Using a Bipap Auto SV and using a Vpap Adapt SV

[-SWS]

Not sure what you mean by periodic respiratory gain--

Periodic respiratory controller (disorder)

Banned

Gottcha!

Assuming irregular breathing does not entail symptology or pathology, would the SV still help?

Not to confuse perfectly normal irregular breathing that entails no pathology with irregular or dyscontrolled breathing that entails SDB-related pathology. I personally don't think the entire population falls in that latter category. But to answer your question: if perfectly normal irregular breathing results in no pathology, then SV has absolutely nothing broken in physiology to fix.

And if it ain't broke... why risk inducing other problems in an attempt to fix it?

The question at least in my own mind is: how many who are diagnosed with "vanilla OSA" fall in that latter category entailing controller-related pathology? I would personally suspect those people in particular stand to gain benefits from adaptive SV.

[Banned]

if perfectly normal irregular breathing results in no pathology, then SV has absolutely nothing broken in physiology to fix.[/i] And if it ain't broke... why risk inducing other problems in an attempt to fix it?

I can't argue with that, but isn't dsm suggesting his perfectly normal irregular breathing with no pathology still is adequately addressed with the SV and provides him with sounder sleep?

Banned

[danmc]

This is a great thread. I intended to try all the machines available, including the high level "not aimed at osa" machines. After all, I have a lifetime of it to deal with, I might as well explore every avenue. Most people try to talk me out of that idea, I'm not entirely sure why yet.

Cheers to you DSM, for having the courage and fortitude to test the supposition that the high end machines may be an improvement in general or simply suit you, even in the face of the general consensus that they wont.

Cheers also to the intelligent debate contributed by SWS and others - just makes the thread that much more valuable and interesting.

Thanks for sharing DSM.

[Banned]

Cheers to you DSM, for having the courage and fortitude to test the supposition that the high end machines may be an improvement in general or simply suit you, even in the face of the general consensus that they wont.

Cheers also to the intelligent debate contributed by SWS and others - just makes the thread that much more valuable and interesting.

Thanks for sharing DSM.

I couldn't agree with you more! So the final summation is the SV tidied up dsm's 'non-pathological' irregular breathing. An expensive comfort measure, but hey, if it works, go for it. Life's too short to not grab the best sleep you can get!

Banned

[-SWS]

if perfectly normal irregular breathing results in no pathology, then SV has absolutely nothing broken in physiology to fix. And if it ain't broke... why risk inducing other problems in an attempt to fix it?

I can't argue with that, but isn't dsm suggesting his perfectly normal irregular breathing with no pathology still is adequately addressed with the SV and provides him with sounder sleep?

"Sounder sleep" implies something in pathophysiology got fixed. Does it not? Arousals? Cyclic alternating pattern (CAP)? Sleep architecture? Not only are we not measuring exactly what physiologic mechanism gets addressed in real-time in physiology here---but we're also not empirically measuring all the sufficient physiologic markers that might constitute Doug's "sounder sleep".

If we measure but a meager subset of those physiologic markers, and detect slight improvement is say SpO2, can we really say that slight increase in SpO2 was the factor that resulted in Doug's "sounder sleep"? A one or two percent increase in already-sufficient SpO2, for instance, may not yield any gains whatsoever in systems disturbance-oriented pathophysiology (in other words: marginal SpO2 gains only lend promise, but no subjective or even measurable hard guarantees).

If we are so bold as to presume a slight increase in the SpO2 marker alone improves Doug's sleep, we still haven't attributed that slight SpO2 improvement as having resulted from smoothing out obstruction, smoothing out central respiration, or "other" indirect or incidental factors having somehow been addressed in sleep-related physiology.

Regardless, if truly adverse symptomology is removed with treatment, then some undetermined pathology was presumably addressed (even if comfort related). And the fact that Doug has presumably addressed some undetermined pathology does not at all imply that everyone therefore must have some pathology just waiting for that magical panacea known as the SV.

