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rested gal wrote:

Banned wrote:I'm reluctant to accept that different machines do different things, especially when I know the the ResMed Adapt SV does it all, even the stuff you don't know about.

"does it all", eh? Interesting statement.

I truly am glad you like your machine, Banned, and that you feel it's doing the job for you.

Banned wrote:It would be my hope that even the most hardened soles on this forum would come to the realization that anything a cardiologist may recommend, including meds, O2, and surgery, would not preclude the use of Adaptive Servo Ventilation.

I don't think anyone who has been making suggestions in this thread is a hardened soul. When things like Cheyne-Stokes respiration are mentioned, it's time to see a cardiologist, don't you think? Getting the heart checked out doesn't at all preclude the possibility that an ASV machine is best for Elaine's husband.

There's also the possiblity that that's not the machine he needs. Jury's still out on that, and as SAG said, it would be good to have a closer look at his titration. A closer look by someone (not me!) who knows what the squiggles mean.

It would be my hope that the most enthusiastic user of a particular machine would come to the realization that the very specialized machine he uses is not necessarily the one-and-only be-all, end-all treats-all does-everything machine for everyone. Yes, that machine can be a lifesaver for people with specific conditions who really need that particular machine. It could also give poor treatment, imho, to someone who needs a completely different machine.

I agree absolutely with:

kteague wrote:Elaine,

Your hubby is blessed to have you on the lookout.

I can't speak to the specifics of his medical problems, but I wonder why this ENT doc didn't refer him to the appropriate specialist. It's just my opinion, but an ENT, now that a sleep study has revealed the complexity of your husband's issues, should not be the major player in this picture.

and with Julie about needing to see a cardiologist.

Hi RG,

Hardened souls was an unfortunate choice of words and I apologize. I have learned immensely from everybody on this forum and look forward to being a part of this community. I appreciate the forum for allowing me to be the unofficial renegade poster-child for the ResMed VPAP Adapt SV.

Hi Elaine,

I'm glad you are back. My concern is that any respiratory therapist who hands you a CPAP machine and tells you these are the worst numbers she has seen in 11 years should never be handing you a CPAP machine! I can hear Dr. Phil asking, "Are you kidding me!". Sometimes, to get the proper level of care (especially at a sleep lab) you need to tell them straight out what is unacceptable and what it is you need. We can suggest what it is you need. That would still be a ResMed VPAP Adapt SV or a respironics BiPAP Auto SV. I would recommend the ResMed VPAP Adapt SV, and yes, you would need to insist that he be titrated on one. His numbers are screaming for it!

Cheers

rested gal wrote:
<snip>


Neither of those machines is "mediocre", imho. As best I understand them, the Respironics machine is designed mainly to handle obstructives, and centrals secondarily. The resmed machine is primarily for centrals, especially to normalize Cheyne-Stokes respiration, and obstructives secondarily. But I may be completely wrong about that.

<snip>

RG,

I'd love to read any info that looks at one SV vs another - clearly you have found some info that indicates one is better at dealing with obstructions & the other at centrals (& CSR). The explanations would be a good read.

Can you share any authoritive links that explain the differences.

Cheers

DSM

From resmed's site:

http://www.resmed.com/en-us/products/fl ... _sheet.pdf

VPAP® Adapt SV and Adaptive Servo-Ventilation
With its advanced Adaptive-Servo Ventilation (ASV) algorithm,
the ResMed VPAP Adapt SV provides ventilatory support to
rapidly treat all forms of central sleep apnea (CSA), mixed apnea
and periodic breathing, commonly known as Cheyne-Stokes
respiration (CSR).

----

the underlying end expiration pressure (EEP) is clinician
adjustable from 5 to 10 cm H20, helps reduce obstructive
events and can also reduce central events.

"helps reduce"

They don't say something like "eliminates most" when speaking of obstructive events.

People who have primary Obstructive Sleep Apnea and need more than 10 cm pressure while exhaling to prevent obstructive events, aren't going to get more EEP.

From resmed's own technology sheet, this machine seems (to me) to be aimed primarily at treatment of CENTRAL apneas. It does that very specific job very, very well. They have other machines designed to treat primary Obstructive Apnea.


_____________________________________________
_____________________________________________


From Respironics' site:

http://bipapautosv.respironics.com/


The BiPAP autoSV sleep therapy system is specifically designed to be
the best choice for managing complicated sleep-disordered breathing patients.
It combines a number of technologies to recognize and react to changing
pressure needs, and it's clinically proven to treat obstructive, central
and complex apneas and hypopneas, along with periodic breathing.

http://global.respironics.com/UserGuide ... 042977.pdf


The emphasis in that Respironics titration guide seems to be on resolving obstructives first (as in a standard cpap titration) while watching for signs of complex sleep disordered breathing or CSR. If persistent centrals or periodic breathing (I take "periodic breathing" to mean Cheyne-Stokes Respiration) appear, the titration changes direction to go down the Auto SV path.


