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

Casiesea · Post by **Casiesea** » Fri Feb 29, 2008 3:22 pm

Something isn't right. He said his sleep was "awesome" during the last 1/2 of the titration. Yet, when we bring this machine home...he isn't doing well. I don't get it.

I changed the numbers last night. EEP 9 Min PS 3

Of course, he passes out immediately. I was catching up on Oprah and I noticed he was very restless and something just was not right about his breathing. I could hear the machine ramping up the pressure, but he would not take a breath. Eventually, it would blow his mouth open or he would startle and the whole thing would start over again.

He felt like there was too much air pressure (yeah, cause he wouldn't breathe) and he felt like he was struggling to exhale. Anyway, I switched it back to see if he was still startling - but I fell asleep.

This mornings numbers -

Leak 29L/M
VT 274-740
resp 12-18
mv 5-10

Casiesea · Post by **Casiesea** » Fri Feb 29, 2008 3:30 pm

You are right banned, I should do a pom pom check! Or maybe I should see if it is actually a cricket!

Do you think he is fighting the mask?

Will this thing work with the other software or does it have its own?

Is there an AHI with this machine?

dsm · Post by **dsm** » Fri Feb 29, 2008 3:59 pm

[quote="Casiesea"]You are right banned, I should do a pom pom check! Or maybe I should see if it is actually a cricket!

Do you think he is fighting the mask?

Will this thing work with the other software or does it have its own?

Is there an AHI with this machine?

Banned · Post by **Banned** » Fri Feb 29, 2008 4:39 pm

dsm wrote: Casiesea,

The actual MV & Resp etc: numbers look ok but it looks like he is resisting the pressure - kind of looks like pressure induced centrals.

Again, because I am not experienced with this machine I am cautiously suggesting upping the EEP only by 1 CMS from the original EEP setting supplied - leave the PSmin as is. If this works ok then next night up it 1 more CMS.

DSM

I don't think hubby is fighting the mask, the pressure was too high. dsm is correct, you could change the EEP to 7cmH2O and leave the MIN PS at 3cmH2O which would bring the inspiration pressure back to the prescribed level of 10cmH20. Theoretically, your husband would have a slightly easier time exhaling at 7cmH2O than if you put him back on prescription at EEP 6cmH2O (and MIN PS of 4cmH2O). I would possibly put him back at the prescribed 6-4 level for a week trial, see how he does, and than try the 7-3 trial for week, and see if there is any difference/improvement. I'm surprised his inspiration pressure is so light. At the lighter inspiration levels the Adapt SV has fewer options for EEP relief, as you can see. I'm thinking the new Adapt SV 'Enhanced' may allow more expiration pressure relief at the lower settings. I have heard the data can be hard to interpret even when you do get it out of the Adapt SV. Hopefully more knowledgeble folks can talk about the data capabilities. Thanks for putting up with us. Let us know what you decide you are going to do between the two possible scenarios

Banned

Snooze_Blues · Post by **Snooze_Blues** » Fri Feb 29, 2008 4:53 pm

Forgive the intrusion.

Casiesea wrote:...I could hear the machine ramping up the pressure, but he would not take a breath. Eventually, it would blow his mouth open ...

Q: is he using the Quattro FF mask? I didn't realize your mouth could be an exit point unless the air was being fed only into your nostrils.

and...

This mornings numbers -

Leak 29L/M
VT 274-740
resp 12-18
mv 5-10

Can someone explain the "mv" number to a newbie? I'm thinking it means "minute ventilation", which I think of as the volume of air breathed each minute, in liters. If that is the case, 5 - 10 liters a minute seems low. Is it? if not, I must be understanding this incorrectly.

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?

Note: I'm being titrated on an ASV machine in a couple weeks.

Casiesea · Post by **Casiesea** » Fri Feb 29, 2008 5:08 pm

I think we will try the 7-3 tonight.

Guest · Post by **Guest** » Fri Feb 29, 2008 6:18 pm

Yes I don't understand that either. Why would a Higher EEP be easier to breath against than a Lower one? I would guess that the maximum pressure of 10 would be the most difficult, not the least. Unless it is somehow backwards? Any info appreciated.

Banned · Post by **Banned** » Fri Feb 29, 2008 7:28 pm

Casiesea wrote:I think we will try the 7-3 tonight.

