New to this- Husband vpap III 5 days but not taking breaths

Hi Casiesea,

Good to hear from you. The Adapt SV will adjust for a new elevation if you run Learn Circuit before use at the new elevation, but I'm sure you did that. Has your husband had the sleep-study on the BiPAP Auto yet? Did your insurance buy your 'enhanced' Adapt SV yet, or are you still using the loaner with the crickets inside? Let us know what the RT's have to say. Hope you had a great vacation!

Banned

We FINALLY received my husbands medical records.

His first PSG (08/26/05)...

1. Severe obstructive sleep apnea characterized by overall apnea/hypopnea index of 29.8 and overall respiratory disturbance index of 38.1, a NREM AHI of 5.8, a REM AHI of 67.0, a NREM RDI of 10.9, and a REM RDI of 80.2. The patient had 59 obstructive apneas; 24 mixed apneas, 75 central apneas, 54 hypopneas and 59 flow limitation events (RERA). Positional influence was a contributing factor. The patient was suprine for 370.0 min with a suprine AHI of 33.7 and a suprine RDI of 42.4; non-suprine for 56.5 min with a non-suprine AHI of 4.2 and a non-suprine RDI of 10.6.

2. Moderate oxygenation desaturations wer noted with a nadir attained being 79%.

3. Periodic limb movements were not an independent factor contributing to sleep disturbance. Limb movements resulted in an average of less than one brief arousal per sleep hour.

4. Snoring was noted as moderate in intensity.

5. The patients ECG displayed normal sinus rhythm.

6. Moderate sleep fragmentation was seen with 31.2 brief arousals per sleep hour. Sleep fragmentation was due primarily to upper airway obstruction. Sleep architecture showed 6.6% stage 1 sleep, 39.0% stage 2 sleep, 14.7% stage 3 sleep, 0.5% stage 4 sleep, and 39.3% stage REM.

7. Diagnosis: 780.53 OSA/Hypersomnia


Recommendations

1. Review treatment options including nasal CPAP, which would be the most rapid method of overcoming the upper airway obstruction that was noted.

[quote="Banned"]Hi Casiesea,

Good to hear from you. The Adapt SV will adjust for a new elevation if you run Learn Circuit before use at the new elevation, but I'm sure you did that. Has your husband had the sleep-study on the BiPAP Auto yet? Did your insurance buy your 'enhanced' Adapt SV yet, or are you still using the loaner with the crickets inside? Let us know what the RT's have to say. Hope you had a great vacation!

Banned

_________________


Yes, he did the learn cycle. No home bipap study, yet (however, I left them a colorful message this morning). Are all sleep docs incompetent or just a southern thing?

We still have the machine with the crickets. We did get the insurance statement for last months rent, though. I think it was around $150.

The vacation was great! North Carolina has some beautiful areas!

Anonymous wrote: Are all sleep docs incompetent or just a southern thing?

I think it's more of a bottom-of-the-barrel thing rather than a southern thing. These sleep-doc guys and gals probably barely made it out of med school and if it wasn't for the low-level opportunity in the medical profession for sleep medicine they could really be dangerous. So, having you believe that different machines do different things rather than some machines do everything better than others, does pay their rent. Maybe that is why you are feeling frustrated. At least you can look at them and smile, knowing that they are off the streets and they really can't kill anybody in the near term, it's just air. God, now I'm even depressed. Sorry about that. Anyway, that's why you are taking all this into your own hands and making your own decisions!

Banned

Anonymous wrote:We FINALLY received my husbands medical records.

His first PSG (08/26/05)...

1. Severe obstructive sleep apnea characterized by overall apnea/hypopnea index of 29.8 and overall respiratory disturbance index of 38.1, a NREM AHI of 5.8, a REM AHI of 67.0, a NREM RDI of 10.9, and a REM RDI of 80.2. The patient had 59 obstructive apneas; 24 mixed apneas, 75 central apneas, 54 hypopneas and 59 flow limitation events (RERA). Positional influence was a contributing factor. The patient was suprine for 370.0 min with a suprine AHI of 33.7 and a suprine RDI of 42.4; non-suprine for 56.5 min with a non-suprine AHI of 4.2 and a non-suprine RDI of 10.6.

2. Moderate oxygenation desaturations wer noted with a nadir attained being 79%.

3. Periodic limb movements were not an independent factor contributing to sleep disturbance. Limb movements resulted in an average of less than one brief arousal per sleep hour.

4. Snoring was noted as moderate in intensity.

5. The patients ECG displayed normal sinus rhythm.

6. Moderate sleep fragmentation was seen with 31.2 brief arousals per sleep hour. Sleep fragmentation was due primarily to upper airway obstruction. Sleep architecture showed 6.6% stage 1 sleep, 39.0% stage 2 sleep, 14.7% stage 3 sleep, 0.5% stage 4 sleep, and 39.3% stage REM.

7. Diagnosis: 780.53 OSA/Hypersomnia


Recommendations

1. Review treatment options including nasal CPAP, which would be the most rapid method of overcoming the upper airway obstruction that was noted.

