Auto SV,who is it for?

[grandpap]

I recently was perscribed a bipap and am currently set to an auto of 18-25cm.The pressure is difficult to deal with and am still having OSAs with NRs.I started at an auto of 10 and 25 and now have slowly moved up to 18 and 25 with somewhat better results.The AHI is running about 10-13 with IAP of 25 and EAP 19-20.
My question is could an SV type unit better treat complex sleep disorders and help lower pressures.Could a more complex ventilator controlling breathing rates treat apneas better? My Bilevel is not doing the job,it doesn't clean up the apneas and seems to generate centrals.

[rested gal]

Wouldn't hurt to ask your doctor what he thinks about giving you a titration on an ASV machine. I'd want a titration with both machines, if possible, since the Respironics BiPAP Auto SV and the ResMed Adapt SV go about their jobs differently. One might suit you better than the other -- if SV treatment is what you actually need.

That would be a good thing to discuss with your doctor -- and hope he's really "up" on adaptive servo ventilation therapy, as well as being "up" on the different approach those two brands use. Many doctors aren't very familiar with how those two machines do their thing...or with everything to do with sleep disordered breathing, especially if it isn't fairly straight-forward Obstructive Sleep Apnea.

[grandpap]

My doc is pretty good sleep doc and has his own clinics.We have good rapport and our discussions are at the advanced levels.I have not approached him with my data yet but I will soon.I am trying to educate myself on other types of ventilators so as to find a better suited machine for my condition.Is the SV more suited for cyclical breathing? Can it(SV) bring complex disorders with deep and shallow breathing more towards normal?

[rested gal]

SV machines are often used nowadays for treating the central apneas associated with "CompSAS" (complex sleep apnea syndrome) as well as for their original purpose... to normalize Cheyne-Stokes Respiration, often associated with Congestive Heart Failure. CSR is a waxing/waning cycle of increasingly deep breaths followed by increasingly shallow breaths ending with a central apnea, then increasingly deep breaths again, and so on.

What you are describing about your sleep disordered breathing sounds like an adapt servo ventilator might help. Dunno. Worth a try, if your doctor ok's it.

[JohnBFisher]

... My doc is pretty good sleep doc and has his own clinics. We have good rapport and our discussions are at the advanced levels. I have not approached him with my data yet but I will soon. I am trying to educate myself on other types of ventilators so as to find a better suited machine for my condition. ...

Someone after my own heart. Knowing your options is a great way to ask the right questions to lead toward effective therapy. An educated patient can frighten some doctors. But the better doctors recognize the patient has the most "skin" in the game, so should be concerned about their conditions and treatment options.

... Is the SV more suited for cyclical breathing? ...

That is one problem they can solve. From the ResMed site:

Unlike conventional sleep-disordered breathing (SDB) therapies such as continuous positive airway pressure (CPAP), adaptive servo-ventilation:

• treats complex sleep apnea syndrome and central sleep apnea
• normalizes breathing, completely suppressing CSA and/or Cheyne-Stokes respiration (CSR)
• improves sleep architecture (the amount of time the patient spends in slow-wave and REM sleep increases).

Peer-reviewed literature shows that adaptive servo-ventilation:

• enhances quality of life for patients with CSA

How does it accomplish this:

The adaptive servo-ventilation algorithm:

• adapts to the patient’s ventilatory needs on a breath-by-breath basis
• automatically calculates a target ventilation (90% of the patient's recent average ventilation)
• adjusts the pressure support to achieve it.

Maximizing patient comfort and compliance

• ensures pressure support is synchronized to the patient's own recent breathing rate and flow pattern
  provides a constant, low level of pressure support.

So, they can help address central sleep apneas (CSA). It helps address periodic / cyclic breathing, it helps address Chyne-Stoke Respiration (CSR). It helps address Complex Sleep Apnea Syndrome (CompSAS). I personally have both obstructive and central sleep apneas. Due to a neurological problem I fail to breathe as I fall asleep and once asleep. No effort is made at all. It's not complex sleep apnea (though it has some similarity to it). To the best of my knowledge, I do not have heart problems at this point - and hope to keep it that way. I just fail to breathe.

Without the SV unit, I do not sleep - or only minimally so. But with my SV unit, I sleep without ANY apneas. None! It's remarkable!

So, in your shoes I would explore a sleep study with an SV unit. But be prepared for a fight by your insurance company. The units are quite expensive. They even cost quite a bit when purchased from an online supplier.

As you can see from my signature, I use a ResMed VPAP Adapt SV unit. It is an older unit than the Respironics unit. As a result, it is a bit more affordable. It works well for me, but does not always work well for everyone. As Rested Gal notes, if you can try it before you buy it, that would be best.

By the way, because I now *require* the SV unit, I changed my Medic Alert "conditions" to include "Requires Ventilator At Night" along with the "Sleep Apnea". My hope is this will help emergency room staff realize that I will need ventilation if I am not conscious.

Here are the pointers to the ResMed and Respironics web pages for their ASV units:

http://www.resmed.com/us/products/vpap_ ... pt-sv.html
http://bipapautosv.respironics.com/
http://bipapautosvadvanced.respironics.com/

It appears the Respironics BiPAP AutoSV Advanced unit also auto titrates the EPAP pressure. That is a new feature to that unit.

