Using a Bipap Auto SV and using a Vpap Adapt SV

[dsm]

Wendy,

Am comfortable that your Centrals are not so serious as to requite SD & I needing malpractice insurance

we are looking for what effect different changes have & can turn back-up rate off momentarily (day or two)
while we look at the data. Your cold is a complication at the moment.

Also, I had to re-read the various posts to recall that CA is an issue for you however the data from your
charts shows a pretty regular self driven breathing pattern (AFAIKT).

You can make the call as to turning back rate back on & perhaps while the cold persists we can err on
the side of caution & reactivate it.

DSM

[Snoredog]

One thing we all need to appreciate is that with such a small gap between epap & ipap, the mechanism for dealing with centrals is all but negated.

To explain ...
The PS mechanism doesn't respond to centrals only to the 4 min Peak Flow Target. The Central mechanism is purely the breathing timing (set from the back-up rate) & probably the reason why the RT set a back-up BPM of 10 - if Wendy drops below 10 BPM then the Central mechanism kicks in but if the epap to ipap gap is a mere 1 CMs or 2 CMs the central mechanism has little pressure to get Wendy breathing again. If Wendy doesn't breath in (due to a central) the PS algorithm sits there waiting until she does, it is not time driven but is flow target driven. The back-up rate is the timing by which the machine on its own flips from epap to ipap but if the pressure isn't enough & the central persists then PS doesn't get activated.

To me a
- 2 CMs gap is the bare minimum epap to ipap gap for a normal user
- 3 CMs is more optimal for normal users
- 4 CMs starts to benefit people with centrals
- above 4 CMs gap is best recommended by an RT & they can set it as high as 8 CMs for serious cases

The actual AI & HI numbers if relatively small (say under 4 or 5) can be acceptable if the centrals are being dealt with & no desats are occurring.

I agree with SD's desire to get Wendy breathing deeper & slower. But, we do need to think about the extent that backup rate is needed.

Cheers

DSM

Doug,

Yes but that is the protocol for that machine it calls for setting backup BPM at 10 when set manually, that is where you set backup when obstructive events are addressed and centrals are present. I believe that is where her doctor last left it. But at this point we are rolling back for a second to improve the obstructive AHI getting obstructive events as low as possible then those other settings will get adjusted to correct settings. I agree they are low,

Normally backup BPM is set -2 below the spontaneous rate. But at this point in the game we are hoping that number comes down even from last night's 17 (dropped by 2 from 19.5 from last night increase to EPAP), so putting backup in "Auto" mode for the time being seems logical. If her spontaneous BPM drops as a result of the changes the Auto mode should automatically handle the back up rate for her within 2-4 breaths, so one less thing to worry about, again following mfg protocol for settings.

I'd like to see her down in the 15 BPM avg. range if possible, from my perspective she is breathing too fast and too shallow exhausting more Co2 in the process which only contributes to centrals showing up. She's on the high end of the normal breathing scale at 19.5, that most likely is due to the asthma, but if her RR can slow down a bit I see that as a good thing towards avoiding her CA threshold.

I also think you are right her EPAP needs to go to 7 then we can increase the PS by moving IPAP Minimum up. IPAP Min was at 8.0 baseline from her doctor when she started (but again, protocol calls for first bringing IPAP Min down to within +1 of EPAP until obstructive or AI is eliminated) or where you want it, then move it up for greater PS as you suggest.

As you know moving EPAP up or down will have a dramatic impact on HI seen and that part is already handled by the machine automatically, that is why HI is nearly always at zero. As you know this machine is manual setup on EPAP like a CPAP, so that is what is happening here manual titration of EPAP until AI is more desirable.

My understanding she is scheduled for another PSG, would be nice for her to have that and find out her settings match what they find in the lab, so these are short term settings anyway. Of course we can't see the centrals, we can only see how much time she is spending in spontaneous breathing mode, if she is staying close to that 99% rate she can't be spending too much in the backup mode (I haven't see her Encore reports, just going by raw data), but I was suspect with the old settings machine was ever switching to backup, appears it does.

But what we don't know is if this machine "probes" on backup rate like it does on other machines, meaning any change seen in the spontaneous usage may have been from the machine probing for back up mode settings. I haven't seen the report to know if that happened. But I think she will be fine in the Auto mode for backup for time being until the EPAP is established as BPM can be a moving target. Once spontaneous settings are found the backup can be switched to manual with better values used.

SO is her drop in spontaneous breathing seen from 99% to 97% a result of the moving/changing IPAP working pressure?

We know that moving pressure too fast can cause that, but I would suspect this machine was designed to compensate for and/or reduce that risk. Last night working IPAP moved from 7.0 cm to 12.8, or a maximum PS of 6.8 cm (i.e. IPAP avg=12.8 -EPAP=6.0 =6.8 PS). Granted that PS of 6.8 came from the machine's Auto algorithm. That drop in spontaneous breathing could have come from that algorithm finding that IPAP pressure. Just sorta following machine protocol established by the mfg and so Wendy understands it as we go.