I'm willing to dismiss any placebo possibility for the sole reason of keeping our analytical inquiry both simple and interesting. Psychological factors can influence not only physiologic responses and treatment subjectivity itself, but also methodology selection and data interpretation by the researchers. And that is why researchers religiously try to heed human psychology and, of course, missed control factors with double-blind randomized studies that are submitted for peer review. And even that sophisticated methodology is known to miss the boat. Regardless, any methodology or rationale put forward in this thread is far less controlled and far less factorized IMO.

Makes for great conversation, great opinion formulation, but woefully remiss scientific conclusions IMHO. And on that note I think this is a great thread based on two out of three!

Cheers to all!
.

[-SWS]

Cheers to you DSM, for having the courage and fortitude to test the supposition that the high end machines may be an improvement in general or simply suit you, even in the face of the general consensus that they wont.
-----
Thanks for sharing DSM.

I agree as well! I can't express my gratitude enough to DSM for sharing all that he does!

I couldn't agree with you more! ...hey, if it works, go for it. Life's too short to not grab the best sleep you can get! Banned

And I couldn't agree with you more, Sir Banned! If it works it works! And that alone makes it great!

[danmc]

You are a person of singular reason and logic SWS. I can see that the point of many of your remarks has been to try to distill crucial information from the available data even if it means you run the risk of appearing argumentative. I personally find such an attempt hard work amongst friends, so my hat off to you and others here like you.

It is difficult to draw conclusions safely with small samples. Of course, given the difficulties involved it is a wonder that DSM is able to provide the excellent data that he does - subject, observer and researcher in one, I do not mean to suggest that his effort and results have been anything but inspiring.

The experiment would do well with more data though , more subjects, more resolution.

I would happily purchase a machine myself and add observations - the only thing that stops me is that I am aware that I am a complete novice. I doubt I could offer the kind of skilled observer/patient point of view that DSM has thus far. Also the data would be less valuable given that I am not a long term, stable xpap user. And it might be plain dangerous to embark on such a course as a newcomer. I learn quickly so perhaps not so far off.

I wonder though what kind of useful information you guys might glean from more samples, and how more samples might be put within your reach.

I also wonder, would concurrent eeg and ecg data from DSM be applicable to the ideas that you are crunching? I don't pretend to fully understand some of the deeper concepts you are angling into yet, mostly because I have to stop and look up acronymns a lot..lol.

Anyhow, my point is - what methods could be deployed to help resolve some of the interesting possibilities that you and others have raised?

[dsm]

I am going to put forward what I believe are immutable facts that we can work from then add opinions


IMMUTABLE FACTS SECTION:

1) Primary: Respironics state that the Bipap SV can address OSA using a Bilevel titration (OSA being Obstructive sleep apnea)

2) Secondary: Respironics state that the Bipap SV can address Central Sleep Apnea - using timed mode (as does the Bipap S/T)

3) Secondary: Respironics state that the Bipap SV can normalize Periodic Breathing by applying pressure support (PS) using an algorithm that tracks peak-flow over a 4-min window.

#2 (covers when the Bipap SV is used where the sleeper has no OSA)
4) SV only mode. This is where Epap is set the same as IpapMin. And, IpapMAX gets set higher than IpapMIN. Then the machine is primarily in PS mode. This allows the Timed Mode & PS to normalize Periodic Breathing where the sleeper may have little to no OSA symptoms.


Item 1) covers vanilla OSA and uses a Bilevel titration to set the Epap and Ipap values.

Item 2) covers Centrals and uses Timed Mode to switch from Epap to Ipap if the sleeper stops breathing. The machine assumes OSA is taken care of with a proper bilevel titration.

Item 3) is the new bit and the big bonus and the eye of much contention. What it looks for is waxing and waning of breathing (it does not look at zero airflow, that is the Central Time Mode component) - if airflow drops to zero after exhalation, the Timed Mode kicks in (Epap to Ipap switch). But if airflow (peak volume) drops below the expected target during inspiration, of any breath the machine will raise pressure within that breath. The PS mechanism merely boost the air intake within a breath so as to match the target.