I may have missed it but what were the recommended (CPAP) settings during this study, if any? I'm still thinking his current inspiration pressure of 10cmH2O is pretty light. Why don't you bump MIN PS to 4.4cmH2O, tonight.

Banned

After his initial PSG, the doc suggested a CPAP titration. His pressure was started at 8cm H2O. A month later they decreased him to 7cm because he was holding his breath at night.

I will try to scan all these results tomorrow. It would take forever to type. Basically, his first CPAP titration started with a pressure of 0/5 and went to 0/9. AT 0/5 his AHI was 5.7 and RDI was 19.1. At 0/6 - AHI 7.4 RDI 8.8. At 0/7 - AHI 2.9 RDI 6.3. At 0/8 - AHI 4.3 RDI 8.0. At 0/9 - AHI 9.4 RDI 11.4.

Banned wrote:having you believe that different machines do different things rather than some machines do everything better than others

Banned, when you say "some machines do everything better than others" (emphasis mine) are you saying you think there's a machine or type of machine that treats all kinds of sleep disordered breathing better than a different machine could treat a specific sleep breathing disorder?

On the VPAP III his IPAP was changed from 12cmH2O to 13.4cmH2O. I thought there was some improvement at the higher level. That's why I'm thinking his Inspiration pressure may be a little light at 10cmH2O on the Adapt SV. When you get the data posted SAG, SWS, and RG can help. dsm is at a car show and will be back in a few days.

Banned

rested gal wrote: "you think there's a machine or type of machine that treats all kinds of sleep disordered breathing better than a different machine could treat a specific sleep breathing disorder?

The notion that a different machines treat a specific sleep breathing disorder IMO is highly over-rated. CPAP machines can and do eventually create more problems than they cure. So why would an ethical doctor prescribe anything less than a bilevel as a basic machine? Maybe not everyone needs a Bilevel with SV. But, a doctor saying an Adapt SV would not necessarily be good for people with OSA or shallow breathing sounds to me like an idiot. The thought of Casiesea's husband doing better on a bilevel Auto than the current Adapt SV would tell me that his ASV was not setup properly.

Banned

But, a doctor saying an Adapt SV would not necessarily be good for people with OSA or shallow breathing sounds to me like an idiot. The thought of Casiesea's husband doing better on a bilevel Auto than the current Adapt SV would tell me that his ASV was not setup properly.

The makers of the Adapt SV state very clearly that it is not the treatment of choice for people with OSA or shallow breathing, since it speicifically , epecially programmed to create hypoventilation.

Being knowledeable means looking for informaion in many sources, and sifting through the information. Some people think they know everything always because they have a very high opinion of themselves, and a very low opinion of others. This is a special kind of idiocy, and its prevalence is not restricted to doctors.

Anyone who reads information on a forum has to educate themselves and learn to separate the chaff from the wheat. Fortunately, Resmed publishes infromation for those who want to learn about the Adapt SV:

http://www.resmed.com/en-us/dealers/med ... daptSV.pdf

A longer-term correction is effected by the trailing 3-minute
memory of minute ventilation and pattern of breathing. After
a 3-minute initial collection period, the Adapt SV then sets a
minute-ventilation target that is 90% of the previous minute
volume. Hence there is a weak downward force on total minuteventilation
that nudges the PCO2 upward 2 or 3 millimeters of
mercury, decreasing or eliminating the frequent CO2 dips below
the apnea threshold that drives the central events. Because of
this 90% target, the manufacturer cautions that the device
should not be used in patients who have a condition that might
result in hypoventilation (severe COPD, neuromuscular disorders,
etcetera). At least theoretically, the downward force on
minute ventilation could worsen hypercapnia [too much CO2] in this patient group and perhaps even precipitate respiratory failure. We
have not seen this potential complication, even though several
patients we have studied have had PaCO2 values at, or a little
above, the upper limit of normal.

http://www.vpapadaptsv.com/product.html

Support when it's needed
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.


Clinical references
1. Young et al. Am J Respir Crit Care Med. 2002; 165: 1217–39
2. Teschler H et al. Am J Respir Crit Care Med. 2001; 164: 614–19
3. Philippe C. Heart. 2005; Published online Jun 20
4. Töpfer V et al. Pneumologie. 2004; 58(i): 28–32

Simply put, the aim of the Adapt SV it to make sure you have a liitle more CO2 in your blood than normal. That is not something one can recommend for every person who has OSA or shallow breathing. Shouldn't, recommend, I'd say.

Can one setup an Adapt SV to function as regular bi leve machine? Yes. Is hobbling the machine's special features the right way of using it? No.

All added emphasis and links are mine.

Edit on April 8 2008: I have been informed by DSM and Banned that the the Adapt SV cannot be setup as a Bi-level machine. Clearly, my rhetoric got away with me...
O.

_________________

Banned wrote:When you get the data posted SAG, SWS, and RG can help. dsm is at a car show and will be back in a few days.

Of those four people SAG is the only qualified health professional. I know RG well enough to be absolutely certain that she would never attempt to suggest pressure changes in the cases of CSA, CSR and/or CompSA/CSDB. I know -SWS even better than I know RG! And he would never suggest pressure changes in any of those cases either. I have never once observed SAG, who is a well-qualified professional, attempt titration anywhere but in the lab.