... Can it(SV) bring complex disorders with deep and shallow breathing more towards normal? ...

The short answer, yes.

The longer answer is that the ResMed and Respironics units do it slightly differently, but accomplish the same results. The ResMed unit calculates my target ventilation volume. If it notes that I am breathing shallowly, it will increase the pressure to increase my CO2 exchange. When my ventilation kicks back in, it decreases the pressure to make certain it maintains the constant volume. The Respironics unit (on which I titrated) tends to play more of a "follow the leader" game. We all have some pattern to our breathing. One or two deep breaths, followed by some shallower breathing, repeat. Well, I would tend to start to breathe shallowly, then stop all together. Often it was on the deep breath. The Respironics unit would mimic the breath I *should* take. As a result, it seemed to suddenly surge toward a higher pressure. I found that more disruptive than the ResMed approach.

But frankly, either would work well for me. I would get used to the Respironics approach, since I sleep more deeply with either unit than without it.

Hope all that rambling helps.

[grandpap]

Thanks RG and John, I will be scheduling a discussion with my doctor soon.I feel it is imperative that I find a suitable treatment because of a mild heart condition . I would say that the information I have rendered will be persuasive to him(my doc) but the insurance may be a problem.That's "if" I am correct about my sleep issues.I may have to foot the bill on a used machine but if I need it,so be it.It would be money well spent on a very valuable asset,my health.

[montana user]

Thanks RG and John, I will be scheduling a discussion with my doctor soon.I feel it is imperative that I find a suitable treatment because of a mild heart condition . I would say that the information I have rendered will be persuasive to him(my doc) but the insurance may be a problem.That's "if" I am correct about my sleep issues.I may have to foot the bill on a used machine but if I need it,so be it.It would be money well spent on a very valuable asset,my health.

I have used the ASV on numerous Pt's with complex sleep apnea and Central apneas, and the machine works great for these conditions! I have not looked at price lately, but when we first started using them it was a very last option as the cost was (like most new things) ridiculous. Hopefully they have come down in price!! Never hurts to try different options/machines/masks if your not feeling better!

[JohnBFisher]

... I may have to foot the bill on a used machine but if I need it,so be it.It would be money well spent on a very valuable asset,my health.

... I have not looked at price lately, but when we first started using them it was a very last option as the cost was (like most new things) ridiculous. Hopefully they have come down in price!! ...

You can sometimes find them on CPAPaution.com. There are two listed there now. One is (at the moment) very reasonably priced (less than $1,000). I expect the current bid to go higher as the deadline looms. If I had the spare cash I would consider purchasing a unit myself. But we've had a ton of other expenses.

[FeistyWifey]

Just want to thank you for a most needed, timely thread. Very very helpful to us! My husband has all Centrals and is scheduled for a titration on an SV. Your information, John, especially gives me hope that he will not have these exhausting episodes anymore once he's on the proper machine. I stay scared, counting the seconds he's not breathing while I nudge him harder and harder trying to "restart" his breathing. I'm so thankful for your posts. Grandpap, you have the right attitude about your health. Keep doing what you are doing. Best wishes for getting that perfect machine and wonderful, restful sleep!

[dsm]

<snip>

It appears the Respironics BiPAP AutoSV Advanced unit also auto titrates the EPAP pressure. That is a new feature to that unit.
<snip>

John,

As always you have provided excellent points & these are well & clearly stated (a real talent you have ). One point you mention caught my eye & am interested if there is mention of this anywhere (per quote above).

Reason I ask is I had thought the 'Advanced' Bipap Auto SV was named after the 'tank' style model that superceeded the Bipap AutoSV that came in the older Synchrony style case. The 'tank' style allows for a heated humidifier to be attached (the prior model didn't) & it was this aspect that I believed earned it the 'Advanced' label (I posted some stuff on this from the Respironics patents for the machines sometime in Nov).

I believe Respironics have looked at using the auto algorithm to adjust epap in the Bipap AutoSV but don't think they have done so in any current model.

Cheers DSM

[dsm]

Thanks RG and John, I will be scheduling a discussion with my doctor soon.I feel it is imperative that I find a suitable treatment because of a mild heart condition . I would say that the information I have rendered will be persuasive to him(my doc) but the insurance may be a problem.That's "if" I am correct about my sleep issues.I may have to foot the bill on a used machine but if I need it,so be it.It would be money well spent on a very valuable asset,my health.

I have used the ASV on numerous Pt's with complex sleep apnea and Central apneas, and the machine works great for these conditions! I have not looked at price lately, but when we first started using them it was a very last option as the cost was (like most new things) ridiculous. Hopefully they have come down in price!! Never hurts to try different options/machines/masks if your not feeling better!

Just want to say how good it is to have more people posting here who put patients through titrations & esp someone who has employed ASV machines.

The knowledge we pick up here is priceless & this thread is indicative of the high calibre of info being learned & shared among us xPAP users.