Item 4) Uses Timed Mode and PS to keep the sleeper breathing to a target airflow (Peak Flow).

At this point the Timed Mode & Centrals should be clearly understood. This mechanism has been with us for years.

The Bipap SV machine can be set as a straight Bilevel (s/T) by setting ...
1) Epap (less than IpapMIN)
2) IpapMIN (greater than Epap)
3) IpapMAX = IpapMIN
4) BPM (a fixedrate or AUTO)

The Bipap SV machine can be set as a Servo Ventilator by setting ...
1) Epap (less than IpapMIN)
2) IpapMIN (greater than Epap)
3) IpapMAX = (greater than IpapMIN - thus adding PS)
4) BPM (a fixedrate or AUTO)

The Bipap SV machine can be set to focus on Servo Ventilation by setting ...
1) Epap (equal to IpapMIN)
2) IpapMIN (equal to Epap)
3) IpapMAX = (greater than IpapMIN - thus adding PS)
4) BPM (a fixedrate or AUTO)


OPINION SECTION:

PS is the difference, the magic that the SV introduces. Now if we look at what triggers PS it is when the airflow drops which can be due to any number of normal and abnormal events.

It is arguing about these events that has been driving this thread of late.

SWS very astutely looked at the Patient Triggered Breaths data & using plain math said that this statistic shows that for 68 times each hour, the machine switched from Epap to Ipap because it decided it needed to. But then the speculation disagreement began. DSM says that yes, this machine is tracking my BPM which averages 14 & if I roll over or switch from mouth to nose, my BPM will be impacted & the SV's Timed Mode tracking will kick in - but that is normal. SWS says this is abnormal.

What we need is another pure vanilla OSA person (DANMC ?) to do a night with an SV and to see if he/she achieves 100% patient triggered breaths or gets a result like DSM (approx 99+0.x %). If other pure vanilla people achive similar numbers to DSM then the data reflects a normal nights sleep & DSM is correct. If the other Vanilla OSA sleepers always score better than DSM then SWS is correct but then we would need to work out what causes the difference. DSM might assert that nasal congestion is the only other probability. But if someone else with nasal congestion and vanilla OSA scores like DSM then DSM is correct else there is some other respiratory problem and that I believe is SWS's assertion.

The other issue is what DSM calls smoothing out residual events. If we agree that the airway is correctly held open with Epap, then there are two types of events that can occur that will trip off the SV PS mechanism (we should agree that a central will be managed by the Timed Mode) ...

1) A looming obstruction (hypopnea, flow-limitation) + what can be called a central hypopnea or flow-limitation.

2) Periodic Breathing irregularity (which manifests itself to the machine as a hypop or flow-lim)

Now PS will activate and boost pressure in response to either event - as stated above it samples peak air-flow & if the target flow for a given breath looks like it won't be met the machine boosts pressure to a higher setting than IpapMIN (and up to IpapMAX) & based on how far off target the sleeper is and how many breaths this has been going on for (PS will be increased if the 1st pressure boost (in one breath) didn't bring the sleepers air flow back to the target).

So DSM has stated that based on his observations, he believes PS sorts out residual OSA events (hypopneas and flow-limitations) & does it very well. This has triggered comments from SWS and Rested Gal who appear not to accept this observation. They believe there are other irregularities that are not normal.

That is all for this post & I just want to add that I really do enjoy the challenges SWS & Rested Gal have thrown up, we give each other curry at times but I greatly admire and respect both of them for their wisdom & commitment to matters related to SA & SDB.

I'll give either more curry if I am convinced either is putting forward less that adequate arguments or proofs & I know they will return the flavour

DSM

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CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, bipap, Titration, auto

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CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, bipap, Titration, Hypopnea, auto

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CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, bipap, Titration, Hypopnea, auto

[dsm]

Last night had a successful run with the Adapt SV. I will use it again tonight & drop PSmin to 4.5 CMs.

