CPAPtalk.com

ozij wrote:

SAG wrote:And a getting a PFT.

And that would be a Pulmonary Function Test? (Guessing...).

O.

Right. A 39 year-old with borderline O2 saturation even on pressure therapy, and by history:

Casiesea wrote:Yes, he is a smoker (he quit about 2 weeks ago).

He was exposed to smoke/oil fires in Desert Storm (among all the other chemicals) and worked on helicopters in the Marines.

Since we're ordering stuff, what the hey, let's get an ABG, too.

SAG

I haven't read everyones posts yet. I don't have time at the moment. Just wanted to give yall a quick update:

Stayed at 7/3 last night

He said "I actually felt like getting up this morning". I would say that is progress!

StillAnotherGuest wrote:
<snip>

Well, here's my free advice.

I don't think you should let Moe and Larry there talk you into wingin' them dials around arbitrarily. It is clear that there is a very narrow therapeutic window, and "Pick a number from 1 to 10" or "If you had a such-and-such you could..." is any way to do things.

Speaking of using a "such-and-such", since a major component of the ASV titration was clearly spent addressing the RERA portion of the RDI, a "such-and-such" won't help. The "Arousal" portion of the RERA can only be seen on PSG.

Snooze_Blues wrote:And a question for Banned: Q. Why do you say that EEP 10 is the easiest to breathe against? Wouldn't it be easier to breathe against an EEP of 6?

You're absolutely right.

Snooze_Blues wrote:Two interesting things about the data that I notice with my limited eye:

1. The best set-up (#3) was the only period with REM sleep; and

2. There were zero (0) central apneas in all of the set-ups.

Yeah, that central number kinda snapped my head back, too.

REM in true CSBD is quite stable, so there shouldn't have been a great contribution of RDI there. That said, the relative amount of REM wasn't enough to make a big dent (if there were no events during REM, the NREM RDI during that period was still only about 6.6).

I think taking a look at the BiPAP titration would be very helpful.

And a getting a PFT.

SAG

Casiesea,

What SAG is saying (translated) is that the PSG is your husband's best guide & your doc is already giving your husband the best advice. He is also saying that an SpO2 (Reslink) won't add any really useful info in this case as SpO2 data won't address the RERAs (non apnea relate arousals) which were adequately addressed by the Adapt SV settings chosen.

His advice is valuable (and here, free ).

DSM

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CPAPopedia Keywords Contained In This Post (Click For Definition): bipap, Titration, RDI

I think we have decided to go to 6/4 this evening and see how it goes.

He fell asleep sitting on the couch today. I was watching him breathe. I didn't see any slow breathing or startling. Maybe he should sleep sitting up all the time!

Thanks everyone! I will let ya know tomorrow!!! Goodnight

dsm wrote:... Now compare the above chart with this chart where I had set the Vpap to cpap mode & ran the CMS up to 16 CMS. What do you notice about the mv ?

Finally got the pages to load and looked at them...

Looks like you dropped about 2 liters MV when you cranked up to 16 cm. I guess it was a lot harder to exhale with 'your head out the window'.

Also looks like your pulse jacked up more and you had more apneas, which seems strange at a higher pressure, unless they were centrals, and I didn't think central events were captured by ResMed's 'Stooge Software' data display.

And on top of it all, your O2 spent half the time below 95 at 16 cm, but that's only about a 1% drop. Is that significant?

"Hey Moe, I'm readin' charts!" "Add a can 'a panna-puh!"

-- Curly

SAG, Thanks for the reply.

Snooze_Blues wrote:

dsm wrote:... Now compare the above chart with this chart where I had set the Vpap to cpap mode & ran the CMS up to 16 CMS. What do you notice about the mv ?

Finally got the pages to load and looked at them...

Looks like you dropped about 2 liters MV when you cranked up to 16 cm. I guess it was a lot harder to exhale with 'your head out the window'.

Also looks like your pulse jacked up more and you had more apneas, which seems strange at a higher pressure, unless they were centrals, and I didn't think central events were captured by ResMed's 'Stooge Software' data display.

And on top of it all, your O2 spent half the time below 95 at 16 cm, but that's only about a 1% drop. Is that significant?

"Hey Moe, I'm readin' charts!" "Add a can 'a panna-puh!"

-- Curly

SAG, Thanks for the reply.

Physical -

PFT - normal
O2 sats - normal
Chest xray - negative

Thyroid (tsh, t3, t4)- normal - from last week
CBC - normal
BMP - normal

EKG - Not completely normal (or what he would expect for a 39 yr old) but the doctor said he wouldn't call it abnormal. Scheduling Echo for next week with a cardiologist.

