she says with the ST, it is a ventilator and has the risk of building up the wrong gas balance and causing alkalosis.
I don't have central apnea, which is the usual necessary diagnosis. I thought I had respiratory conditions bad enough to justify it. And I once did....until recently! I had full respiratory testing a couple weeks ago and arterial blood gases and everything came out great! Which is puzzling since I had been told I had early emphysema and other problems not likely to improve.October 06 2005

All the data records from my year and a half of VPAP III indicated RR of 10-12.

But was this influenced by your unconventional IPAP & EPAP spreads and min/max time settings? Which may not reflect a true reading since an unusually long IPAP & EPAP would have limited the number of breaths per minute?

..Readers may remember that I set the IPAP max and min on the VPAP to as long as it would go, to get to the better results. Different from usual guidelines. Looking back I think that worked because it minimized the amount of CO2 washout.. May 21 2006

Then I decided to depart from the conventional wisdom of maintaining 4 points of pressure between max and min paps. I put the exhale up to 12, only 1.5 between. But oh what a difference! AHI went to 2, apneas to .2, and I feel so much better. The kind of clear, alert, energetic, able to act spontaneously instead of thinking about it and never getting around to it - being HERE! September 14 2004

From BI first PSG: The patient has self titrated pressures of 11.4 cm over 9.6 cm of water in the BiPAP mode.Wed Aug 02, 2006

Ok, fine by a technical standard, but it resulted in the autonomic reactions of anxiety, chills, shivering, GI motility that woke me and kept me from going back to sleep. I did not feel well. Maybe it is possible to get to and be in deep levels of sleep despite things that are not good for one's well being, or simply that we learn to submit to or comply with.

Just from my personal experience, my sleep studies have been fairly accurate in when I wasn't sleeping well because of chronic GI issues (gastroparesis), and any resultant nausea, chills, anxiety, etc. If anything, there were times I thought I slept better then the results indicated. But that's just me.

My initial study showed complex problems including cyclic patterns.

I thought you said it didn't show any cyclic SDB? And even the report from BI noted that.

I got my results, and once again my REM-related apnea was confirmed. It did not show any cyclic SDB. But - there is a problem - they read the study as if I had no deadspace used since they did not see the pattern to put it into use.

From the first BI PSG report:
***She had no evidence of periodic breathing or complex sleep-disordered breathing

***There were some episodes of waxing and waning of airflow with pressures of 13/10 centimeters of water which is suggestive of possible destabilizing effect of BiPAP on the respiratory control system.

***These findings were all consistent with REM dominant obstructive sleep disordered breathing. There is no clear evidence of sleep fragmenting respiratory dyscontrol noted and CPAP would be the preferred mode of support over that of BiPAP.

***She is unstable on BiPAP during unstable NREM sleep. This is her best indicator of instability. (note, from the CSDB article from your doctors, it states: Under description of OSA “With a focus on unstable NREM sleep, typically characterized by unstable breathing + low-frequency coupling + CAP EEG...”)

***Arousals are vigorous for visually subtle airflow obstruction.Wed Aug 02, 2006

The EERS for the CO2 needs made a big difference in how I feel and function. It was monitored and provided for in the sleep studies. I understand that it can be sensitive to alot of influences. Right now it seems to fit as a help for me.

But does it show you really need it? They never tested you with the 50cc EERS they prescribed. And what is the EERS fixing? Mild instability during nonstable NREM sleep? It sounds like they were aware they had tried EERS on you by the technicians notes, but that it wasn't needed. I don't know what transpired between the original report and the addendum, other then I know you contacted them when you were frustrated with the original results, but it doesn't sound like they were totally convinced you needed EERS to me.

The patient did have end tidal CO2 evaluated with a nonvented mask alone and it was 43-44 and with 70 cubic centimeters of enhanced end expiratory rebreathing space it was 47, with 140 cubic centimeters it was 50.

I don't understand end tidal CO2 measurements, I'll defer to SAG on these, but the 50 definitely looks high, possibly the 47...but his alter ego SD posted in TMOAT about CO2: “Just for laughs, I put on a mask, ran the CPAP at about 5 cmH2O and occluded the exhalation ports. Monitored FECO2. It went from 40 to 51 in 3 minutes. That's bad. That's bad. If you don't how how bad that is, then you shouldn't be playing around with this. If you do know how bad this is, then you won't be playing around with this.”

My problem also involves the two different types of apnea I have.

REM obstructive events are the norm of OSA, which is what SAG has been trying to tell you since you started TMOAT over at TAS.

FQ: Could we generalize to all the folks here who have persistent hypopneas who have responded in the past to the description I have posted about such, who have said they had similar? In other words, if someone is on PAP and not feeling well and has a high hypopnea rate, or has to use a high pressure to prevent it, could they likely be in this category of CO2 problem?

