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

I feel like he slept better last night. He feels "a little better", but he is very tired. He is still dozing off all the time. The doc gave him a script for provigil, so hopefully that will help him tomorrow! He is GRUMPY as He** but I am sure he will feel better soon. He has to fly to Maryland tomorrow, so I won't be able to obsess over his sleep for a day or two! What will I do with all my time?

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.

Casiesea,

You may well have an excellent case for compensation from the Marines - I fear your husband my have some issues with his lungs & may well need a specialist look at why his SpO2 is so consistently low.

The chemicals are more likely to be the origins than the smoking (but would need more info on the extent of that).

His best asset at the moment is you.

Cheers

DSM

Casi,

Some additional info for you

RERAs: Respiratory Effort Related Arousals. Episodes that are not
apneas or hypopneas, often related to loud snoring, that generally do not cause a decrease in oxygen saturation.

(ref) http://www.sleepservicesofjasper.com/1- ... r_PSG1.pdf

A Mayo Clinic ref ...

Sleep-Disordered Breathing
During sleep, air should move freely and rhythmically in and out of the lungs via the nose and/or mouth just as while awake. When this normal breathing pattern is disrupted during sleep, "sleep-disordered breathing" is said to occur. Sleep-disordered breathing refers to a range of breathing disturbances, including apneas, hypopneas, snoring, and respiratory effort-related arousals.

When airflow completely stops during sleep, it's called an apnea. When airflow slows significantly, but not completely, it's called an hypopnea. In obstructive sleep apnea (OSA), apneas and hypopneas occur because of complete or near-complete blockage of the upper airway (throat). In central sleep apnea (CSA), apneas and hypopneas occur because the brain and central nervous system fails to generate a rhythmic signal to breathe. OSA is much more common than CSA. CSA typically occurs only in people who have experienced heart failure, stroke, or kidney failure.

Snoring occurs when air flows through a narrowed throat. The turbulence created by the air as it passes relaxed tissues causes them to vibrate, and that vibration is the sound of snoring. Because snoring and OSA are both due to narrowing of the throat, people who snore are more likely to have OSA.

Sometimes the throat narrows enough to cause loud snoring and hard breathing, but not enough to produce apneas or hypopneas. Breathing in this situation can be difficult enough to wake the sleeper, an occurrance referred to as a respiratory effort related arousal (RERA). Most people with OSA have some combination of loud snoring, RERAs, hypopneas, and apneas when they sleep, so the term OSA is commonly used to encompass all of these phenomena


DSM


#2 PS - when I up my CMS to 14+ from 13, I experience a biiiig jump in RERAS. SpO2 looks ok - AHI looks ok - but I feel like I have had a very interupted sleep.

On the other hand, if I drop my ipap epap gap to 2 CMS, I feel like I get a great nights sleep, but don't want to get up early nor exercise

Still trying to figure these gems out

D
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CPAPopedia Keywords Contained In This Post (Click For Definition): Arousal, Hypopnea, CSA

For me this has been a totally fascinating thread!!!!
dsm - it's great to see your posts again!!
Casiesea, you are getting some incredible info here - you are also providing some great information as well.... I would have to agree with dsm in that you are the best resource your hubby has at the moment. I hope that once he recovers from his fatigue that he will post some of his experiences and feelings about how the treatment is going.
I do recall an earlier post that he has a "Beard thing" going -- I've had a beard for over 30 years, but if I needed to use a FF mask (I have an HC431 FF mask which leaks like a sieve because of facial hair) the blade would come out and the hair would be gone -- it'll grow back (fortunately though I am not a mouth breather) -- to make the FF mask work properly.

I too would like to see more of the data be public if possible so we can learn from those interpreting. My PSG and titration showed Centrals, but so far my APAP is doing me well (in CPAP mode). My RN wife, who has been in denial has finally made her appointment with the neurologist, so we may soon be a dual xPAP family.

Thanks all for the thougthful and considered data being presented here!!!!

cheers
goose

That's wonderful news!

As for this

His spo2 never went above 89%, wouldn't that be a bad thing?

Yes. And I guess this is what rattled your doctor. Hospitals start supplemental oxygenation on patients when they drop below 90%. And here is your hospital sleep lab sending your husband off with treatment that leaves him at 89%.

No wonder she was so upset at the lab and tech. Though the question remains: Who analysed the PSG? Who Rx-ed the machine with that configuration?

What will you do with your spare time? Get some sleep - you've earned it!
O.

