Why doesn't APAP respond to apneas?

I had bought an oximeter, but couldn't get it to work with Vista on my laptop. So returned it. Anybody have a recommendation for a good one? That works with Vista? The one I got said it would work with Vista, but it wouldn't.

Bev

-SWS wrote:If it were me I'd run another night at 14 cm. Then I'd switch to 15 cm for a while and see if symptoms improve.

If moving on to baselining with BiLevel I'd try to get my hands on an overnight recording pulse oximeter somehow. Buy, borrow, or even get it R/X'ed by any doc, including your general practitioner.

I'd go ahead and move it to 15 cm on EPAP and see what happens. Bumping EPAP up by one might just settle down the things that caused IPAP working pressure to go nutso.

OutaSync wrote:I had bought an oximeter, but couldn't get it to work with Vista on my laptop. So returned it. Anybody have a recommendation for a good one? That works with Vista? The one I got said it would work with Vista, but it wouldn't.

Bev

The one James Skinner had purchased seemed like a pretty good one to me, the reports were great, I think he runs Vista, you might want to ping him on it.

I'd also like to see you ween off the Ambien even if that meant doubling the dose of melatonin for a while. All the papers I have ever read you can safely take up to 9 mg/day. I think you are using 3mg now, I would try 6mg for a night or two and see what happens, also monitor your daytime fatigue for any change.

I have tried Ambien several times in the past while it puts you to sleep I also felt way more fatigued the next day.

Bev, here's just one thread about a Vista compatible oximeter:
viewtopic.php?f=1&t=34591&p=295937#p295892

Snoredog wrote:

-SWS wrote:If it were me I'd run another night at 14 cm. Then I'd switch to 15 cm for a while and see if symptoms improve.

If moving on to baselining with BiLevel I'd try to get my hands on an overnight recording pulse oximeter somehow. Buy, borrow, or even get it R/X'ed by any doc, including your general practitioner.

I'd go ahead and move it to 15 cm on EPAP and see what happens. Bumping EPAP up by one might just settle down the things that caused IPAP working pressure to go nutso.

I agree that may be the best EPAP value for SV. I still think she needs to first baseline that 15 cm value at CPAP to compare against her 14 cm data and especially subjective assessment of symptoms. Also, before ever turning SV back on, I think she needs to incrementally introduce these deltas while baselining a small fixed BiLevel PS of 3 cm (while phsyiologically acclimating to small, controlled doses of BiLevel):

1) spontaneous BiLevel at 17/14 or 18/15, depending on best baselined CPAP (no BPM yet means only one delta is introduced for later comparison)
2) auto BPM BiLevel at 17/14 or 18/15, again pending CPAP results (now adding a second delta for comparison)
3) manual BPM/IT also at 17/14 or 18/15 (if there's a clear cut comfortable winner of these three, that's how the SV modality experiment should be set up next, using just a slightly higher IPAPmax at first)

She definitely needs a recording pulse oximeter to go beyond CPAP baselining. A PSG/MSLT would be absolutely positively best. No question about that. None. However, home-based testing is far better than indefinitely languishing with poor daytime symptoms at the doctor's request IMHO. I would have gotten a new sleep doctor long ago. Also a new Encore Pro programmer...

I think she wants to avoid the Narcolepsy diagnosis and stigma and monetary ramifications that goes along with having that disorder. All the MLST is going to show is how tired she is, we all ready know that, once you have the test and some doctor fires off the shot for the diagnosis you are screwed, you cannot take it back. She has not mentioned cataplexy at all nor any sleep attacks. Sometimes simply having a diagnosis is worse than the disorder itself on one's lifestyle.

Having the diagnosis is NOT going to make her sleep any better. All they can do is control the symptoms, to do that, they give you drugs to keep you more alert during the day, most of them addicting controlled substances.

Let's hypothesize what if a person does have Narcolepsy? There is no cure. What will they do to treat it? There is a long list of medications to control it,

http://med.stanford.edu/school/Psychiat ... tions.html

What are we hoping to accomplish with the SV?
Avoid Central Dysregulation so she hopefully sleeps better?

Doesn't seem all that bad on Aflex, she could probably use an increase to 15 cm even on that machine.
Is there something else disrupting her sleep architecture? that is what the jest of the SV trial is in my opinion,
and I agree she needs to try another sleep lab, one more experienced with her condition. Her complaints about
EDS is really no different than others we have seen with CSDB.

