ResMed's "failed" trial of ASV machines

Morbius wrote:I think the titration protocols need to looked at closely, specifically if they created a milieu that discouraged venous return (i.e., aggressive EPAP and baseline IPAP (vs. like PSmin = 0)).

I always feel uneasy when I see suggestions from people on the forum of what to change someone's BiPAP pressures to. I think this has been a perfect example. Not even the experts know what's happening yet, so I'm unsure if the public should be changing it (especially when it's not even your machine) I wouldn't set a patients BiPAP machine on anything without consulting a sleep physician.

Just my 2 cents.

Morbius wrote:I think the titration protocols need to looked at closely, specifically if they created a milieu that discouraged venous return (i.e., aggressive EPAP and baseline IPAP (vs. like PSmin = 0)).

Then, look at the NPSG baselines, comp group, etc. to see just what the heck they were trying to prove.

Because if the O2 sats weren't too bad, then what little gain in oxygen levels that would be achieved in ASV would be lost by decreasing the cardiac output (IOWs, even if your oxygen level was a million, it doesn't do any good if that blood is slow getting to the periphery)(and given these guys' EF, it wasn't so hot to begin with).

sleepstar wrote:...I wouldn't set a patients BiPAP machine on anything without consulting a sleep physician.

Just my 2 cents.

Well, my 2 cents is that sleep physicians shouldn't be in the cardiology business, especially if all they know is AHI.

I wonder, has there been a similar study on Respironics version of this machine?

[edited to add] Never mind. I missed the message that Respironics has put out the same warning for their machines.

Morbius wrote:

sleepstar wrote:...I wouldn't set a patients BiPAP machine on anything without consulting a sleep physician.

Just my 2 cents.

Well, my 2 cents is that sleep physicians shouldn't be in the cardiology business, especially if all they know is AHI.

I understand your point, however, I'm sure you know how related sleep, respiratory and cardiology are. Indeed, I work with some who are all 3.

And I need to find the originator of that quote that went "the only way a CPAP machine can hurt you is if it falls on your head".

Morbius wrote:I think the titration protocols need to looked at closely, specifically if they created a milieu that discouraged venous return (i.e., aggressive EPAP and baseline IPAP (vs. like PSmin = 0)).

Trying to follow what you're saying, but I need some clarification:

Are you saying that PSmin = 0 is more or less likely to discourage venous return than agreesive EPAP and baseline IPAP?

Morbius wrote:And I need to find the originator of that quote that went "the only way a CPAP machine can hurt you is if it falls on your head".

The only reference I find is:


viewtopic.php?f=1&t=26896&start=90#p244699

sleepstar wrote:

palerider wrote:

sleepstar wrote: These findings really scare me. I hope they release some data soon. Very interested to see.

in other news, the sky is falling, film at 11.

How is that helpful?
The attitude of some people on this forum is terrible.

it ads perspective. you're 'really scared' about a slight percentage increase in a study concerning an edge case with desperately ill people who already have a very good chance of dying from their condition.

unless you're a heart failure patient, WITH a low ejection fraction, AND central apnea, then the study doesn't apply to you, and that 2.5% increase in mortality chance (which may not be significant in any event) doesn't have anything to do with you... ergo, you shouldn't be "really" scared.

feel better?

sleepstar wrote:I always feel uneasy when I see suggestions from people on the forum of what to change someone's BiPAP pressures to. I think this has been a perfect example. Not even the experts know what's happening yet, so I'm unsure if the public should be changing it (especially when it's not even your machine) I wouldn't set a patients BiPAP machine on anything without consulting a sleep physician.

Just my 2 cents.

My $50,000's worth... I get a chuckle over comments like the above.

First is the assumption that the titration was some miracle process which nailed what my settings should be with 1/2 of a nights worth of monitoring, all hooked up, uncomfortable in a strange bed etc.. Even at home, I have to look at a number of nights to see if there might be a trend taking place.

When I got my first RX 9yrs ago with 20 to 27cm RX based on lying on my back the entire time in the sleep test that I never did when I actually slept in my own bed. I never even saw a sleep DR then. and in fact it was 9 years later before I actually met one for the first time.

Over a couple months, I got the RX reduced so that I could use a more usable machine with data so I could monitor my usage and found I needed much less than that. Again, no DR, not even a DME that had a clue.

I wouldn't set a patients BiPAP machine on anything without consulting a sleep physician.

What sleep physican? There is no monitoring of that. I saw the Sleep Dr once after I got my machine, gave him full data and ALL he was interested in was if I was in compliance. After seeing that, scheduled a followup 12 months from then. How is that supposed to help? He is out of the equation now. Who is supposed to be consulted on it now?

As for my Cardiologist, he knows I use a CPAP machine, but as far as I know has never seen any data about it and has never even commented on its use other than it was good it was helping me sleep better.

There is no magical consultation going on between them and my PCP is not in the connection either even though she is interested my use of the machine.

So I am not using my CPAP BiLevel because of my CHF, but only because it helps with my sleep, which indirectly also helps with other body functions as an extra benefit.

I'm not using an ASV model.

robysue wrote:

Morbius wrote:I think the titration protocols need to looked at closely, specifically if they created a milieu that discouraged venous return (i.e., aggressive EPAP and baseline IPAP (vs. like PSmin = 0)).