[quote="Banned"]Ohhhhh.. YOUR'E GOOD, Now that is how to get a sleep-doctor to practice medicine! Wish I had that doctor! Don't give your doctor any crap, just suck-up, become the essence of sweetness and light, and go with her program. Tell hubby he's gotta kiss that goofy nasal pillow nonsense goodbye. He will need to get serious with the Quattro FF. He will have 3 positions to sleep in with the Quattro, right side, left side, or on his back. His head will have to be at the edge of the pillow when he is sleeping on his side. To maintain the seal while sleeping on his side, the Quattro FF mask will basically be off the pillow as he sleeps. Yes, he may have to adjust it several times during the night. That's life, no mask is perfect. THE QUATTRO FF IS THE ONLY ACCEPTABLE MASK TO USE WITH THE RESMED VPAP ADAPT SV. Sorry for shouting. The Adapt SV will put an end to his non breathing and startled awakenings. It's a dream machine. It does take some getting used. Basically, let the machine do the work, relax, don't fight it, breath into it, and let it breath you when it needs to. It will save his life. Adjusting the Expiratory and Inspiratory pressure is a simple as 1-2-3. You just have to understand the logic behind changing the parameters. It is super simple. More about all that later.
For FDA (Federal Drug Administration) purposes, you are going to plead total ignorance to adjusting any parameters not previously set by your RT.

The reason that the Quattro FF Mask is the only acceptable mask for the ResMed Adapt SV is because the swivel and vent geometries (which are critical components of proper air delivery) in the mask were specifically engineered for use with the Adapt SV.

Cheers,

I'm not a medical professional either. In fact, my sleep-lab doc said he would never prescribe a ResMed Adapt SV for me. Some doctors really suck!
Machine: ResMed Adapt SV
Mask: Quattro FF
Humidifier: ResMed Sullivan HumidAire (Old style stand-alone)

Goose,

I agree - this is an unusual situation compounded by the seriousness of it & rewarding in how Casiesea is taking the bull by the horns in seeking help.

The clinic's handling of it is a very big worry. But, that seems to be being rectified - thank the lord!.

DSM

I'm also following this thread with interest. My PSG showed more centrals than OA's and I have a 2nd PSG scheduled in a couple weeks. If acclimating to CPAP at 6 cm H2O for the past two months doesn't get rid of the central apneas during the first half of the night, they are going to titrate me on an ASV machine.

I'm not sure if I'll have a choice between Respironics BiPAP Auto SV or the ResMed Adapt SV [Enhanced?], so I'm trying to find time to look for info on cpaptalk about both. I think I know what Banned will recommend.

FYI: My sleep doctor, who is board certified as both a sleep med doctor and a pulmonologist, claims that some of us with lots of centrals (I think I had about 29 per hour on CPAP during the PSG) will acclimate to CPAP and the centrals will "go away". He recommends two months of CPAP and then another PSG. If enough central apneas are still present, then he recommends an ASV device (but I forgot to ask him which one).

I hope to hear about your husband's ASV experiences. Good luck to you both.

When a relatively young, mildly obese, smoker, presents with a failed attempt at CPAP, a failed attempt at VPAP, and observed prolonged non-breathing episodes followed by startled awakenings, any doctor should be compelled to move quickly. Not long ago, her only alternative would have been to add O2 to hubby's VPAP therapy. Even then she would have known the additional O2 would be no help. The fact that this doctor would like to be present during the study and would like a ResMed professional available during the study is indicative of someone who is eager to learn more about the ResMed VPAP Adapt SV as a life saving tool.

Casiesea, some stuff to think about when you get bored obsessing about all this stuff.. The Adapt SV is a totally different animal from a VPAP machine.

In the Adapt SV 'EPAP' or Expiration pressure is referred to as EEP. EEP ranges from 4cmH2O to 10cmH2O. The Expiration Pressure at 10cmH2O is lightest (and is the easiest to exhale setting). 8cmH2O EEP would be the Adapt SV's default Expiration Pressure.

'IPAP' or Inspiration pressure on the Adapt SV is indicated in two (2) ways, as MIN PS and MAX PS. MIN PS can be manually set from 3cmH2O to 6cmH2O in .2cmH2O increments. The default Inspiration pressure is 5cmH2O.

MAX PS is automatically set by MIN PS and will always be 5cmH2O higher than MIN PS.

Setting the Expiration Pressure (EEP) and Inspiration Pressure (MIN PS) is a simple, two step process.

First, in the EEP menu you would select the most comfortable Expiration Pressure between 4cmH2O and 10cmH2O.