He feels like he is sleeping very well now (past 2-3 nights), but still feels like he could sleep all day every day.

No still has explained why the fellow said over and over again that the higher the EEP the easier it is to breath. Example, if you are having difficulty at a setting of 6, raise it to 7 or 8 and it will be easier for you. Is this true? Not true? If it is true, that breathing against a HIGHER pressure with the CS2 machine is easier, can you tell why? Puhleese?

Anonymous wrote:No still has explained why the fellow said over and over again that the higher the EEP the easier it is to breath. Example, if you are having difficulty at a setting of 6, raise it to 7 or 8 and it will be easier for you. Is this true? Not true? If it is true, that breathing against a HIGHER pressure with the CS2 machine is easier, can you tell why? Puhleese?

SAG answered that question. Here's his reply (below my original quoted question) from a previous post on page 8 of this thread:

Snooze_Blues wrote:And a question for Banned: Q. Why do you say that EEP 10 is the easiest to breathe against? Wouldn't it be easier to breathe against an EEP of 6?

You're absolutely right. [--SAG]

"you're absolutely right" is just a glib response that says nothing. Maybe what the first fellow said was true, he certainly repeated it often enough. And maybe the fellow who just tossed of "you're absolutely right" with no explanation or further comment, maybe what he is saying is incorrect?

Anonymous wrote:"you're absolutely right" is just a glib response that says nothing. Maybe what the first fellow said was true, he certainly repeated it often enough. And maybe the fellow who just tossed of "you're absolutely right" with no explanation or further comment, maybe what he is saying is incorrect?

It was my "Wouldn't it be easier" question, and SAG answered it directly and to my satisfaction with an implied "Yes." and an explicit "You are absolutely right". I see nothing glib there.

Why discourage experts we ask to educate us by denigrating their responses just because we don't understand their answers? (That's rhetorical and requires no response.)

Snooze_Blues' statement was almost universally correct in my opinion. And I believe SAG's assessment of Snooze-Blues' statement to be correct as well. SAG manages a sleep lab and has been trained to titrate patients on ASV.

However, Banned has repeatedly made this kind of seemingly counter-intuitive statement throughout this thread:

Banned wrote:The EEP numbering scheme may be counter-intuitive but the higher the number, the easier it is to exhale. The Adapts EEP is between 4 and 10cmH20. 10 cm is the factory default.

I believe that statement to be counterintuitive because virtually everyone here has greater difficulty exhaling against higher pressures. Banned's statement would thus be false for most of us.

However, Banned may be experiencing atypical obstruction during expiration (perhaps mid-phase or earlier). If this speculation were true, then Banned may actually have an easier time exhaling against greater pressures--if those pressures are required to clear his airway during much of expiration.

Banned may thus actually require greater airway dilation (via static EEP) earlier on during expiration. By contrast, the rest of us would simply sense that greater diaphramatic effort were required to breathe against higher EPAP pressures. The expiratory dynamics of these two cases would be very different, and they would be perceived differently as well. I believe the perceptions would actually be diametrically opposed---which might well explain Banned's repeated counter-intuitive statements.

If Banned's expiratory etiology is as atypical as I suspect, then his ASV titration advice (which is inexperience-based on his own atypical physiology) becomes highly questionable IMO. No offense to Banned. However, I believe this is an important point of consideration for readers.

I too wondered about the EEP set higher is easier to breath out against point. But took it to mean, that an EEP set too low feels for most people like they aren't getting any air.

The mechanics of EEP are basically similar to epap, but using a different label (as explained in an earlier post here).

I believe though, that EEP is not arbitary in that the machine will only go that low if the user's breathing is with the Vpap's 90% targets for volume & rate. So if a breather is maintaining their 90% target for volume & rate, the machine will go as low as EEP is set to. But, I am guessing that this is how it works.


DSM

If person A says a dozen times that such and such is true. Someone asks if it's really true. Then person B says "no it's not" and with no further explanation, i would call that a glib! response. I don't care if he is in charge of 100 sleep labs.

dsm wrote: The mechanics of EEP are basically similar to epap, but using a different label (as explained in an earlier post here).

The mechanics of EEP are virtually identical to that of a standing wave in physics.

EEP is a static-pressure component upon which alternating pressure variations are superimposed. EEP is a purely static-pressure component and is functionally identical to that of static-pressure CPAP. Both of those static pressure components (EEP and CPAP) are used to address the obstructive component of SDB.

Note that EEP is the same pressure constant regardless of respiratory phase (inspiration or expiration), and that pressure constants are used to address obstructions in the cases of ASV and CPAP. In both cases they inflate the airway with static pressure to clear obstructions (which tend to occur during both expiratory end-phase and inspiration).