BIPAP AUTO-SV SETTINGS HELP

[dsm]

Oximeter showed good numbers throughout the day when I had one on for a day so I don't think that is the issue. Blood sugar levels OK too. I do know that I do not breath all of the time during the day. Kind of like I just forget to do it, or daytime apnea. Doesn't appear to be often though, but who knows - not something you can keep track of because if you try to do that you will be sure to breath.

I am interested in anyone's thoughts & comments on the impact of vary blood sugar levels during the day.

One gotcha I have to grapple with just lately is that old falling asleep in meetings in the middle of the day syndrome.
It has started as we have come into warm weather here.

To CROWPAT, are going into winter where you are & was wondering how you see such changes from one season to another affecting you ?.

DSM

[JohnBFisher]

... I am interested in anyone's thoughts & comments on the impact of vary blood sugar levels during the day. ...

dsm, that is one that I can unfortunately answer. During an all day business meeting, one of the quickest ways to knock folks out for an afternoon meeting is to have lots of carbohydrates in the lunch meal. Guaranteed half the audience will be falling asleep after lunch. The proverbial spread of pizza is a great way to do it. Or a nice heaping serving of pasta. Bingo!

In fact, many people (not just diabetics) can be very sensitive to carbohydrates early in the day. It's not until we get active and have a higher metabolism later in the day that we can tolerate higher levels of carbohydrates.

Of course someone that has diabetes or is "pre-diabetic" needs to watch those carbohydrates even more closely. So, more veggies and proteing and fewer carbohydrates can help. Boring, but it helps.

[CROWPAT]

DSM - I have never noticed any seasonal changes in therapy other than using the Aussie hose when it gets really cold here in Virginia.

[dsm]

This is a brief summary of the thread & of CROWPATs details thus far gathered.

I guess the next step will be to talk through the data if any talk is needed & perhaps
then review the suggestions for machine adjustments.

DSM
*****************************************************************************************************

Using Bipap Auto SV for 2 years - normal settings of Epap=12 IpapMin=14 IpapMax=22 - Av peak Ipap 15.7 - Av RR 14
Typical tidal volume around the 550 mark

- has experimented with RR setting from Auto to Fixed(12) & noted Pat Trig Breaths drop to 85% & bad sleep)
- feels sleep just before waking is when problems occur, breathing not as smooth
(JBF: Comments on experiencing similar)
(SWS: Mentions morning as REM intensive & prone to more obstructions)
(DSM: Self also wondering if this is REM effect - I have noticed same with my own sleep )

Discussion shifts to AUTO vs Manual rate & what to set & the importance of Insp time
(SWS: Offers suggestion that Insp time being used may be far too long)
(Banned: Offers AUTO vs Manual RR observations from using similar machine)

Debate follows on significance of some settings

Issue of the importance of Risetime gets discussed
(SWS: highligts the reduced V_(T) that occurs as RT is lengthened - also points out the WOB (Work of Breathing is increased)

SWS suggests a range of steps to try to see what might improve the use of the machine

DSM offers a set of questions feedback is that CROWPAT ...

- Age 64
- Weight 250 lbs (gained 20 of them in past 2 years)
- Height 6ft 1in tall
- General health = Heathy
- Busy work life but mainly desk work
- Stress & Anxiety said to be normal (for a busy working man)
- Exercise (target 3-5 Kms / day)
- No known lung issues (smokes cigars but this doesn't involve breathing the smoke into lungs)
- No serious heart issues, but, mentioned PAROXYSMAL SUPRAVENTRICULAR ARRHYTHMIA (under regular medication)
http://en.wikipedia.org/wiki/Supraventr ... achycardia


NOTES
- AHI averaging about 2.0 (which on the Bipap AutoSV can mean 1 HI & 1 AI event all night)
- Despite otherwise good AHI data (2.0 is pretty good) - grappling with tiredness bouts that start 1 hr or so after waking.

#2 Updated from Pat's additional post

[CROWPAT]

This is a brief summary of the thread & of CROWPATs details thus far gathered.

I guess the next step will be to talk through the data if any talk is needed & perhaps
then review the suggestions for machine adjustments.

DSM
*****************************************************************************************************

Using Bipap Auto SV for 2 years - normal settings of Epap=12 IpapMin=14 IpapMax=22 - Av peak Ipap 15.7 - Av RR 14
Typical tidal volume around the 550 mark

- has experimented with RR setting from Auto to Fixed(12) & noted Pat Trig Breaths drop to 85% & bad sleep)
- feels sleep just before waking is when problems occur, breathing not as smooth
(JBF: Comments on experiencing similar)
(SWS: Mentions morning as REM intensive & prone to more obstructions)
(DSM: Self also wondering if this is REM effect - I have noticed same with my own sleep )

Discussion shifts to AUTO vs Manual rate & what to set & the importance of Insp time
(SWS: Offers suggestion that Insp time being used may be far too long)
(Banned: Offers AUTO vs Manual RR observations from using similar machine)

Debate follows on significance of some settings

Issue of the importance of Risetime gets discussed
(SWS: highligts the reduced V_(T) that occurs as RT is lengthened - also points out the WOB (Work of Breathing is increased)

SWS suggests a range of steps to try to see what might improve the use of the machine

DSM offers a set of questions feedback is that CROWPAT ...