I agree with you Casiesea. I would want the easiest expiration pressure. Give 7-3 a one week trial. Your husband still needs to get used to the Quattro FF and the Adapt SV, and that takes awhile. We took too big of a leap and the machine probably induced centrals (and then tried to correct for them at the same time) leaving your husband's airway thinking, 'HuHHH?", as dsm suggested. Sorry 'bout that. Make sure the backlight in the LCD in the Adapt SV is turned on. When you check on him at night, the EEP and (total) Inspiration Pressure will always be indicated in the LCD on a breath by breath basis. If 7-3 is a bust after a one week trial you can try 7-3.2 (and slowly increase MIN PS, if needed). Let us know how he feels tomorrow.

Snooze,
Let us know how your titration goes. Dont know what mv means.

Guest,
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.

Cheers

dsm · Post by **dsm** » Fri Feb 29, 2008 7:49 pm

Snooze_Blues wrote:Forgive the intrusion.

Casiesea wrote:...I could hear the machine ramping up the pressure, but he would not take a breath. Eventually, it would blow his mouth open ...
Q: is he using the Quattro FF mask? I didn't realize your mouth could be an exit point unless the air was being fed only into your nostrils.

and...

This mornings numbers -

Leak 29L/M
VT 274-740
resp 12-18
mv 5-10
Can someone explain the "mv" number to a newbie? I'm thinking it means "minute ventilation", which I think of as the volume of air breathed each minute, in liters. If that is the case, 5 - 10 liters a minute seems low. Is it? if not, I must be understanding this incorrectly.

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?

Note: I'm being titrated on an ASV machine in a couple weeks.

Banned · Post by **Banned** » Fri Feb 29, 2008 9:18 pm

I just laid down to get the feel for 7-3 with the Adapt SV and Quattro FF. Very comfortable pressure. Eases you into a very distinct and comfortable exhale space. Definitely sweeter than my old Vantage S8 that I used to run at 9cmH2O with an EPR of 3. He shouldn't need his mask as tight as I have with my current Adapt SV pressure settings of 9-5.4 (but then I don't have a beard). Let's see how it goes.

Banned

Guest · Post by **Guest** » Sat Mar 01, 2008 3:27 pm

Last night:

EEP 7
min ps 3

Leak 15 L/M
Avg Press 8.8
VT 275-675
Resp 13-19
MV 4-10

He was breathing all night long. It was kind of nice. He feels like he slept a little bit better. The thing is...he was still startling a little bit (but he was breathing).

His PSG from 2/25 came today.

Diagnosis: Complex Sleep Apnea, titrated on Adapt SV to EEP 6cm, minimum pressure support of 4 cm and maximum pressure support of 14 cm H2O.

Really Freaky - His heart rate dropped to 15 bpm at one time!!!

OXIMETRY BY CPAP/BIPAP LEVEL:
5EEP, 3 min PS, 15 max PS - RDI 15.8 - NREM O2 90%
6EEP, 3 min PS, 14 max PS - RDI 15.4 - NREM O2 89%
6EEP, 4 min PS, 14 max PS - RDI 5.2 - NREM O2 88% - REM O2 90%
6EEP, 5 min PS, 14 max PS - RDI 12.5 - NREM O2 92%
7EEP, 5 min PS, 13 max PS - RDI 25 - NREM O2 89%

AROUSAL SUMMARY:

NUMBER OF REM NON-REM SLEEP
ARO RES 0 57 57
ARO LIMB 0 19 19
ARO SPONT 4 28 32

TOTAL
PER HOUR
ARO RES 0.0 10.2 9.2
ARO LIMB 0.0 3.4 3.1
ARO SPONT 6.4 5.0 5.2

CPAP/BILEVEL/ OXYGEN TITRATION TABLE:

VPAP SLEEP REM NREM NREM No. No AHI RERA RDI
ADAPT TIME TIME TIME RDI HYP CEN
SV

5EEP 0:34:13 0 34:13 3.5 2 0 3.5 7 15.8
3MIN
15MAX

6EEP 2:00:28 0 2:00:28 3.5 7 0 3.5 24 15.4
3MIN
14MAX

6EEP 2:54:50 37:30 2:16:35 0.9 2 0 0.7 13 5.2
4MIN
14MAX

6EEP 33:38 0 33:38 1.8 1 0 1.8 6 12.5
5MIN
14MAX

7EEP 09:36 0 09:36 6.3 1 0 6.3 3 25.0
5MIN
13MAX

ECG Normal Sinus Rhythm, Bradycardia
PLM Mild source of arousal
Sleep Architecture: Stable, condensed sleep with periods of fragmentation

COMMENTS : Patient came in or an Adapt SV titration. Patient cycled thru all stages of sleep in both suprine and lateral positions. Periods of mild snoring was noted and eliminated with titration. Bradycardia and EMG activity in REM were noted.