Second you go to the MIN PS menu and select any number between 3cmH20 and 6cmH20 in .2cmH2O increments that will equal the desired Inspiration Pressure (IPAP).

Example, tonight you want to adjust hubby's Inspiration Pressure (MIN PS) to 13.2cmH2O. You have previously set his EEP to 9cmH2O. You simply goto the MIN PS menu and put in 4.2cmH2O and the Adapt SV will indicate a baseline Inspiration Pressure of 13.2.

The ReMed VPAP Adapt SV's titration numbers generally will look like x/x (i.e. 9/4.2 where the 9 is the EEP and the 4.2 is the MIN PS. Since they are additive you know it means a baseline pressure of 13.2.

Now, what about that additional 5cmH2O (MAX PS) that you didn't have to play with? That's the extra punch for the Servo Ventilation. When your husband has an apnea or otherwise ceases to breath those additional cmH2Os are standing by, ready to kick in, ramping his mask with air in a controlled fashion and forcing him to breath.

The Adapt SV has a small, additional proximal sensor tube that runs the length of the six foot hose from the machine to the base of the Quattro FF mask. this tube senses your husbands exhales on a breath-by-breath basis. When that sensor line at the mask misses an exhale, the machine will immediately begin ramping up to 18.2cmH20 to the mask. And that is just the beginning. If the Adapt SV reaches 18.2 cmH2O and hubby has still not taken a breath, it will continue to increase air pressure beyond 18.2cmH20 into his mask until he does breath.

So be sure and tell him not to be cute and hold his breath for too long.

Have a nice trip. And let me know if the old boy ever gets the right mask!

Cheers

I'm not a medical professional either. In fact, my sleep-lab doc said he would never prescribe a ResMed Adapt SV for me. Some doctors really suck!
Machine: ResMed Adapt SV
Mask: Quattro FF
Humidifier: ResMed Sullivan HumidAire (Old style stand-alone)

Am just restating Banned's points re settings & will try to equate to the Vpap III

(ps I cheated & got bits of this from Resmed's site as I don't always remember over time, the myriad of acronyms any more than most )

RESMED: 'EEP stands for End Expiratory Pressure. It was named to represent the fact that the pressure waveform is a gradual decay rather than an abrupt drop-off of pressure like a standard bilevel unlike the square wave of a traditional ventilator that holds the expiratory pressure throughout expiration.'

This is the equiv of epap but they are saying they named it differently becuse it is not quite the same as the way epap usually gets reached.

PS = Pressure Support & is in effect the epap to ipap gap. So that EEP + PS = what we call ipap on the VPAP III. This is typically going to be about 3 or 4 CMS assuming a normal user (not COPD or CSR patients)

Max PS = Maximum extra pressure the machine will go to (which on a vpap sort of means the same as if the ipap could decide to go up to ipap + 5 CMS). With a Vpap Adapt SV, if the patient's breathing misbehaves & doesn't work in a regular fashion it will automatically push the pressure up (stopping either when the user resumes breathing or after increasing by 5 CMS) and it can do this very quickly.

So the Adapt SV also acts like a Timed bilevel in that it will not wait long after a breath ends before it kicks in and actively ventilates the user if its sensors indicate the user has stopped breathing. Active ventilation is what hospital ventilators do.

Again taken from Resmed's sie (I got this bit wrong last time I mentioned it here at cpaptalk so have copied from the horse's mouth - I previously said something like 80% of tidal flow which is not quite the same.

RESMED: 'automatically calculates a target ventilation (90% of the patient's recent average ventilation)'

That leaves some room for settling into sleep & varying one's sleep breathing but not much - step outside the 10% & the machine will take over.

DSM

I'll do some research on the Bipap SV to see what it does & how it reacts with a CSA patient.

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CPAPopedia Keywords Contained In This Post (Click For Definition): resmed, bipap, CSA

Bipap SV

https://www.cpap.com/productpage-advanc ... nformation

From the link you can see that Respironics call the development a 'revolutionary algorithm' - that is marketing talk for 'we did it by extending the software on an existing model'. The existing model is the Auto Bipap & the extension is that they added a timed element to the algorithm that isn't present on the Bipap Auto.

The Bipap SV doesn't try to sample pressure at the mask & generally works with most existing masks (as does the Bipap Auto). By this is meant that there is no ancillary pressure line attached to (or inside) the main air hose (like there is in my Puritan Bennett Knightstar 330 & the Vpap Adapt SV).

Respironics rely on their evolving Auto-trak algorithm (software code) to determine what is going on at the mask at the end of the air hose. Auto-trak 1st appeared in their 2nd generation Bipap range and is their way of working out what is leak and what is breathing. They have developed this to a fairly high level of sophistication and A-Flex is an example of that evolution.