- Age 64
- Weight 250 lbs (gained 20 of them in recent months)
- Height 6ft 1in tall
- General health = Heathy
- Busy work life but mainly desk work
- Stress & Anxiety said to be normal (for a busy working man)
- Exercise (target 3-5 Miles / day)
- No known lung issues (smokes cigars but this doesn't involve breathing the smoke into lungs)
- No serious heart issues, but, mentioned PAROXYSMAL SUPRAVENTRICULAR ARRHYTHMIA
http://en.wikipedia.org/wiki/Supraventr ... achycardia


NOTES
- AHI averaging about 2.0 (which on the Bipap AutoSV can mean 1 HI & 1 AI event all night)
- Despite otherwise good AHI data (2.0 is pretty good) - grappling with tiredness bouts that start 1 hr or so after waking.

Pat here with a few edits.
Exercise walking 2-3 km per day.
Superventricular arrythmia is a non-life threatening aberation of nerve impulses sent to the ventricle of the heart wherein multiple beats appear so close together that the patient feels like he is skipping one or more heart beats. My cardiologist says that no one knows why this occurs. I am on medication that controls its occurence. It in no way limits activities of any kind. I accept it as is and don't worry about it much anymore.
Weight change is over the last 2 years versus 2 months.
I do much volunteer work that requires physical activity in machine maintenance and construction.

I am absolutely not nitpicking, but want you all to have the facts correct to help you help me.

Tonight I am going back to 12/14-22, Auto, 5 until I hear other recommendations.

[dsm]

Pat
Have corrected the points raised.
Can you remind me what mask you are currently using ?

Also how do you get by regarding masl leaks - IIRC your charts reflect normal leak rate ?

Tks

DSM

[CROWPAT]

Quattro. Used to use UltraMirage but switched when the Quattro came out. Leaks are very low at 36 or so when I use the medium and 40 or so when I use the large. No idea why the two have different leak rates. The large is more comfortable for me, but AHI of 1 is not common with it. I average AHI of 2 over long periods (months) with either of them. Virtually no large leaks ever with either of them if I do my part.

[dsm]

... I am interested in anyone's thoughts & comments on the impact of vary blood sugar levels during the day. ...

dsm, that is one that I can unfortunately answer. During an all day business meeting, one of the quickest ways to knock folks out for an afternoon meeting is to have lots of carbohydrates in the lunch meal. Guaranteed half the audience will be falling asleep after lunch. The proverbial spread of pizza is a great way to do it. Or a nice heaping serving of pasta. Bingo!

In fact, many people (not just diabetics) can be very sensitive to carbohydrates early in the day. It's not until we get active and have a higher metabolism later in the day that we can tolerate higher levels of carbohydrates.

Of course someone that has diabetes or is "pre-diabetic" needs to watch those carbohydrates even more closely. So, more veggies and proteing and fewer carbohydrates can help. Boring, but it helps.

John,

You may have answered my current challenge - I have noted that the days the meeting tiredness hits seem to coincide with a recent habit I developed for buying a bacon filled sandwich from the cafeteria at work at around 7:30am. Might have to give that up for awhile to see if indeed it is the trigger. I hadn't made the connection between it as carbohydrates & the midday effect. Had been thinking it was a harmless thing because I had cycled to work beforehand & was only looking at it from the calorific perspective.



DSM

[dsm]

Twilight zone here again so will be offline for next 8 hrs.

But, the questions that I have in regard to the info we have are ...

1) Is there evidence of other factors causing Pat's daytime tiredness ?
If yes then what are the possibilities / probabilities
If no, then lets look at the therapy

2) Is the machine doing a reasonable job ?
If yes then what minor changes should Pat try (as per several already suggested by SWS)
If no, then what other therapy might do better ?

DSM

#2 corrected 2nd yes/no Q

[-SWS]

Very good questions. I have yet to suggest a more exhaustive series of pressure experiments. I am admittedly reluctant to do so, without CROWPAT's doctor in the loop---or at least explicit advanced approval from the doctor in light of this:

PAROXYMALSUPERVENTRICULAR ARYTHMIA

CROWPAT, the pressure experiments I would propose entail acquiring a fixed-pressure baseline after months of CSDB/CompSAS biological adaptation, exploring a larger constant PS value, and even exploring a potentially less disruptive/intrusive backup rate. If it turns out that you are eventually interested in running any of those BiPAP autoSV experiments, then I would have to insist that your doctor be in the loop.