The chart linked to below is the best off that machine yet. I had attached a Reslink expecting it would include flattening data which would go a long way to explaining what is happening at the times the machine increases pressure (which it did many times - at least double what I would expect from the Bipap SV). The reslink data wasn't there so will look into that.

The leak rate is very acceptable compared to the 3 prior nights on this machine. but I had to tighten the mask and that felt a bit uncomfortable.

Again, sleep seemed to be more shallow than I get from the Bipap SV. But, last night was one of our coldest this year & that may have contributed to more restless sleep. Woke up feeling fine & went for morning 5km jog so am going to use the Vpap Adapt SV again tonight.

As before, it seems that this machine is right on top of any variation in breathing, if I yawn it starts upping pressure straight away !.

http://www.internetage.com/cpapdata/dsm ... 8jun08.pdf


DSM

#2 Reslink - I had without realising it, made the card read-only. Now fixed.

#3 The linked to data is interesting for a particular reason. Up to 5:30 I was nasal breathing (I took a spray of Nasonex & Otrivin before bed). At 5:30 I got up and went for a break & when I returned was only really able to breathe through mouth. The data from that point on is wilder than up to that point.

Also wife has put the kybosh on me using the Vpap again tonight. She said tha although it is a lot quieter my restlessness was worse than any noise from the other machine. So its back to the BipapSV - in a week, wife will be running a training session away for a week so I'll resume testing the Vpap then.

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CPAPopedia Keywords Contained In This Post (Click For Definition): bipap

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CPAPopedia Keywords Contained In This Post (Click For Definition): bipap

[ozij]

A few comments:

99.2% is 99.2% , and the larger the total, the larger the 0.8% is in numbers. But percentage was invented to remind us that a number sometimes has context. And dsm's machine-initiated breaths occurred in a context of self initiated breathing.

dsm makes a very important point, that I would express it like this: Does anyone breathe at a consistent rate that will keep a timed machine from ever initiating any breaths?

We are not machines, our normal healthy breathing patterns may cause any mechanical device to attempt to put our unruly biological responses back on it its mechanical track. Looked at from the opposite side, one may want to ask: what is the breathing pattern that makes physicians prescribe a timed machine?

The machines are can not be trusted to diagnose anything. dsm was diagnosed with OSA - however he has often told us that his typical breathing patterns are anything but the breathing patterns typical of most people (remember his meditation, shallow breathing training, etc.). So the fact that a pattern analysing machine is reacting to his atypical breathing pattern is neither here nor there. An S/T machine would feel the need to initiate breathing for all of us if it were connected to us when we were awake.

We have a number of issues here: breathing is one. Sleep - and what makes it refreshing is another. Oxygenation is a third. The individual's psycho-physiological response to variability - in oxygenation, in pressure transition, in mask comfort - and how those impact his / her sleep is a fourth. And then of course comes the question of what make a persons sleep more refreshing.

Research starts with an attempt to find major trends, and then it discovers individual variability. Penicillin is great it save live, but some people are allergic to it - the may ever die. Nexium is fantastic, yet it gives some people stomach aches - and nobody knows ahead of time who will be in the non-trend group.

Democracy means we let the majority set the law. Statistics and probability help us decide what is right "as a rule". However, we should always remember that "The Median is not the Message".


O.

[rested gal]

ozij, thank you for posting that link:
http://www.edwardtufte.com/tufte/gould

That was beautiful to read, as well as informative.

A keeper.

[dsm]

Ditto to RG's comment

Tks

DSM

[-SWS]

Danmc- thank you, sir, for those comments!

Anyhow, my point is - what methods could be deployed to help resolve some of the interesting possibilities that you and others have raised?

The position that I hope to emphasize most is that sleep science research and especially conclusions are not within the methodological means of message board patients.

The real sleep researchers, with abundant state-of-the-art instrumentation and the scientific method at their disposal, are still essentially at a loss regarding many of the central issues raised in this thread. Many of the best researchers will essentially contend: "We don't know precisely what sleep apnea is."

They then go on to academically debate such topics as severity indicators, physiologic markers, etiologic complexities, interpretive diagnostics, best methods and practices in general, and even the general direction sleep medicine should take.

