Non Vented Mask - Periodic Breathing Disorder - Anyone Else?

[dsm]

One of the questions I can answer for you is about the two different machines. The ResMed Adapt SV and the Respironics BiPAP SV. They are both 'servo ventilator' machines designed to treat conditions like yours. (Too bad it so long to get your periodic breathing recognized). As described to me, the Adapt SV machine tries to enforce a constant tidal volume by aggresively controlling pressure, on a breath-by-breath basis. The BiPAP SV machine, which seems more common here, is a little less aggressive, but can still quickly adapt to changes in your breathing. Both of these machines will attempt to 'jumpstart' breathing when you stop breathing; it is specifically for central apnea issues and periodic breathing.

The BiPAP SV has a lot more fine tuning 'handles', and is a newer machine design. But some people find they like how the Adapt SV feels. The Adapt SV is a fairly old design, and requires an odd power supply voltage and an older (but still useful) computer interface.

Users of both of these machines report that they really help them.

Just wanted to add some extra info

Both machines go back to approx 2000-2002 (development was actually well underway prior to 2000). The Vpap Adapt SV started out as the Sullivan CS, then the Resmed CS2. The Bipap Auto SV started out as the HeartPap.

Both machines have had upgrades over the years but it wasn't until (either 2007 or 2008) that FDA approval was granted for general use. I believe that prior to FDA approval the machines were being used in trials in the USA as well as being sold in some countries outside the USA.

In late 2009 the Bipap AutoSV had an upgrade that added auto titration to the epap pressure - designed to adjust for OSA events - I understand that the algorithms perfected in the Bipap Auto (with Biflex) machine (a bilevel auto) were what was added to the SV algorithms to come up with the new machine now called the Bipap AutoSV Advanced. The BiFlex exhalation relief was also added.

In 2007 (or 2008) the Resmed Vpap Adapt SV had an upgrade that added the ability to record AHI (HI & AI data). This was not available on the 1st model, only: rate, minute ventilation, and volume data.

The main difference between the machines has to do with their targets. The Vpap Adapt SV targets 90% of previous volume tracked in a 3 min window. The Bipap Auto SV tracks Average Peak Flow tracked in a 4 min window.

Both track breathing rate - the Adapt SV does this automatically. The Bipap SV can do it automatically or can be set to track rate to a fixed value.

Both are very capable machines.

DSM

Here are some pics & links & more detail of the early SV models ...
viewtopic.php?f=1&t=46681&st=0&sk=t&sd= ... ap#p419693

[phorts]

Thank you Timberline for that information, if it happens that i need an ASV machine, it's good to know what the options are out there. I generally spend hours and days before making a decision (took me 3 months to decide on my HDTV, lol). So thanks for your breakdown.

Thank you DSM, it's clear you are an expert here (i dunno, maybe the 6000 posts gave it away..lol), and so your insight is most helpful. Thank you.

I had a question specific for you. Your sig says that you use the Vpap Adapt SV now. Do you have a link that describes your history? I'm curious why you started on an AVS machine.

My other question is more general. After reading your posts and their associated links, it appears there are a few different types of periodic breathing and CSA, and a few different potential treatments. What i dont understand quite yet is what determines the type of machine that is used in the treatment? I seem to be finding conflicting information like, "APAP should not be used" and that CPAP can actually worsen CSA. So is the AVS the only type of machine that can treat CSA?

I think my dr will be setting me up w/ a standard CPAP (but will trial other machines throughout the night) and will just be adding extra tubing to increase the rebreathing of CO2. But i think he's doing this because he knows that my insurance will not cover the Adapt SV (or very little of it).

Anyways, i want the best treatment available, not the "cheap" version. So understanding the fundemental differences is key to me. If the "cheaper" version works, just as well or better, then great, but at this point i dont want to just "Accept" a treatment protocol without fully understand the options.

Maybe it's just not sinking in, but i think it's the different terminilogy and classifications that's confusing things, along with the contradicting information aobut the treatments.