To me (and as I've said repeatedly, I could be wrong about this) resmed's information puts the emphasis on treating centrals and Cheyne-Stokes Respiration, with a nod to treating obstructives.

The Respironics information puts the emphasis on treating obstructives, with a nod to treating centrals and periodic breathing (CSR) in more or less a timed backup mode way.

One is aimed at treating centrals -- the resmed machine.

The other is aimed at trying to treat a complicated gamut -- the Respironics machine.

If centrals were almost exclusively what I had, I'd want the resmed ASV machine.

If obstructives were primarily what I had, along with a significant number of "some" centrals but considerably less centrals than the number of obstructives during titration, I'd want the Respironics SV machine. Especially if it took more than EEP of 10 to satisfactorily treat the obstructives.

RG,

Thanks I appreciate the comments & your interpretation. I would really like to see some data from sleep labs or studies that comment on this.

One thing that doesn't seem right in the 'EEP won't go higher' assumption is that the SV machines (both of them) vary the pressure based on maintaining the users volume & rate based on sampled data from a period beforehand.

The only way I can see EEP being inadequate is if the sleeper has an OSA on exhalation which is not the norm. OSA can occur between exhale & inhale but that is not really that normal would be preempted by flow limitations or hypopneas & thus detectable & would allow the SV to not drop that low that an OSA event would get a footing - EEP is only the lowest the SV machines will go to (from what I surmise) if they detect it safe to do so.

Your point seems to assume an SV machine will always drop to the 'set' EEP but I don't believe that to be the case (I may well be wrong as I am taking an educated guess at this ) I believe that an SV machine will only drop as low as its collected data considers safe.

This epap to ipap point is an interesting one to consider.

Cheers

DSM

As a general question, does anyone have the setup data for the Bipap SV, what are the various parameters & ranges ?


Tks

DSM

#2 am asking because I can't really make this info out from the links at Resp - tis a bit confusing.

_________________

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

To complete RG's info, here's Respironics:

http://bipapautosv.respironics.com/

The BiPAP autoSV sleep therapy system is specifically designed to be the best choice for managing complicated sleep-disordered breathing patients. It combines a number of technologies to recognize and react to changing pressure needs, and it's clinically proven to treat obstructive, central and complex apneas and hypopneas, along with periodic breathing.

From the FAQs: http://bipapautosv.respironics.com/faq.aspx

Which patient types can utilize the device? The device is designed to treat complicated breathing patterns. Complicated breathing patterns are mixed breathing patterns with OSA, Central, Mixed/Complex Sleep apneas and periodic breathing components, such as Cheyne-Stokes Respiration (CSR).

And

Is it possible to use BiPAP® autoSV™ patients with COPD, OHS and NMD? The BiPAP® autoSV™ is designed to treat complicated breathing patterns in sleep patients. Nevertheless, utilizing the 3 different pressure settings and a standard backup rate of 4 -30bpm, the device can be set similar to that of a standard S/T device. The ASV algorithm is not able to assure a volume which would be most beneficial for these types of patients.

Is a Bi-level S/T device better for these patients (COPD, OHS and NMD)? A Bi-level ST device would be better for these types of patients. Experience with the VPAP adapt on these patients showed that over time the device can not treat them as well.

(Underline mine)
OHS is "obesity hypoventilation Syndrome" NMD is "neuromuscular disease"

Respironics is actually quite clear about the ASV algorithm not being the treatment of choice for COPD patients (like Slinky).

And Resmed too, is clear about the fact that the ASV is not a good algorihtm for treating cases of hypoventilation.

This strategy of using an adaptive target would not work for
respiratory insufficiency or hypoventilation, but does work
for CSA/CSR, which is an overventilation syndrome

.

O.

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

Just reading the manual for the Bipap SV, it looks just like an ST but with varying epap & ipap as per the Bipap Auto (it has an INSP + a BPM setting). I am having difficulty seeing it as a true 'servo ventilator' despite what Resp say.

I would like to get hold of one to compare the the Grey model S/T.

DSM

Banned wrote:We can suggest what it is you need.

We? Who is we? "We" haven't got enough information to suggest anything, other than having that CSR closely examined by a qualified individual.