Specifically, central dysregulation patients are all-too-often medically challenging, such that well-qualified doctors and health professionals need to approach those cases with methodical caution and diligence. Garden-variety obstructive apnea is an altogether "message board manageable" condition that message board posters manage to straighten out here on a regular basis (to their credit IMO).

But experimentally spinning the dials via message-board titration in cases of potential CSA, CSR, or CompSA/CSDB seems like extremely poor judgment to me. My apologies to everyone involved when I candidly tell you that I was absolutely dismayed at what I personally perceived to be very avid "hobbyist-style" dial spinning. It seemed to me as if the intent or spirit of helping was right on the money. But those who suggested dial-spinning did not seem to perfectly understand either the complexities of the machine or---much more importantly---the burdening complexities and subtle variant-differences of central dysregulation itself.


I suspect that Casiesea's husband's central physiology may be inherently variable (from night to night) and/or transitional with respect to one or more comorbidities. If that conjecture is true, then it may explain why multiple doctors and multiple sleep studies encounter difficulty achieving optimal treatment. CompSA/CSDB in particular can be very difficult to treat since the pressure requirements for the obstructive and central components can be not only diametrically opposed, but the two required pressures can theoretically be preclusive of each other as well. And night-to-night variability of pressure preclusiveness, then, theoretically becomes a stark possibility (regarding achieving an efficacious balance of both the static and oscillatory pressure components).

My suggestion is that we limit our input to suggestions that Casiesea and her husband can take back to their health professionals. And admittedly one of those suggestions might be that they keep searching until they find an adequate health care team. This is very challenging medicine IMHO.

I mean absolutely no reproach to anyone. I'm simply sharing my opinion of what I believe to be a very frustrating/challenging case. I also acknowledge that the health system has a very long way to go, and that Casiesea's frustrating encounters are unfortunately not uncommon. Once again that leaves the understandably frustrated SDB patients and their families on the horns of a health-care dilemma.

My understanding and encouragement to Casiesea and her husband. Things tend to get better with good old fashioned optimism and perseverance! Everyone in this thread wishes you only the best!

ozij wrote: The makers of the Adapt SV state very clearly that it is not the treatment of choice for people with OSA or shallow breathing, since it speicifically , epecially programmed to create hypoventilation.

The makers of the Adapt SV may state this very clearly somewhere, but it is at odds with the Adapt SV literature and case studies that are filled with references to the successful treatment of OSA. When my turbinates become so enlarged that I normally would not be able to breath through my nose (not pressure induced) the Adapt SV always forces a comfortable airflow into my upper airway. It may not be OSA, but it certainly is obstructive. Also, isn't shallow breathing a large component of Cheyene-Stokes? The point of all machines to keep the airway open and not create more problems than it cures? I would not necessarily believe everything a doctor has to say, including a ResMed doctor who has never experienced the relief the machine can provide.

Banned

Thank you, SWS. I appreciate everyones input!

The whole "dial spinning" thing started with the VPAP III. When we changed the settings on that machine, it made a dramatic difference in my husband's sleep quality. At that point we were desperate for any and all help we could find. I have to admit, changing the pressure on the Adapt SV scared me straight that night. I had no idea about the complexities of that machine (or my husbands condition). Truthfully, as a nurse, I should have known better. We are begining to realize he does not have the run-of-the-mill type of sleep apnea. His sleep seems to be stable at this time (not great, but stable). He feels and looks 1000 times better than he did 1.5 months ago and I give every bit of credit to all of you all!

This entire situation has me completely stunned. I cannot believe how messed up this portion of the health care system is! I have never seen a more needy group of patients treated so nonchalantly in my entire career! This condition is ruining his heart, brain, life, and who knows what else. Yet his health team displays no urgency (team #1 or #2 (i can guarentee you there will soon be a team #3)).

I spoke with Doc #2's nurse this morning. The home titration has been ordered and we are waiting for the supplier to set it up (its only been 3 weeks after all). I am assuming our insurance company will not like this new wrinkle in his treatment. I guess we will soon find out.

Good luck, Cassi, and do keep us posted when you can.

O.

Hey Cassi
As SWS said, we wish only the best for both you and your husband. I haven't posted much here because I have nothing to offer but encouragement!!!!!

I have to say that I am totally fascinated by the entire discussion, and hope it continues to a very successful conclusion!!!!! So please, keep us up on how things are progressing......

One of the reasons this forum exists in the form it does is due to the dismal condition of the medical profession when it comes to sleep disorders. Thankfully our sponsors have kept it open which keeps it alive!!!!

I am very aware that I am extremely fortunate to have a sleep doctor that not only listens, but acknowledges others knowledge while imparting hers.
Interestingly, in my last meeting with her we discussed this board specifically and her comment was "I check that board about once a week or so, there are some really smart people on that board. Smarter than me!!!!" Now I happen to think that's one hell of an admission from a medical professional, and being a nurse (I'm married to one ) I'm sure you see the "problem" every day......

Again, the best of luck to you both and I'll keep reading!!!!

take care
cheers
goose