Thanks for any insight as always or pointing me in the right direction of som emore clearer or "dumbed down" epxplaination.

keith

[dsm]

Keith,

Let me start by saying that I am in no way any kind of expert on OSA/CA - I have though put a lot of effort into looking at the various machine types & how they work in the distant hope that understanding exactly what a machine does, may give me some insights into what they are trying to cure - very much a round a bout way of learning.

We have regulars here with considerable expertise in the medical aspects of OSA & CA. The best I can ever offer is my interpretation of what I think happens in particular circumstances. It is important that you understand that I am willing to offer my understandings & interpretations but that these are not always right when it comes to medical interpretations. But, I am not frightened to explore aspects of the therapy.

Very briefly, what led me to ASV type machines was my having a lack of progress when I started with cpap & apap. After ony 5 months on 1st cpap then auto, I got pretty desperate & tried several brands of bilevel then started to see light at the end of the tunnel. I had looked into how ASV machines worked & concluded (rightly or wrongly) the the principle of their operation looked such a natural progression from cpap itself. I had been using bilevels with timed mode & was getting by comfortably but my wife repeatedly would say to me - "you seem to be fighting the machine". She said I would just slowly stop breathing & the machine would whine & then air would leak & she would push me to breathe again. There was rarely any snoring involed. After 9 months or so on bilevels I was starting to feel that cloudiness in thinking plus feel the tiredness during the day.

Then I was able to buy a Bipap Auto SV at a good price. From the day I started using it I loved it - the sleep I was getting was so sound I called the box my 'dream machine'. I then managed to get a Vpap Adapt SV at a good price. The way I would describe my experience with the Vpap Adapt SV machine is of the two SV machines, that it forced me to change the way I breathe at night. For 2 months on & off I would use it then get very frustrated with it & revert to the Bipap Auto SV which was always very easy to use. after 3 or so months I got a better mask & then found I could work with the Vpap Auto SV. I have been on these two SV machines for just under 2 years and am fitter & healthier & have lost a lot of weight (am around 88KG at the moment) and am able to sustain it. My confidence has returned & so has my belief that ASV was the best therapy for me. I can't really explain why in therapy terms, I can only point to my state of health & fitness.

One other thing I did from the start, was to buy lots of cheap machines (before Yahoo Auctions dropped out) & along with the newer ones I pulled them all apart & being an engineer with an in-depth electronics background, felt I was able to see how the machines were designed and had evolved from the early 1990s models through to the very sophisticated machines of today. Again I was working on the belief that if I looked at what they did it may help me understand what they were trying to cure.

*************************

I am game to offer some thoughts on the different uses a Bipap Auto SV can be put to but there are others here who can provide more authoritative info on this that I can. Again I am in no way any kind of expert here & on this topic.

The different types of Periodic Breathing appear to be between PB related to heart problems and PB related to blood CO2 issues where respiratory control failures other than heart problems, are responsible. The blood CO2 complications appear to divide into several sub- complications.

The basics elements as I see them (rather simplistically) include ...
- chemoreceptors in the brain that monitor the blood CO2 levels in the blood ( http://en.wikipedia.org/wiki/Chemosensor )
- gas exchange in the lungs where the lungs take in oxygen, transfer it into the blood, & expel CO2
- the heart pumping the oxygenated blood around the body

Considerations
- excess CO2 can lead to disorientation, panic, hyperventilation, convulsions, unconsciousness, and eventually death (hypercapnia- http://en.wikipedia.org/wiki/Hypercapnia )
- too little CO2 in the blood can lead to transient dizziness, visual disturbances, and anxiety plus, A low partial pressure of carbon dioxide in the blood also causes alkalosis (because CO2 is acidic in solution), leading to lowered plasma calcium ions and nerve and muscle excitability. This explains the other common symptoms of hyperventilation —pins and needles, muscle cramps and tetany in the extremities, especially hands and feet. (hypocapnia, http://en.wikipedia.org/wiki/Hypocapnia)