The Bipap SV can still report AHI scores because AHI is what triggers its reactions to events (vs Adapt SV that anticipates them). The Bipap SV will assess if an apnea event is taking place (OSA or CSA) and if a CSA (central) will attempt to trigger the user to breath by upping the pressure rapidly to a higher level (set in the menu). It can do this very quickly via the internal high-speed air valve (as used in all 2nd & 3rd gen Bipaps - this device is a very effective air control approach). The Bipap SV has a constant speed motor (as do the other Bipaps) and uses the air valve to either send air to the user or recycle it back to the blower based on what the software algorithms command. The Bipap SV can make a decision as to if the users breathing is not maintaining pace by sampling the breathing rate & saving the data internally & will push the user to maintain their breathing rate by switching to a higher pressure to force the user's breathing cycle.

This is not as detailed as I would like it to be but the intricate info on this unit is hard to come by.

DSM

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CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, bipap, hose, Puritan Bennett, AHI, CSA, auto

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CPAPopedia Keywords Contained In This Post (Click For Definition): respironics, bipap, hose, Puritan Bennett, AHI, CSA, auto

Casseia - I'm SO glad you said he's just quit smoking because if you're unaware of it, doing so makes most of us VERY sleepy during withdrawal (what he's been going thru') and is NOT directly related to OSA as such, though his lungs may not appreciate the difference. Relax, he's probably having all kinds of issues related to withdrawal (including colds, which again are 'expected') and other transient problems. Wait a month and see how many of them are still in place - bet the sleepiness improves a LOT! Get him to drink lots of cold water now, it helps flush the nicotine.

Nicely stated gentlemen, and thank you for your kind words.

The ResMed VPAP Adapt SV is a hospital grade servo-ventilation device. When Respironics realized the opportunity to use the same (USA) FDA approval loop-hole for approval that ResMed used with the VPAP Adapt SV, the BiPAP SV was Respironics quick and on-the-cheap response to the VPAP Adapt SV. I would be hard pressed to recommend a Respironics BiPAP SV to anyone with serious CSA and other breathing issues. The Respironics unit would be more akin to an BiPAP on steriods than a true, real-time, SV. If you have ho ability to sample at the mask, whatever SW features you are boasting are suspect at best. And the latency period to do the job on a breath-by-breath basis is still a problem. Anyway you slice it, the ResMed VPAP Adapt SV is the superior machine.

That being said, the ResMed VPAP Adapt SV is being upgraded in a new model called the ResMed VPAP Adapt SV 'Enhanced' to meet the higher output as currently found in the Respironics BiPAP SV. Remember the Adapt SV with an EEP of 10cmsH20 added to the MIN PS of 6cmsH2O only reached 16cmsH2O (not including the extra MAX PS of 5cmH2O). So the new Enhanced Adapt SV will be adding another 5cmH2O (probably by increasing the EEP to 15cmH20) to equal the output of the Respironics BiPAP SV for those users at the high pressure end.

Just a note to let you know the reason I use the handle 'Banned' is because my sleep-doc would neither titrate or script a ReMed VPAP Adapt SV for me. And I was waking up nights tearing my ResMed Vantage mask off and gasping for air!

Cheers

I'm not a medical professional either. In fact, my sleep-lab doc said he would never prescribe a ResMed Adapt SV for me. Some doctors really suck!
Machine: ResMed Adapt SV
Mask: Quattro FF
Humidifier: ResMed Sullivan HumidAire (Old style stand-alone)

Banned - Did u go to a diff doc to get it?


Last night stunk!!! The vpap kept shutting off and saying "check tube". We called the number they gave us to report the problem, they said "well you will have to bring it in tomorrow". He can't take it in because he flew out of town this morning. So he will be going the next 4 nights without it. He used his cpap last night (don't know if it will do anything but had to try something) and took it with him too.

The sleep tech from the new lab called to confirm this morning. I guess they canceled the patient they had scheduled on Monday to make a place for my hubby (I feel bad, but obviously that patient isn't an emergency case). I wish I could be a fly on the wall at this titration on Mon.

Yall are all so amazing for helping! I don't know where we would be without all the help!

Thanks,
Casie

Casiesea,

Did the tube get damaged by any chance - check at each end to see if a hole has developed (happend from pulling the hoses on & off),

I think the machine is saying that there is a leak in the tube.

Tonight fit him with it & listen all along the tume for any noticable hissing. Also check the mask for any loose part.

DSM