Banned wrote:My concern is that any respiratory therapist who hands you a CPAP machine and tells you these are the worst numbers she has seen in 11 years should never be handing you a CPAP machine! I can hear Dr. Phil asking, "Are you kidding me!". Sometimes, to get the proper level of care (especially at a sleep lab) you need to tell them straight out what is unacceptable and what it is you need. We can suggest what it is you need. That would still be a ResMed VPAP Adapt SV or a respironics BiPAP Auto SV. I would recommend the ResMed VPAP Adapt SV, and yes, you would need to insist that he be titrated on one. His numbers are screaming for it!

Once again, this is nonsense! If

Elaine wrote:Everything was fine with CPAP at level 8.

then this says that ASV is NOT needed. Reimbursement for ASV is based on set criteria, including

The ruling out of CPAP as effective therapy if either CSA or OSA is a component of the sleep-associated hypoventilation.

That means if CPAP works, insurance won't cover ASV. And if CPAP works, you don't need ASV.

http://reimbursement.respironics.com/do ... autoSV.pdf

And 4 grand is a lot of coin to be shelling out for nothing.

ewains wrote:Also, it should be noted for the record that my husband is fairly young (early 30s). Other than being overweight he is generally in good health. He takes no medications for anything heart related as he has never had any issues with his ticker ever.

Do you live at altitude (Denver, etc.?)

Have 'em print out that portion of the sleep study so you can show it to whomever you decide to follow up with. Also the "Sleep Architecture" graph to show the location during the night. If the "CSR" doesn't have the definitive crescendo-decrescendo appearance then it ain't CSR. Or if those centrals are only at the beginning of night, then they could be normal (Periodic Breathing at Sleep Onset).

That they apparently disappear with low-level CPAP may also mean that they could really be obstructive in nature.

rested gal wrote:Another pair of eyes looking at the supposed "Cheyne-Stokes" breathing on his sleep study might be a good idea...especially since the sleep doctor did not comment on that or tell ewain's husband to get himself to a cardiologist.

Right, there is also the possibility that the CSR is misidentified (not really CSR at all), and perhaps a well-trained polysomnographer could also tell you that (not that I know where one of those would be). Regardless, some qualified individual needs to make the call, it is or isn't CSR, and/or it is or isn't significant.

Banned wrote:And I defer to SAG as the senior unofficial spokesmodel for the (albeit mediocre) Respironics BiPAP AutoSV.

Newbies. Who needs 'em.

SAG

ewains wrote:Hello,
His ENT requested another follow-up study, which was recently completed. This study showed far worse sleep apnea than the first study.

Hi Elaine,

Let me try and be more clear. Your husband has failed CPAP therapy. Over time it has made his condition worse which is often the way of CPAP (induced centrals, lowered his O2, etc.) To put him back on CPAP is simply letting the fox back into the henhouse. I recommend you cancel the Cardiologist and contact a Pulmonoligist (lung doctor). When you see the Pulmo, tell him or her that you observe your husband at night on CPAP and it appears he now stops breathing and then startles awake, or gasps for air on occasion (periodic breathing). Don't ever be afraid to exaggerate his symptoms (or your own) to get whatever medical attention you need. The Pulmo can recommend a new sleep study with the Adapt SV. Your current sleep lab doctor doesn't have a clue (which is often the case). You just need to self-direct your husbands therapy as you seem willing to step-up and do.

Cheers

Banned wrote:Hi Elaine,

Let me try and be more clear. Your husband has failed CPAP therapy.

Banned, we know nothing about Elaine's husband's CPAP use between his first sleep study in 2005 and his recent study.

We don't know what machine he was given after the first study, what kind of support he received, what kind of monitoring and followups (if any) were being done to assess treatment efficacy, whether a machine was being used that would give full data (doubtful) to show if there have been huge leaks all along totally wrecking cpap therapy, whether the machine was being used for every sleeping moment including naps, whether the first pressure prescribed was still an effective pressure as the years went by...etc., etc.

In other words there is no way to say at this point, that CPAP at the right pressure, with the right comfort features, with the right mask, with good leak control, used consistently, cannot be the correct treatment for him.

Elaine, there have been people on here who have reported that their sleep study showed over 100 apneas/hypopneas an hour, and who have been well treated with "CPAP." Perhaps your husband had mask problems, leak problems, difficulty exhaling problems, went some nights without using it all night long...there can be so many things that can interfere with getting good "cpap" treatment that might be easily fixed now that you've found your way to this message board.

I think Banned is well meaning and sincere in urging you to "cancel the Cardiologist." However, I think that's very poor advice. I also think he's pushing an ASV machine at you prematurely and possibly ill-advisedly.