Actions ...
- The rate we breathe at is normally in balance where the blood oxygen is at a healthy level & the CO2 in the blood is also at a
healthy level. The chemoreceptors in the brain will react if the CO2 level goes out side normal ranges.
> If too much CO2 begins to show up the chemoreceptors with initiate faster/deeper breathing in an attempt to 'blow off' the excess CO2
> if too little CO2 is showing the chemoreceptors will signal slower breathing, often ceasing breathing, until the CO2 builds up (often seen a s a central apnea)

Observations on PB (based on the info posted earlier)
If a heart disorder causes slow flow of the blood & there is a lag in the CO2 level being detected at the chemoreceptors, the patient can exhibit the classic form of PB called Cheynes-Stokes Respiration which is characterized by fluctuating cycles of deep/fast breathing followed by slowing & cessation of breathing all in a repeating cycle. The typical time for such a cycle is around 2 minutes. This is triggered by the lag in the chemoreceptors getting the accurate CO2 level in the brain. The Vpap Adapt SV and the Bipap Adapt SV both look for the cyclic fluctuations & attempt typically to adjust pressure, often very quickly, breath-to-breath such that the machines compensate for the weak heart that is the cause of the cyclic breathing.

The above pattern called CSR is due to a lag in the brain getting the correct CO2 blood levels. It can also be caused by "Abnormally elevated chemoreflex sensitivity associated with increased sympathetic activity". This too can trigger CSR.


Another form of PB is "damage to the respiratory control center in the brain that impairs the feedback mechanism for controlling inspiration and respiration" which is explained as causing regular centrals followed by bursts of hyperventilation. Not necessarily in the cyclic pattern seen with typical CSR.

Some of the symptoms described above (see hypercapnia & hypocapnia) are as much side effects from the CO2 imbalance as they are direct effects of an imbalance.

*******************************************

This is as much as I can figure out for now. As said though, I am offering my amateur interpretation of medical matters way outside my expertise. Am hoping I may have succeeded in lifting some of the haze that typically surrounds this topic. I apologize in advance if I have got any bits wrong.

DSM

[phorts]

Thank you kindly again for taking the time to share your knowledge. I realize that you're not an "expert" per se, but i value your input as a longstanding member and someone who is quite obviously a very detail oriented and inquisitive person like myself. I can very much appreciate the method to your madness

SO, understanding the differences of the machines, your history, and the basic nature of this complex disorder, I suppose it's unfair to ask which machine you prefer. However, i would still like to know which, in your opinion, is the more advanced and therefore (hypothetically speaking) the most beneficial to a wider array of complications. Meaning, which machine, should i choose to purchase one, would likely provide the most complete array of therapy options depending on the issue(s) that ail me?

I assume either of these can be set to straight CPAP, BiPAP or APAP? Maybe that's a bold assumption.

THe other consideration is, i'm a stat junky. So, ideally, i would have a machine that would provide me with the most detailed data possible so that i can monitor my therapy and adjust as necessary with the need to involve doctors and sleep studies and the like.


One last thing about the 2 potential therapy methods i'm being considered for. Have i got this right?

1. added "dead space" for increased Co2 inhalation

a. machine independent? (CPAP, APAP, BiPAP or ASV)
b. attempts to reduce or eliminate central aplneas by providing a higher level of Co2 in the blood thus negating the signal from the brain to (wherever) to stop breathing.


or

2. ASV machine - attempts to help the patient breath so as to keep a regular breathing pattern and thus a healthy amount of co2 in blood so as to eliminate centrals.


Do i have that right? If so, which is, in your estimation, the more desirable approach both for effecitive treatment of the therapy and long term results?


Thanks for any and all help!

i'm stillw aiting for a call back from my doctor before tonights sleep study.


PS - Can i request a full printout or readout or file from my doctor that has all of my polysomonogram data tha twas captured? I dont just want the overview, i want the actual Raw Data. Can i request that? If so, what should i ask for and what ?