This message board has a history of anecdotal comparisons and trial-and-error toward genuinely improved therapy. I'm very happy with that, despite the fact that I would personally hope to see everyone at least try to find competent and professional health care (sadly much easier said than done). But again, I'd like to emphasize that sleep science research and especially conclusions are not within our methodological grasp.

Aside from not having adequate technical means toward adequate methodology, we are virtually destined to under-factorize that proposed methodology as well.

What we need is another pure vanilla OSA person (DANMC ?) to do a night with an SV and to see if he/she achieves 100% patient triggered breaths or gets a result like DSM

I would hope that we don't impose amateur methodologies on our fellow patients. My point about 68 backed up breaths per hour is that there is plenty of theoretical room in those late or missed breaths for deteriorated sleep. If I receive 68 backed up breaths per hour with no averted desats or arousals, should that imply everyone who receives 68 backed up breaths per hour entailed the same underlying dynamics and deteriorating factors in physiology?

What if my backed up breaths would have otherwise been frank central apneas? By contrast some hypothetical person's physiology out there will also incur exactly 68 backed up breathes----yet entail only marginally latent breaths having been averted. With this proposed methodology we conceivably have severe central pathology averted at the rate of 68 times per hour, but we also have absolutely no pathology averted with 68 marginally latent breaths backed up per hour. And we also have the complete spectrum of severity gradients in between! All those potential severity gradients at exactly 68 backed up breaths per hour!!! Hence my point about not imposing under-factorized methodology on our friends and fellow patients pursuant message board science.


But your suggestion comes right from the heart, DSM---a heart of gold. That and the fact that you will so amiably tolerate my differences of opinion are what make you a good friend to me. I'm so glad you share here what you do. But I am even more grateful for having made your acquaintance!!!

So the fact that a pattern analysing machine is reacting to his atypical breathing pattern is neither here nor there.

But it's potentially here and it's potentially there!

I appreciate that link as well. Here's an excerpt that I found interesting:

I had encountered a classic example. Attitude clearly matters in fighting cancer. We don't know why (from my old-style materialistic perspective, I suspect that mental states feed back upon the immune system). But match people with the same cancer for age, class, health, socioeconomic status, and, in general, those with positive attitudes, with a strong will and purpose for living, with commitment to struggle, with an active response to aiding their own treatment and not just a passive acceptance of anything doctors say, tend to live longer.

When it comes to health attitude counts! I am personally convinced that hope and optimism are potent medicines. If there is any experiment that we should amateurishly impose on our fellow man, perhaps it is that we should lavish them with good will and hope.


.

[Guest]

The position that I hope to emphasize most is that sleep science research and especially conclusions are not within the grasp or methodological means of message board patients.

I understand your reservations SWS. I don't necessarily agree with that statement however. Rest assured, my plans are not a result of this thread. Before I found this excellent forum I read the documentation for all the available machines and just wondered if there was an implied benefit for vanilla osa. Nothing I have come across thus far has denied that possibility. I had decided to investigate further anyhow. So no one will be imposing anything on me, but I may well add some more interesting observation later, even if it is of little use beyond my own experience.

At any rate, I have significant goals to achieve before I can embark on a similar venture to DSM.

What I was hoping was that you and other bright minds here would consider that perhaps the data that DSM collects might be useful. I was hoping you would all lend your intelligence to developing the methodology in fact. Even if only as an interesting theoretical exercise. As you say, the real researchers are sometimes at a loss so perhaps there is room to improve at every level.

I will equip myself with eeg, ecg, video and sound recording simply because I can. And because more data can't hurt. And its fun. And I want to play around with neural feedback. Don't mistake my enthusiasm for irresponsibility or foolhardiness.

I do have a question though that you may be able to answer. What equipment would an advanced research lab have that you wouldn't also find in a sleep study? MRI I'm guessing. But I cant think offhand what else they might be using.

[danmc]

Hmm I thought I logged in but at 4.44 am, maybe not. That was of course me waffling on above.