Again, her numbers are not really that bad, just trying to improve the conditions seen while keeping her centrals at bay or so that she knows she is getting the best therapy she can expect from the machine. If she knows what a particular setting does or doesn't do she'll be able to fine tune her own settings for optimal therapy.

[dsm]

Snoredog,

I agree - we are cautiously (IMHO) exploring some variations & both feel comfortable setting BPM to Auto for a while.

Wendy is an unusual case - her data fluctuates quite a bit.

DSM

[wlo2008]

I wonder why it does that. I always have to be the odd ball. LOL

[wlo2008]

Last night was not a good night to report on. My sleep was chopped up through the night with this cold. I keep ripping my mask off like I did the night before. So I am going to keep these setting till I am over the cold, that way I can really see the true results from them.

[Banned]

dsm,

What does the IPAP/EPAP Drop Time (switch) feel like on a BiPAP Auto SV when you have 6 cmH2O of separation between EPAP and IPAP Min.

On the Adapt SV IPAP/EPAP Drop Time (switch) is silky smooth no matter howe big the EPAP/IPAP Spread.

You recently said, "over the last two years, you discovered a 3 cmH20 spread was optimal to avoid that nasty drop time in Respironics units".

For me the 6 cmH2O spread between EPAP and IPA Min is not a comfort measure.

Is your 3 cmH2O spread between EPAP and IPAP Min a comfort measure for you to avoid the IPAP/EPAP switch, or are those 'prescribed' settings either through a Dr. or self-titration.

Banned

[dsm]

dsm,

What does the IPAP/EPAP Drop Time (switch) feel like on a BiPAP Auto SV when you have 6 cmH2O of separation between EPAP and IPAP Min.

On the Adapt SV IPAP/EPAP Drop Time (switch) is silky smooth no matter howe big the EPAP/IPAP Spread.

You recently said, "over the last two years, you discovered a 3 cmH20 spread was optimal to avoid that nasty drop time in Respironics units".

For me the 6 cmH2O spread between EPAP and IPA Min is not a comfort measure.

Is your 3 cmH2O spread between EPAP and IPAP Min a comfort measure for you to avoid the IPAP/EPAP switch, or are those 'prescribed' settings either through a Dr. or self-titration.

Banned

Banned,

This line doesn't ring any bells with me ???
'You recently said, "over the last two years, you discovered a 3 cmH20 spread was optimal to avoid that nasty drop time in Respironics units".'


I have said these things (your line looks like an amalgam of some varying points I have made) ...

> a gap of 2 CMs is workable - a 3 CMs gap is (based on my own experimentation & manuals published by Resmed) an optpimal gap for normal users of Bilevels - 4 starts to help people with CA & beyond 4 is best set by an RT as big gaps can start to create other problems (such as complex apneas).

> that for me, the Respironics Bipap Pro II & Bipap S/T did have a habit of switching too early from ipap to epap & that there were no adjustments I could find to prevent them doing this. Over time I came to realize that this was due to my recurring nasal constriction & the way those Bipaps sense flow. Other brands of Bilevel did not cause this early flipping problem. But with those particular Bipap models, whenever I breathed through my mouth (with a F/F mask) that early switching didn't happen. Over time I learned to switch breathing as needed - nose - mouth. But, the Bipap Auto SV doesn't seem as intolerant of nasal constriction that the other Bipap models exhibited. This discovery was for me a big break through in liking Respironics Bipap designs. In fact the Bipap Auto SV really surprised me with how much better it is in this area.

> That when I used my PB330 A/C (Puritan Bennett Knightstar bilevel S/T model), It could be set such that the drop from Ipap to epap was 'heavy'.

> That the Vpap III latest versions introduced adjustments to soften rise & fall

> that a risetime of 1 on a Bipap (100ms ) was too fast even for me & that 2 (200ms ) was doable but 3 (300ms ) was pretty good & didn't diminish the flow volume the way a setting of 6 (600ms ) would. The longer the rise time the better it feels but the less air gets delivered in one breathing cycle and so some people were adjusting their risetimes out to 5 & 6 thinking it felt good (which it does) but then wondering why their daytime drowsiness seemed to reappear - due to having reduced the volume of air delivered per breath.

Hope this clarifies the points for you.

DSM

[meltifa]

Well I am hoping I am not to late to get some help on this seeing the thread is quite old. I was diagnosed with
central and obstructive sleep apnea after seven years and 6 sleep studies later (don't ask me why but the very last sleep study revealed this)

I read this thread and felt like I was in advanced calculus for a moment..

Here is my situation. I experience the same exact thing. My Min Vent alarm goes off at 4 a.m every night (deep sleep begins)
I have tried 4 different masks. My prescription is: (epap,epap min, ipap) 13,8,8 I have BPM set to 12

My LPM setting is only at 2 and the alarm still goes off.

I literally just got off the phone with the respiratory company and they said to try again with full face mask and keep LPM set to
2 to see if this fixes.

She told me that you have to adjust the LPM up or down depending on if your pressure goes up and down..