[SleepingUgly]

PS - Can i request a full printout or readout or file from my doctor that has all of my polysomonogram data tha twas captured? I dont just want the overview, i want the actual Raw Data. Can i request that? If so, what should i ask for and what ?

Yes. Tell them you want the sleep study on CD and clarify that you mean the actual data/graphs, not just a report.

[phorts]

Ok, cool. Probably a question for another topic, but what type of form does the data come in and can it be read by standard applications (.pdf, .doc, etc?) or do i need special software to read it?

I'm such a nerd man, which i'm sure most of us nowadays are... i just dont trust everything to subjective response..i wanna know what's UP for REAL.

[BleepingBeauty]

Thank you everyone for your prompt and insightful responses. I have read through everything and even the included links and feel I have a little better understanding of what I may be dealing with. I have responded to each of your posts individually as I would like to pick your brains about this stuff. So, thanks again and hopefully I can get some relief and someone in the future will benefit from this thread.

Bleeping:
1. You said your diagnosis is in your "Signature" line. What did you mean by that? I remember the doc saying i have mixed apnea and when he zoomed in close he could see that my breathing would flatten out, then i would have no effort for a period of time (not sure how long maybe 10 seconds or so?), followed by hyperventilation (or hypo whichever one means to breath out heavy and fast) and an arousal. There wasnt a RIDICULOUS amount of these events but there was a siginificant amount to be concerned about he said

Hi, Keith. The "signature line" appears at the bottom of each of my posts, under the list of equipment I use.

2. Your post suggests you have a Resmed Adapt SV, but your signature says you have a BiPAP Auto SV. Are these the same type of machine just different manufacturers?

Yes, same type of machine (but different algorithms). I have the Respironics BiPAP Auto SV. (I would have purchased a ResMed Adapt SV if I'd found that model first. I just wanted to try ASV treatment to see if it worked better for me than CPAP or APAP.) As it turned out, I'm glad I got the Respironics model, as I already have the software and card reader for it.

3. So you had no luck with APAP, did you try CPAP? What was your luck with that? My first trial was with CPAP and i didnt even give it a REAL try as i couldnt tolerate the mask and was really just doing it to get the surgery. The second trial was with the APAP and i often found myself waking up to the thing blowing a hurricane in my face. Even when i was able to keep the mask on all night, i felt like CRAP (worse than usual) the next day. I'm curious, what made you go back for another sleep study and what gave them the impression that the Adapt SV machine would help. Did they not see during the titration of the APAP that your breathing wasnt stable and that you were still having fragmented sleep?

Yes, I've been on fixed CPAP pressure from the beginning. I only tried APAP (with a tight range of various pressures) last month, to see if I could even handle the changing pressure. (Happy to find that I could.)

My history, in a nutshell:

Diagnosed in 11/07 (two studies) by the Medical Director at the sleep lab. Put on CPAP at 12cms. Found a sleep doc to manage my treatment. Complained to him over the course of the 16 months I was under his care, resulting in him ordering four APAP trials and two additional sleep studies (done in his lab, of course - $$$). My pressure was changed from 12 to 10 to 14, and then back to 12 again. My therapy was still not effective, but I had no data to verify that.

Joined this forum in April of last year and began my xPAP education. The experienced vets here looked at my sleep studies and mentioned ASV might be what I need.

Found a new sleep doc in May. Asked her about the ASV, but she doesn't think it's "necessary" in my case. I asked for an ASV trial or titration. Had my fifth sleep study, which was NOT done on an ASV, as I thought it would be. No change to my therapy, except the addition of supplemental O2 (I live at high altitude).

Bought myself an M Series APAP on CL last June, just so I could have data. New doc wasn't interested in any of it. So I just monitored it myself. In the meantime, I was searching CL for an ASV (just so I could try the damned thing!), and finally found my new machine a couple of weeks ago. So far, it's working well for me.

So neither of my sleep docs even considered an ASV in my case and, as with every other aspect of this therapy, this forum has been far more helpful to me than any sleep professional I've encountered.

Best of luck with your study tonight!

(And sorry for the delayed response - serious storms here in AZ, resulting in no internet connection yesterday and no power last night.)