Get the heart checked out. If things look good on the cardiac front, start working on comfort issues with "CPAP", including getting a cpap or bilevel machine that can record full data for you to check each morning at home using software....looking particularly for high leaks.

Elaine, what is the full name of your husband's machine (will be written out on top of the machine) and the name of his mask?

You've said that his most recent sleep study came up with a pressure of 8 as working well for him. Do you remember what pressure he was prescribed after his sleep study in 2005, and was that pressure continued for the next two years?

Did your husband take naps during those two years, without using the CPAP during the nap?

Did he take the mask off very much during the night, to finish out the night not using the machine and mask?

In the past year, had he begun not using the machine at night every night, perhaps thinking that since he wasn't feeling better, why bother to use a machine or put an annoying mask on?

Has your husband ever been diagnosed with GERD? (acid reflux.)

Thank you all for your continued monitoring of this thread and your responses.

Rested gal, here are the answers to your questions:

1) His OLD machine was a Respironics REMstar Plus set to a level 7; his NEW machine is a Respironics REMstar Auto Series M set to a level 8. I'm not sure what brand of mask it is.

2) He was at a level 7 for the last two years and slept very comfortably. I never heard him snoring, choking or gasping as I did before he started CPAP in 2005.

3) Yes, my husband sometimes falls asleep in a recliner or on the couch. I would say he does this 1-2 nights per week and then sometimes takes a short nap on the weekend. If I am downstairs with him, I wake him up because he starts the snoring/choking/gasping and urge him to go upstairs to bed where his machine is. But sometimes he is up later than me & dozes off after I've gone upstairs.

4) He never takes the mask off at night. He has always slept comfortably with the mask on & it's never bothered him. He seems to be a very sound sleeper with the CPAP. He sleeps on his back & doesn't move around much.

5) Ever since he was prescribed CPAP in 2005, he has used it faithfully when sleeping in bed, every night. As I mentioned, there are a few times when he falls asleep on the couch for a while though.

6) He doesn't have GERD. I don't think he's ever even had one incident of heartburn before.

To update further, he was able to obtain a copy of his 2005 sleep study this morning. It showed 76 apenas per hour, 80% oxygen. There were no mentions of central apneas or Cheyne-Stokes at that time. He now has 100/hour - obstructive, central and mixed, plus he apparently has the Cheyne-Strokes breathing pattern at times. I'm obviously no expert, but this seems to have worsened over the last 2 years.

We are currently trying to gather all of his sleep study data - the "squiggly lines" as they were referred to in an earlier post - rather than just the summarized report he currently has. We have called his ENT this morning; we realize he should not be the major player here, but he is VERY well known in this area as a top doc in his field so we are asking his advice on the best doctors to see next - we are hopeful he has some recommendations. We plan to find a more specialized sleep doctor to examine his latest sleep study data. We also plan to see a cardiologist and/or pulmonologist. We have contacted the American Sleep Apnea Association for some guidance on selecting a top doctor, although I'm not sure they will actually do that. We've also been given the name of the local sleep apnea support group leader to try and track down the names of some good doctors. We are positive there's a great doctor out there for my husband, we just don't know how to find him or her...yet. That is today's mission!

Thank you again for all of your advice!

Kindly,
Elaine

Hi, I wouldn't necessarily wait for some famous MD to appear, but would arrange to see a good local cardio person to at least rule out some basic potential common conditions. Even if you choose afterward to see other people, don't you think it's smart to deal with the immediate situation by going to the obvious (to me, who's worked 99% of her career in teaching hospitals) specialist who's available, and worry about the 'ideal' (no one's perfect!) person some way down the road?

Thanks for the very good summary of your husband's CPAP journey over the past two years, Elaine.

Sounds like you're going about what you and he need to do now. I agree with Julie that it would be a good idea to go on and see a local good cardiologist. As you said, your ENT probably knows the best ones in your area and could give your husband a referral.

Do please keep us informed how it goes. You've got a lot of people pulling for your husband and admiring you for all you're doing to try to help him.

For my 0.2c worth, I also would want a heart spc's opinion - CSR really rings alarm bells as does his SpO2 dropping to 80%.

He is very lucky to have you doing this research.

DSM

rested gal wrote:I think Banned is well meaning and sincere in urging you to "cancel the Cardiologist." However, I think that's very poor advice. I also think he's pushing an ASV machine at you prematurely and possibly ill-advisedly.

Absolutely ditto.

All poor medical advice considered, rested gal was wonderfully polite with that statement of hers.