Trying to follow what you're saying, but I need some clarification:

Are you saying that PSmin = 0 is more or less likely to discourage venous return than agreesive EPAP and baseline IPAP?

Agreesive EPAP?

Then the OAs go, "Yeah, that's like great, y'know, whatever..."

Krelvin wrote:

sleepstar wrote:I always feel uneasy when I see suggestions from people on the forum of what to change someone's BiPAP pressures to

My $50,000's worth... I get a chuckle over comments like the above.

First is the assumption that the titration was some miracle process which nailed what my settings should be with 1/2 of a nights worth of monitoring, all hooked up, uncomfortable in a strange bed etc.. Even at home, I have to look at a number of nights to see if there might be a trend taking place.

I wouldn't set a patients BiPAP machine on anything without consulting a sleep physician.

What sleep physican?

sleepstar has a point, in very limited cases, to wit: if a bilevel is prescribed and tuned *by a competent respiratory therapist* to *treat a specific respiratory issue* such as hypoxia, hypercapnia, copd, restrictive lung disease, then yes, diddling around with the settings can negate the benefits of the therapy, and possibly worse.

however, the vast majority of people here are on bilevel because they grabbed one when they could (me) or it makes them more comfortable (you), or they like to play (pugsy). I don't *think* (for what little that's worth) that diddling with the pressures of a bilevel that was rx'd because the person didn't like the back pressure of cpap and wanted more relief is going to be statistically any more of a life threatening situation than diddling with the pressure of their cpap, or apap.

there *have* been a few people on here that had a bilevel rx'd because of respiratory issues, and I've been REALLY hesitant to even suggest changes with those, for the above reasons...

but, yeah, from what I can tell, reading here, "sleep doctors" don't give a crap about that stuff, in general.

Morbius wrote:

robysue wrote:

Morbius wrote:I think the titration protocols need to looked at closely, specifically if they created a milieu that discouraged venous return (i.e., aggressive EPAP and baseline IPAP (vs. like PSmin = 0)).

Trying to follow what you're saying, but I need some clarification:

Are you saying that PSmin = 0 is more or less likely to discourage venous return than agreesive EPAP and baseline IPAP?

Agreesive EPAP?

Then the OAs go, "Yeah, that's like great, y'know, whatever..."

and a bit embarrassed by my typo.

palerider wrote:

sleepstar wrote:

palerider wrote:

sleepstar wrote: These findings really scare me. I hope they release some data soon. Very interested to see.

in other news, the sky is falling, film at 11.

How is that helpful?
The attitude of some people on this forum is terrible.

it ads perspective. you're 'really scared' about a slight percentage increase in a study concerning an edge case with desperately ill people who already have a very good chance of dying from their condition.

unless you're a heart failure patient, WITH a low ejection fraction, AND central apnea, then the study doesn't apply to you, and that 2.5% increase in mortality chance (which may not be significant in any event) doesn't have anything to do with you... ergo, you shouldn't be "really" scared.

feel better?

Perhaps my use of the term 'scare' was not the correct one to use. However, this finding doesn't only impact my patients, it also impacts my father. So there's a personal element there. He has heart problems and central sleep apnea and I have been helping him with ASV since I started my career in sleep medicine. So yes, I do feel a little uneasy about the findings.

Krelvin wrote:

sleepstar wrote:I always feel uneasy when I see suggestions from people on the forum of what to change someone's BiPAP pressures to. I think this has been a perfect example. Not even the experts know what's happening yet, so I'm unsure if the public should be changing it (especially when it's not even your machine) I wouldn't set a patients BiPAP machine on anything without consulting a sleep physician.

Just my 2 cents.

My $50,000's worth... I get a chuckle over comments like the above.

First is the assumption that the titration was some miracle process which nailed what my settings should be with 1/2 of a nights worth of monitoring, all hooked up, uncomfortable in a strange bed etc.. Even at home, I have to look at a number of nights to see if there might be a trend taking place.

When I got my first RX 9yrs ago with 20 to 27cm RX based on lying on my back the entire time in the sleep test that I never did when I actually slept in my own bed. I never even saw a sleep DR then. and in fact it was 9 years later before I actually met one for the first time.

Over a couple months, I got the RX reduced so that I could use a more usable machine with data so I could monitor my usage and found I needed much less than that. Again, no DR, not even a DME that had a clue.

I wouldn't set a patients BiPAP machine on anything without consulting a sleep physician.

What sleep physican? There is no monitoring of that. I saw the Sleep Dr once after I got my machine, gave him full data and ALL he was interested in was if I was in compliance. After seeing that, scheduled a followup 12 months from then. How is that supposed to help? He is out of the equation now. Who is supposed to be consulted on it now?

As for my Cardiologist, he knows I use a CPAP machine, but as far as I know has never seen any data about it and has never even commented on its use other than it was good it was helping me sleep better.

There is no magical consultation going on between them and my PCP is not in the connection either even though she is interested my use of the machine.

So I am not using my CPAP BiLevel because of my CHF, but only because it helps with my sleep, which indirectly also helps with other body functions as an extra benefit.

I'm not using an ASV model.

I'm happy things are going well for you.

I apologize, I think I communicated my message very poorly. I should have said that many of my patients have complex problems (e.g. motor neuron disease, respiratory issues) and I would never change their settings without approval from their sleep physician. I think the system you have experienced is very different to where I am. Where I am, the sleep physician is with you every step of the way. It seems unfortunate it isn't like that in your situation.