If we look at her Bilevel titrations, clearly the central events are the cause of desats to dangerous levels. As long as we are baselining at the single pressure the risk is low, but if any pressure support is added well will need to either enable BPM=Auto or establish fixed parameters to correct it should she go into central dysregulation as that is where the desats occur (according to her PSG).

That same PSG did show she had her first REM period at 21/17 if only for 2.5 minutes with NO central dysregulation seen, then at the maximum 25/21 she had 15 minutes of REM but also centrals again showed back up.

Her PSG's simply don't show much in the way of spontaneous arousals or other microarousals. SAG hasn't mentioned anything on that front either. So is it muscle-skeletal pain causing the interruption to sleep? Maybe she needs to see a pain Specialist?

My ex sees a pain Specialist because she's a PIA , but I think Bev has a entirely different and legitimate reason to see one (not to infer she is a PIA), maybe talk to her surgeon about the residual pain she has, maybe there is something they can do to control it. But it seems they just give her drugs like Lexapro with no care in the world what it does to her sleep.

Just awake - did night with epap=14, IpapMin=14 & IpapMax=14 BPM=auto. Not nearly as nice a night's sleep as with SV mode Data explains it well !. Feeling 'heady'.

Dunno how you can handle that setting Bev - truly ! I'll be back to my regular settings asap !





Full report = http://www.internetage.ws/cpapdata/dsm- ... 0oct08.pdf
Also the night before when I raised epap by 1 CMs to see if that cleared any of the regularly scored AI events. http://www.internetage.ws/cpapdata/dsm- ... 9oct08.pdf

Give me AI scores any day over PB scores

DSM

Snoredog,
You have it right about the cost of things, the insurance and the diagnosis factor. My surgeon referred me to a neurologist, who referred me to a pain specialist. They have agreed on Lyrica as the medication to address what they called musco-skeletal myofascial pain, or something like that. I was hesitant to start the Lyrica because we were just starting the trials with the SV, but I started taking it the night before last. So two nights with the Lyrica. The side effect of that is extreme daytime sleepiness. Today I am so tired that I can see my heart beat in my vision. I just had my eyes examined two weeks ago, so no dings there.

DSM,

What are we looking for in the comparison?

Bev: I would try a single 325 enteric aspirin every night before bed (if you have no problems tolerating aspirin). Try it for 10 days. Use on the enteric coated type. It has a different effect on pain when taken daily, takes about 10 days to build up a level in your blood stream. But I find it controls my sciatica leg pain and when I stopped/lowered the dose once I found I had arthritis and never knew it. You have to be careful if you cut yourself but you won't bleed out or anything. The object would be to see if the aspirin would control the pain better and aspirin has few side effects on interrupting your sleep and no residual daytime fatigue. Unlike other drugs, you don't build up a resistance to aspirin. Same for melatonin, only side effect of melatonin is daytime fatigue if you take too much of it.

DSM: Have you ever had a full cardio workup completed? You seem to go into PB quite easy, and now you know why I wanted to avoid that at all costs with Bev's SV settings. Same for Central Dysregulation, in her case those centrals are long and lead to dangerous desats.

OutaSync wrote:Snoredog,
You have it right about the cost of things, the insurance and the diagnosis factor. My surgeon referred me to a neurologist, who referred me to a pain specialist. They have agreed on Lyrica as the medication to address what they called musco-skeletal myofascial pain, or something like that. I was hesitant to start the Lyrica because we were just starting the trials with the SV, but I started taking it the night before last. So two nights with the Lyrica. The side effect of that is extreme daytime sleepiness. Today I am so tired that I can see my heart beat in my vision. I just had my eyes examined two weeks ago, so no dings there.

DSM,

What are we looking for in the comparison?

Bev,

The main thing was to see how my machine behaved compared to yours with similar setup. I also used ramp set at 11 CMs for 15 mins - notice that the ramp DOESN'T SHOW in the chart like yours did and also notice that the Av Peak Ipap - REMAINS FLAT (whereas your machine had it 1 CM higher than IpapMax) - this suggests to me that there is either an incompatibility in the Encore Pro software or that your machine is not behaving predictably (normally). Your firmware is one level later than mine. My Encore Pro version is 1.8.49 & for me seems to be reporting my data as expected.

The other thing the data tells me is that we are quite different in our needs (should be obvious but the disparity is notable). In your case it seems that your breathing has a troublesome unpredictability and that will make it hard to try to match a predictable xPAP machine (even an SV) to your breathing. The need for medication seems to be a significant factor in these breathing patterns.