Cheers

DSM

[grandpap]

I am sitting here barley able to type and make a coherent statement.I am full of anger and depression.The sleep doctor would not do a study for an asv and said weight loss would be more effective.He said weight loss would lower pressure,apneas and centrals.That I was overreacting and didn't need an asv.That if I insisted that he would write me a perscription for one.
I asked for him to atleast ask the dme to rent me an asv for a short duration home study.I wanted to use the machine to answer the question if asv would help.I got a callback from him and was told rental was 800$ a month out-of-pocket.I asked him if he thougt there was any other treatments for the apeneas,hyponeas,centrals,for the sleepiness all day long and the high pressures of the bilevel.His answer was to lose weight and that I had destroyed too many brain cells(?).
This is the fourth sleep doctor in 20 years and each one seems no better than the last.He knows I am self educated and must feel threatened by that.I was not brash,insistent or uncooperative,I just asked questions.I think he is under the impression that I am an "Internet hypocondriac" meaning that I read it on the net so I must have it.Funny,when I was showing him my data he was the first one to come up with ASV,go figure

[JohnBFisher]

... I believe Respironics have looked at using the auto algorithm to adjust epap in the Bipap AutoSV but don't think they have done so in any current model. ...

That's why I pointed it out. The website is http://bipapautosvadvanced.respironics.com/. It specifically notes:

... Updated algorithms, enhanced by auto EPAP, continually monitor and adjust to changing patient therapy needs ...

This model was not available just a few weeks ago under the USA Product set for Respironics.

[JohnBFisher]

... I am sitting here barley able to type and make a coherent statement. ... The sleep doctor would not do a study for an asv and said weight loss would be more effective.He said weight loss would lower pressure,apneas and centrals.That I was overreacting and didn't need an asv. ...

Arrrgghhh!! You have no idea how well I understand. I went through several neurologist who just told me my symptoms were "psychosomatic". Yeah, right. I just stop breathing in my sleep because I'm making it up. I fail to breathe during the day, because I'm making it up. I have problems with coordination and speaking, because I'm making it up. I have problems with hand eye coordination, because I'm making it up. I have problems tracking moving objects with my eyes, because I'm making it up.

Bull Dinkies!!

It is far more likely that you gained the weight due to the obstructive and central sleep apnea. Many, many people (particularly if CPAP no longer works) tend to use food to (a) stay awake during the day, (b) avoid falling asleep if sleeping is a problem, and (c) to knock themselves out - by having too many carbohydrates.

The result is Type 2 Diabetes and hypertension. Shedding the pounds is NOT possible if the sleep is bad. I was doing a great job of dropping my weight when I suddenly had my sleep fall apart. I had lost 40 pounds (or more). But I've regained most of that ... I am only now starting to drop the weight again.

"Go loose weight" is a bogus answer if you are not sleeping. It just won't happen!

... That if I insisted that he would write me a perscription for one. ...

Oh, how nice. He's doing you quite the favor.

... I asked for him to at least ask the dme to rent me an asv for a short duration home study. I wanted to use the machine to answer the question if asv would help. I got a callback from him and was told rental was 800$ a month out-of-pocket. ...

Take a look at CPAPaution.com. They often have reasonably priced ASV units.

http://www.cpapauction.com/browse/cpap- ... -_sv_.html

... I asked him if he thougt there was any other treatments for the apeneas,hyponeas,centrals,for the sleepiness all day long and the high pressures of the bilevel. His answer was to lose weight and that I had destroyed too many brain cells(?). ...

I can describe him in one word: Idiot! But then I don't really want to insult the true idiots of the world by putting him in their midst!!

... This is the fourth sleep doctor in 20 years and each one seems no better than the last.He knows I am self educated and must feel threatened by that.I was not brash,insistent or uncooperative,I just asked questions.I think he is under the impression that I am an "Internet hypocondriac" meaning that I read it on the net so I must have it. Funny,when I was showing him my data he was the first one to come up with ASV,go figure

You may need to see a board certified neurologist who specializes in sleep medicine. Remember, not every doctor finishes in the top of their class. If your problems tend to just be central apneas, then I personally know the ResMed VPAP Adapt SV unit does a great job. I am certain the Respironics BiPAP AutoSV unit will also work well, but it is more expensive.

Hope that helps.

[dsm]

... I believe Respironics have looked at using the auto algorithm to adjust epap in the Bipap AutoSV but don't think they have done so in any current model. ...

That's why I pointed it out. The website is http://bipapautosvadvanced.respironics.com/. It specifically notes:

... Updated algorithms, enhanced by auto EPAP, continually monitor and adjust to changing patient therapy needs ...

This model was not available just a few weeks ago under the USA Product set for Respironics.

John,

As said your posts are very well explained & informative plus indeed that link clearly explains using the bipap auto algorithm to adjust epap.
I had read it in their patent apps but that never really means it has reached the market. That link says it has!.

That is an interesting advance and is a feather in the cap of Respironics in regard to expanding the capapbility of the Bipap Auto SV. I suspect this announcement will put a dent in sales of the older (current) model I would happily use such a machine to see how well that epap auto titration works. It seems a very logical and sensible advance based on well tried & proven technology.

Great info

DSM