Ok, cool. Probably a question for another topic, but what type of form does the data come in and can it be read by standard applications (.pdf, .doc, etc?) or do i need special software to read it?

I'm such a nerd man, which i'm sure most of us nowadays are... i just dont trust everything to subjective response..i wanna know what's UP for REAL.

Just saw this, as I was about to post the above. There's a link to some of my data reports from my new machine in my first response in this thread, so you can see what the reports look like. Others who use the ResMed Adapt SV may be able to direct you to examples of the reports those machines produce.

For the Respironics machine, you'll need either EncoreViewer or EncorePro software to read the data card, and a compatible card reader. I think the ResMed software is called ResScan, but don't quote me on that, as I'm nowhere near familiar with ResMed machines.

[dsm]

Thank you kindly again for taking the time to share your knowledge. I realize that you're not an "expert" per se, but i value your input as a longstanding member and someone who is quite obviously a very detail oriented and inquisitive person like myself. I can very much appreciate the method to your madness

SO, understanding the differences of the machines, your history, and the basic nature of this complex disorder, I suppose it's unfair to ask which machine you prefer. However, i would still like to know which, in your opinion, is the more advanced and therefore (hypothetically speaking) the most beneficial to a wider array of complications. Meaning, which machine, should i choose to purchase one, would likely provide the most complete array of therapy options depending on the issue(s) that ail me?

I still like both machines but perhaps use the Vpap Adapt SV more because it is dead quiet. The Bipap Auto SV is quiet but does produce some 'white noise'. In terms of comfort, I love the type of sleep I get with the Bipap Auto SV but whilst I seem to sleep lighter with the Vpap Adapt SV, I consistently feel alert during the daytimes. I would not really want to give up either machine. Also with the new Advanced Bipap Auto SV, I would really like to try the auto-titration it now offers for the epap (breathe out) pressure (this is the same as a normal AUTO cpap)

I assume either of these can be set to straight CPAP, BiPAP or APAP? Maybe that's a bold assumption.

The Bipap Auto SV has many modes of operation whereas the Vpap Auto SV is a 'set & forget' type machine with very few settings to adjust (i.e. epap & ps gap). There is little experimenting one can do with a Vpap Adapt SV.
The new Biap Auto SV advanced model can be set to CPAP, AUTO CPAP, BIPAP, BIPAP with BiFlex, Bipap Timed Mode, Bipap Auto-Timed (tracks breathing rate & seeks to maintain a target), Cpap with ASV, Bipap with ASV, etc:. So it can be deployed to be set for a lot more patient scenarios. I do believe though, that from a user perspecive, *we* mostly want set & forget & perhaps just tweak the epap/ipap pressures occasionaly.

THe other consideration is, i'm a stat junky. So, ideally, i would have a machine that would provide me with the most detailed data possible so that i can monitor my therapy and adjust as necessary with the need to involve doctors and sleep studies and the like.

Both machines provide comprehensive data. From a clinical POV, the ResScan data is more granular & allows deep diving into the detail but few people really do much of that (let alone the RTs & Docs - Serious RTs & Docs are likely to prefer fine grained data when they are dealing with complex cases.


One last thing about the 2 potential therapy methods i'm being considered for. Have i got this right?

1. added "dead space" for increased Co2 inhalation
yes

a. machine independent? (CPAP, APAP, BiPAP or ASV)
Yes, but if the patient has obvious centrals or Mixed Apneas or Complex Apnea, then a Bilevel or ASV is probably the better choice

b. attempts to reduce or eliminate central apneas by providing a higher level of Co2 in the blood thus negating the signal from the brain to (wherever) to stop breathing.
I believe this is the intention. If the extra deadspace works & the tendancy to having centrals goes away, then any machine is likely to be ok providing as mentioned above, there are no other complexities


or

2. ASV machine - attempts to help the patient breath so as to keep a regular breathing pattern and thus a healthy amount of co2 in blood so as to eliminate centrals.
Even an ASV can require a non-vented mask if the patient has resipiratory control problems as outlined in earlier posts.