When I started xPAP therapy I was on 15 CMs and stayed on that for about 8 months (2 months on CPAP & 6 months on AUTO) before switching to a bilevel which I ran initially at 8/15 (approx 4 months) then 10/13 (at that time I discovered the clinic had written 15 instead of the correct 13 for my titration CMs thus had me on 2 CMs higher than my titration and that was for over a year.

I am sure hoping that we here (esp SAG now he has your data) can hone in on the best way to stabilize your xPAP therapy. You have gone through a lot of experimenting & deserve a good outcome.

For me, the Bipap SV stays king of the configurable machines & consider myself very lucky to have one.

DSM

Snoredog wrote:
<snip>

DSM: Have you ever had a full cardio workup completed? You seem to go into PB quite easy, and now you know why I wanted to avoid that at all costs with Bev's SV settings. Same for Central Dysregulation, in her case those centrals are long and lead to dangerous desats.

Did a full stress ECG just before going on CPAP - told me I was ' fit as a Mallee bull' (Mallee region in SA produces tough trees & animals) http://www.babylon.com/definition/As_fi ... e_bull/All
Am quite happy am still as fit today

Also, running the SV in SV mode has without doubt produced the best & most consistent results I have had from any machine I have ever used. Straight CPAP (incl AUTO) seemed great for a short while (SWS's placebo effect ) but bilevel was better & SV best. I really believe I have that SV machine tuned to the best possible settings for my needs, I am sure of this right to within 1 CMS for the epap & IpapMin settings.

DSM

So, for tonight I run
EPAP 15
IPAP Min 14
IPAP Max 14

Take aspirin, double my melatoin and cut out the Ambien.

How will I breathe against EPAP higher than IPAP? I thought it was supposed to be 3-4 below IPAP.

Bev

OutaSync wrote:So, for tonight I run
EPAP 15
IPAP Min 14
IPAP Max 14

Take aspirin, double my melatoin and cut out the Ambien.

How will I breathe against EPAP higher than IPAP? I thought it was supposed to be 3-4 below IPAP.

Bev

Bev,

I don't believe you can set epap higher than the other 2 (IpapMin & Max) - I think someone mistyped that setting. I think they meant all at 15.
But, I think SWS was suggesting another night with all at 14 ?.

Doug

Bev-- If you'd like to run at 15 cmH2O tonight just set them all at 15 as DSM mentioned.

Doug- I can see how that autoSV machine gives you great sleep when SV is turned on and fine-tuned. Thanks for that graph!

Snoredog- I think the hope with SV for Bev is that EPAP gets set high enough to mitigate as much as it possibly can, and then SV smooths out or straightens her flow amplitudes. A few pages ago I quoted a failed CompSA/CSDB titration. They set the EPAP equivalent high enough to take care of A & H, but should have gone a bit higher to take care of RERA's. Bear in mind they could have accomplished that much on ordinary CPAP or BiLevel. But that doesn't suffice for patients like that. Supposedly the SV additionally compensates even slight biologic respiratory controller fluctuations (flow amplitude oscillations), and the end result is sometimes much improved sleep.

That's the hope for Bev: to get just as much of her A, H, & RERA out of the way with EPAP, and then allow SV to come in and attempt to smooth out her flow amplitudes---hopefully toward better sleep.

I know you all think Bev's Tidal Volume is ok, and maybe it is, but save for one occurrence that indicated a VT 420ml, she is generally at the very low end of her 5 kg VT minimums. I guessed her Frame: Medium, Height: 5' 7", Weight 120lbs. The 5kg minimum for someone of this stature is 337ml. The light VT maybe worth watching. http://www.healthcentral.com/diet-exerc ... 6-143.html

Banned

OutaSync wrote:So, for tonight I run
EPAP 15
IPAP Min 14
IPAP Max 14

Take aspirin, double my melatoin and cut out the Ambien.

How will I breathe against EPAP higher than IPAP? I thought it was supposed to be 3-4 below IPAP.

Bev

I think SWS wants you at:
EPAP 15
IPAP Min 15
IPAP Max 15

Goal is to see how you do on 15, may be able to try Pressure support if that higher EPAP settles you down.

Yep on the aspirin in place of the Lyrica, 6mg of melatonin in place of the Ambien/Melatonin combo. Goal of this
is to reduce the daytime fatigue side effects. Aspirin daily (taken before bed) 325mg, enteric coated. It will dissolve
in the intestine and not contribute to stomach irritation.