Orders:

Machine : *Enhanced VPAP Adapt SV (but the one he got doesn't say enhanced on it

settings
pressure: with a back up rate of 15 b/m
mask : quattro ff
Special instructions: please use machine which allows for usage/ahi monitoring through electronic downloads

dsm · Post by **dsm** » Sat Mar 01, 2008 7:09 pm

Casiesea,

The figures from the PSG look interesting.

Re the 'enhanced' it should have a label with that on - best way to prove it is to check what range of EEP & PSmin can be set. That will tell as it could be a software upgrade (as is so often the case with both Resmed & Respironics machines).

My educated guess is that no hardware gets changed in the upgrade & it is only a software mod. I can't see them having to change the blower nor any aspect of the sensing. The Vpap IIIs appeared to be the same hardware as the S7 Elite & Spirit, e.g. I tried swapping blowers between them & all work as normal.

Cheers

DSM

Casiesea · Post by **Casiesea** » Sat Mar 01, 2008 8:02 pm

Intrude, please! I can learn from your questions too!

Snooze_Blues wrote:Forgive the intrusion.

Casiesea wrote:...I could hear the machine ramping up the pressure, but he would not take a breath. Eventually, it would blow his mouth open ...
Q: is he using the Quattro FF mask? I didn't realize your mouth could be an exit point unless the air was being fed only into your nostrils.

and...

This mornings numbers -

Leak 29L/M
VT 274-740
resp 12-18
mv 5-10
Can someone explain the "mv" number to a newbie? I'm thinking it means "minute ventilation", which I think of as the volume of air breathed each minute, in liters. If that is the case, 5 - 10 liters a minute seems low. Is it? if not, I must be understanding this incorrectly.

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?

Note: I'm being titrated on an ASV machine in a couple weeks.

Casiesea · Post by **Casiesea** » Sat Mar 01, 2008 8:19 pm

[quote="dsm"]Casiesea,

The figures from the PSG look interesting.

Re the 'enhanced' it should have a label with that on - best way to prove it is to check what range of EEP & PSmin can be set. That will tell as it could be a software upgrade (as is so often the case with both Resmed & Respironics machines).

My educated guess is that no hardware gets changed in the upgrade & it is only a software mod. I can't see them having to change the blower nor any aspect of the sensing. The Vpap IIIs appeared to be the same hardware as the S7 Elite & Spirit, e.g. I tried swapping blowers between them & all work as normal.

Cheers

DSM

Banned · Post by **Banned** » Sat Mar 01, 2008 8:52 pm

Anonymous wrote:Last night:

EEP 7
min ps 3

He was breathing all night long. It was kind of nice. He feels like he slept a little bit better. The thing is...he was still startling a little bit (but he was breathing).

His PSG from 2/25 came today.

Diagnosis: Complex Sleep Apnea, titrated on Adapt SV to EEP 6cm, minimum pressure support of 4 cm

Machine : *Enhanced VPAP Adapt SV (but the one he got doesn't say enhanced on it

settings
pressure: with a back up rate of 15 b/m
mask : quattro ff
Special instructions: please use machine which allows for usage/ahi monitoring through electronic downloads

Hi Casiesea,

Looking at the PSG I think his Oximetry, AHI, and REM sleep levels appear better at EEP 6 than EEP 7. You did say he didn't feel that great when he woke up after his first night at home at 6-4, then again, that was his first night. You can either continue with his therapy at 7-3 for a week, Then next week go back to 6-4 and see if he feels better. Or change to 6-4, tonight. Your call. There goes my business model of titrating people on the Adapt SV over the internet.

Moving forward, it looks like the doctor has indeed prescribed the Adapt SV 'Enhanced' for you. The Adapt SV 'Enhanced' is a whole new machine and not a firmware or software upgrade to existing Adapt SVs, which you husband (and I) are currently using. The problem is the Adapt SV 'Enhanced' has not been released yet. The "Enhanced' Machine will be data collection friendly as your doctor has also prescribed. The current Adapt SVs are not data collection friendly. I like your doctor, continue to be sweet to her. You may call and ask her office when your 'Enhanced" machine will be available. And then of course, you will have to teach us all about it, and I'll want one.

Cheers