Do i have that right? If so, which is, in your estimation, the more desirable approach both for effecitive treatment of the therapy and long term results?

I *am* very biased & would always lean towards bilevel or ASV

Thanks for any and all help!

i'm stillw aiting for a call back from my doctor before tonights sleep study.


PS - Can i request a full printout or readout or file from my doctor that has all of my polysomonogram data tha twas captured? I dont just want the overview, i want the actual Raw Data. Can i request that? If so, what should i ask for and what ?

I believe you can. - Good luck with all this. DSM

[phorts]

Thanks again dsm. Those studies where the increased co2 levels in the ambient air in the room cured peoples centrals is pretty fascinating. But since I have an element of osa as well (andsince I'm sure my fiance would not benefit nor appreciate from that situation) tjat some form of xpap therapy is the best option for me.

Ill update this thread tomorrow with my subjective resilts from tonights study.

[timbalionguy]

Phorts, good luck on your sleep study tonight. I hope that it will shed some new light on your situation.

DSM, now I know why we seem so much alike. We are both engineers!

I, too very much want to try an ASV, probably the Respironics first. My therapy varies over such a wide range despite attention to mask leaks, etc. that I think my current machine isn't 'smart' enough to adjust to what is going on.

[phorts]

Thank you. I' m lying here in this jail cell of a room waiting to get jacked in. I notice they have both the adapt sv and bipap auto sv next to the bed. There's literally a sink in the room and tiled floor. I think this used to be the custodian room.
Oh well they all look the same with ur eyes closed.

G'night!

[timbalionguy]

Thank you. I' m lying here in this jail cell of a room waiting to get jacked in.

G'night!

Just pretend you are in the 'Matrix' after 'jacking in'

Tim Stoffel

[dsm]

Thank you. I' m lying here in this jail cell of a room waiting to get jacked in. I notice they have both the adapt sv and bipap auto sv next to the bed. There's literally a sink in the room and tiled floor. I think this used to be the custodian room.
Oh well they all look the same with ur eyes closed.

G'night!

Great environment to 'rest-in-peace'

Have a good night - lie back & enjoy (if that is possible)

DSM

[dsm]

Phorts, good luck on your sleep study tonight. I hope that it will shed some new light on your situation.

DSM, now I know why we seem so much alike. We are both engineers!

I, too very much want to try an ASV, probably the Respironics first. My therapy varies over such a wide range despite attention to mask leaks, etc. that I think my current machine isn't 'smart' enough to adjust to what is going on.

Either ASV is going to be ok but, the Vpap Adapt SV can take a bit more adjusting to & is really leak intolerant. If you have a good nasal or F/F mask & don't have much difficulty with leak management it works very well.

The Bipap Auto SV though, has so many options for experimenting with if that is something you want to do.

Re engineering - I have done a wide variety of different engineering from early days doing toolmaking (lathes, milling, drilling, boring & shaping) to electronics & have been at different times a transmitter (high power) technitian, a receiving station technitian then a microwave link technitian then a radar engineer. Later became a mainframe computer engineer (IBM) then a software engineer(IBM), later a systems engineer(IBM) then a software researcher - today am an IT architect.

These machines are very much like the different technologies worked on over the years & are thus not difficult to figure out internally.

What line were you into ?

Cheers

DSM

[Muffy]

If you decide to search for an ASV you can afford, just know that they're not easy to come by on sites like CL. But if you can get a prescription, you'll be able to buy one on http://www.cpapauction.com (where they show up a lot more often than they do on CL) or another online medical supplier who has a gently used unit for sale at a decent price.

Oooh, there's one now:

http://www.cpapauction.com/auction-list ... idity.html

Muffy

I got an email from the guy selling this thing who said the actual hours used is 220 instead of 9 (musta been looking at the wrong thing), but ya gotta figure that's still a toddler in machine-years.

Certainly the steal of the century if it goes for 200 bucks.

Muffy