Also, I'd like to reintroduce those physiologic contraindication factors that can make arbitrary SV pressure adjustments potentially risky:

Patients without a spontaneous respiratory drive
• Existing respiratory failure (failure to treat; risk of increased work of breathing due either to incomplete reversal of
upper airway obstruction or to breathing at high lung volume, leading to worsening respiratory failure)
• Pneumothorax or pneumomediastinum
• Emphysematous bullae or a past history of pneumothorax (risk of pneumothorax)
• Acute decompensated cardiac failure or hypotension, particularly if associated with intravascular volume depletion
(risk of further hypotension or reduction in cardiac output)
• Massive epistaxis or previous history of massive epistaxis (risk of recurrence)
• Pneumoencephalus, recent trauma or surgery (e.g., pituitary or nasal) that may have produced cranio-
nasopharyngeal fistula (risk of entry of air or other material into the cranial cavity)
8 Acute sinusitis, otitis media, or perforated ear drum
• Acute or unstable cardiac failure
• Nocturnal or resting angina (risk of infarction or arrhythmias)
• Unstable arrhythmias
• Severely obtunded or heavily sedated patients
• At risk for aspiration of gastric contents
• Impaired ability to clear secretions
If patients are dehydrated or volume depleted, or have persistent atrial fibrillation, their cardiac filling pressures may be
low. In these cases, as with any CPAP or ventilatory support, use of the device may lead to a dangerous reduction in cardiac
output. The device should not be used in patients who are dehydrated or volume depleted, and should be used with extreme
care in patients with atrial fibrillation.

The cardiac factors in particular---either diagnosed or even occult--- can be adversely affected by arbitrary ASV pressure adjustments.

[CROWPAT]

Doctor is not a problem. He supports virtually anything that I try since he can't figure out the problem either.

[-SWS]

Doctor is not a problem. He supports virtually anything that I try since he can't figure out the problem either.

Well, IMO there are a few compelling reasons to explore fixed pressure at this point (EPAP = IPAP_min = IPAP_max). One of those reasons is to find out whether CPAP is a better modality than the BiPAP autoSV algorithm---after what might have turned out to be months of CSDB/CompSAS biological adaptation to PAP. So by temporarily reverting back to CPAP modality, there's an off chance you might discover what is now a marginally better treatment modality for your physiology.

Another compelling reason is to endeavor establishing a new best/least-disruptive fixed pressure as baseline modality upon which ASV's Proportional Assist Ventilation can augment. By attempting to reestablish a new best CPAP pressure, we might also be able to very roughly ascertain: 1) patterns of sustained biological dyscontrol and/or sustained control throughout the night, and specifically 2) to what extent that "hard" early-morning pattern of dyscontrol might have been either assisted or even exacerbated by the BiPAP autoSV algorithm.

If you decide to explore fixed pressure toward: 1) comparing what might be post-adaptation improvement between those two PAP modalities, 2) attempting to establish what might be a more effective base pressure upon which ASV's PAV can augment, and 3) comparing general and early-AM patterns of induced biological control/dyscontrol, then please make sure your doctor is okay with a round of fixed pressure experiments.

[CROWPAT]

Please continue. Doctor is supportive of anything I do with pressures within reason. He was the one who originally put me on CPAP-13.

[-SWS]

Well, while dsm is continuing to work the holistic picture, you might want to set EPAP, IPAP_min, and IPAP_max at your doctor's prescribed pressure setting of 13 cmH2O. We might get a better idea of how your physiology and sleep react to that obstructive-addressing 13 cmH2O after months of opportunity for biological adaptation to PAP therapy.

If any experimental pressure setting seems too disruptive, then feel free to change back to your previously-determined best pressure setting-----even in the middle of the night. If a fixed pressure of 13 cmH2O does not seem too disruptive, then you might want to stay with that pressure for a few nights. The objective of staying with that pressure for several nights would be twofold: 1) a more robust data sample at 13 cmH2O, and 2) a better opportunity to subjectively assess quality of sleep and daytime symptoms while comparing between 13 cmH2O CPAP and your most recent BiPAP autoSV settings.

Depending how well or poorly that 13 cmH2O fixed-pressure data collection works out, you might decide to experimentally tweak the fixed pressure down and/or up for comparison as well. We'll be looking for signs of consistent control/dyscontrol as well as hints of more chaotic breathing dyscontrol in response to the machine.

[CROWPAT]

Thanks for continuing to work with me. I tried both 13/13/13 and 14/14/14 last week with no measurable differences but only for s single night of each per Banned recommendation to try them. Will go with 13/13/13 for several nights to more data and get back to this thread.