SAG:If you're using a high pressure but have an acceptable AHI, then that's probably not CSDB. CSDB starts out with an abnormal AHI, and then gets worse or at least does not improve.
Unless the patient has a bunch of CA, this mode is probably not for them.
Then who? It seems to me that you need at least 3 things in order to be considered for this therapy:

1, Central apneas, and probably a lot of them;
2. Low pCO2 levels as a major contributor to the CA; and
3. The CA is insufficiently treated or made worse by conventional CPAP/BiPAP.

Unless you have a refractory AHI, you really don't fit in here.

FQ posts reply "...I propose that it be considered that there is relevance to a different group. People like me who have "good" AHIs, who feel lousy if it goes over 3-5, and who have not found anything that solves the problem. We are in new territory here.....I will also suggest that the REM events could be described as central events. They occur with certain brain wave activity, not obstructive anatomy I believe."

SAG: What is particular about these [CSDB] events is that they are NOT a REM phenomenon:

From BI article: A characteristic feature of control dysfunction-related disease is a dramatic improvement during REM sleep, which is the reverse of the pattern seen in dominantly obstructive disease
&
[Complex Sleep-Disordered Breathing has] stage-dependent variability (periodic breathing during non-REM (NREM) sleep and severe obstructions during REM sleep)

Therefore, respiratory events during REM are almost certainly obstructive in nature.

The search is for a machine that could make responses to address the REM related ones as the others are more easily dealt with.

I believe that is called a CPAP, and autoPAP at the most, since its been well established you do not respond well to BiPAP by multiple PSG's and have REM dominant OSA. Nothing unusual there, just standard fare when it comes to OSA. With as close as you had your IPAP & EPAP set, you really were not using that aspect of a BiPAP- a ResMed CPAP with EPR would give you the same spread.

Maybe the discussion here could explore possible other options.

It has been explored over and over ad nauseaum, but you have never wanted to consider any of our suggestions that did not fit your limited construct of having some sort of unusual & unique type of apnea.
Start over with non-treatment PSG to see what you are treating
....without all the layers of complexity- BiPAP set at very unorthodoxed settings, homemade mouth guard, EERS, etc.


What was your original PSG AHI? Was it 7.4 that BI stated it had been? Even you said your AHI was mild early on at TAS, but it seems to have gone up with treatment instead of down. That's a big sign something is wrong with the treatment itself, not the underlying problem. Adding more & more complex treatment does nothing, and can even harm, if you don't know what you're treating in the first place.

Did your earlier studies note the AI your first BI study showed? I commented on that several months ago as a possibility of why you continued to have excessive symptoms, but you never seemed to consider it and SAG has noted it again in your recent PSG raw data. BI suggested a Dx of primary disorder of hypersomnolence if you continued to not do well & had good compliance, but you never follow up on that. TAS has a wonder Idiopathic Hypersomnolence board you may want to visit.

I had "mild" OSA on my initial sleep study but my sleepiness scale rating was so high and I had such bad daytime symptoms, my board certified sleep doc had no hesitation in putting me into cpap therapy. The study results are not the only criteria for decisionmaking. May 12 2004

Geez, I get AHIs 13-25 regularly (AI 1-2)..I better get in touch with the doctor.June 09 2004

I had AHI 46 at my first sleep study, 26 at my next one on cpap, couldn't get it down below 15-20 on cpap/bipap until I got my third machine, VPAP III adjusted so that my results look so good now. But remember, this is average for a night, so HI of 2 can mean 12 in a 6 hour night. [url=ttp://www.talkaboutsleep.com/message-boards/v ... ght=#39371]February 22 2005[/url]

BTW for those who don't know my history, I went from AHI 45 to 3 progressing through several machines until I got to the VPAP III with my customized settings. But - had huge hypopneas that the AHI was counting as 1 each but duration of many minutes each seen on the graph. And did not feel really right still. If AHI went above 3 I would feel really bad....September 26 2006

Through heroic manipulation of my 4th machine, a ResMed VPAP III (bipap) I was able to reduce my 45 AHI to less than 3 most of the time. But if it went over 3, even just a point, I felt way more awful than the routine awful I felt otherwise.Mon Jan 01, 2007

Have you even looked back over the CSDB article to see what their other recommendations were, besides EERS that could possible apply? One thing it sounded like they tried doing with the original recommendations from the first PSG was 'permissive flow limitation' - allowing some obstruction to persist and thus avoiding the worsening of control dysfunction, but you never gave it a chance. You pushed that you needed the EERS and higher pressure- "Strategies include using the lowest pressure that allows reasonable control, avoiding modalities that destabilize (continuous and bilevel pressure may be less or more effective in individual patients; automatic continuous pressure machines should be avoided)"