My problem is this:

-The alarm annoying the sh*t out of my wife
-I don't want to shut off the alarm because it is telling me something
-I don't feel refreshed in the morning. It does stop my snoring but if not feeling refreshed I almost feel like
wearing a less evasive mask (nasal only with pillows) and shutting alarm off
-I also wake up and my chest (not heart attack) feels tight or almost like I slept under water all night

Another question. If you increase bipap to 14,9,9 does that increase air flow or decrease

Sorry for all the tangent questions but I am new to this machine and it is very frustrating process after 7 years of marriage on
the couch. I thought this was the light at the end of tunnel but all I have is a snore solution with a built in alarm clock that only goes
off at 4 a.m

[dsm]

Well I am hoping I am not to late to get some help on this seeing the thread is quite old. I was diagnosed with
central and obstructive sleep apnea after seven years and 6 sleep studies later (don't ask me why but the very last sleep study revealed this)

I read this thread and felt like I was in advanced calculus for a moment..

Here is my situation. I experience the same exact thing. My Min Vent alarm goes off at 4 a.m every night (deep sleep begins)
I have tried 4 different masks. My prescription is: (epap,epap min, ipap) 13,8,8 I have BPM set to 12

My LPM setting is only at 2 and the alarm still goes off.

I literally just got off the phone with the respiratory company and they said to try again with full face mask and keep LPM set to
2 to see if this fixes.

She told me that you have to adjust the LPM up or down depending on if your pressure goes up and down..

My problem is this:

-The alarm annoying the sh*t out of my wife
-I don't want to shut off the alarm because it is telling me something
-I don't feel refreshed in the morning. It does stop my snoring but if not feeling refreshed I almost feel like
wearing a less evasive mask (nasal only with pillows) and shutting alarm off
-I also wake up and my chest (not heart attack) feels tight or almost like I slept under water all night

Another question. If you increase bipap to 14,9,9 does that increase air flow or decrease

Sorry for all the tangent questions but I am new to this machine and it is very frustrating process after 7 years of marriage on
the couch. I thought this was the light at the end of tunnel but all I have is a snore solution with a built in alarm clock that only goes
off at 4 a.m

Meltifa,

I just need to get some of your points completely clear rather than assuming I have it right - can you just confirm the following ...

1) You have the Bipap AutoSV machine ? (I am sure this is what you have based on the other settings)
2) Can you clarify what you mean by ' (epap,epap min, ipap) 13,8,8 ' (the Bipap AutoSV in SV mode has settings for - epap, ipap min, ipap max ?)
also ipap is usually going to be set higher than epap but your post implies epap=13 & ipap=8 ?
3) Just confirming your respiratory rate is set as BPM=12 (and not BPM=OFF or BPM=AUTO)
4) You have the LPM (Low Minute Ventilation) alarm set to a setting of 2 (that means it is set to go off if your MV drops below 2 Liters per minute which is quite low - that should not be going off if you are breathing - normal breathing is going to be between 5-10 Liters per minute.

5) You haven't said if the APNEA alarm is set to any value - can you say what setting it shows as (it will be either 0 or some higher number)
6) Do you know if you are prone to leaking air from your mouth (one reason the low LPM alarm might fire off & a very good reason to switch to a F/F mask)

Hopefully we can get to what is causing you your difficulty

Cheers

DSM

[dsm]

Just realised that most people I know who have a Bipap AutoSV get driven mad by that LPM alarm (the machine is supposed to give us a good night's sleep, not wake the household & scare everyone )

At this link look at my 2nd post as it describes my own bad experience with that LPM alarm.
viewtopic.php?f=1&t=30283&start=0

Just set LPM = 0 and that problem will go away.

Cheers

DSM

[wlo2008]

It has been a while sense I have been on. My son was diagnosed with Autism and I have been dealing with his medical issues and mine have been put on hold. But I am still having the same issues. My AHI is setting at 5. But the problem is that is not really acurate. When I look at the data all the Centrals are happening and clustered at the last 3 hours of sleep for some reason. I have been having migraines every day and have not been well at all. So pretty much the last 3 hours the machine is doing my breathing for me. But I have an appointment with my Neuro Doc on the 21st and will be getting a new mask to see if that helps I go in to try on some on the 22nd. And then on the 30th and 31st I go in for my night and day time study. So I will have a busy month on top of all my sons appointments.

[Kiralynx]

My son was diagnosed with Autism and I have been dealing with his medical issues

This is OT for this Forum, but check out a book by Elaine Gottschall called Breaking the Vicious Cycle, and a website at http://www.pecanbread.com.

I've followed the BTVC diet for seven years, and it's literally saved my life. There are more than 3000 parents on the Pecanbread list who are seeing positive results for their children.

[dsm]

That is an interesting website - I have a daughter (now grown up) who was diagnosed at age 24 with Asperger's Syndrome (one of the Autism spectrum disorders).

Probably too late to start changing her diet but the info there is pretty interesting - thanks for that link

DSM

[ThomasMcKean]

It has been a while sense I have been on. My son was diagnosed with Autism and I have been dealing with his medical issues...

I might be able to help you with that...

[dsm]

It has been a while sense I have been on. My son was diagnosed with Autism and I have been dealing with his medical issues...

I might be able to help you with that...

Thomas,

I very much appreciate you supplying that link.

Thanks

DSM