Why doesn't APAP respond to apneas?

Thanks, all,

I raised my lower pressure by .5 to see if that would help. Unfortunately, my "M' was on vacation on Thursday and Friday nights and this morning when I pulled the card out, I didn't hear it ping, so I guess I didn't have it in far enough last night. No data for three nights !@#%%$#@@%^&. Last night I woke up many times and stayed awake once for over an hour. Lots of air passed through me, like gunshots, in their escape. As usual, I went to bed exhausted and eager to sleep and woke up exhausted, feeling as though I hardly got any sleep.

Snoredog, on your suggestion, in June, I lowered my min to 8 to let the auto do it's job. Much worse data. I've been slowly closing the gap to see what worked best as far as AHI. The 14 to 17 has been best so far. But I couldn't figure out why I still had so much trouble waking up and NEVER feel rested. That's when I discovered the lengths of the apneas. That has got to be the key. I can't wait to bet the new machine and see how that works.

BTW, I don't have any two nights that look alike. Even when I have the same routine, my data can look vastly different from night to night. I don't ever recall waking up thinking I was choking, or gasping for air. I wake up and then about 5 seconds later, my whole body gets very hot and I have to throw my covers off to cool down. When I was younge rI would wake up soaking wet. Now I wake up just before the heat sets in. Thyroid tests came in normal.

Echo, I have that problem, too. If I have insomnia one night (as I do when I travel) the next night will be worse. It's a terrible cycle. All I want is to be able to sleep through the night and that has happened to me only one night for as far back as I can remember.

Bev

I'm sure Bev welcomes all opinions and comments

I think one very insightful comment that was made earlier in this thread was about the possible effect of medication on one of the titration results. I would extend the application of that observation. Sleep medications have their place, but the price for using them can be abnormal architecture, increased daytime fatigue, and unpredictable interactions with other common drugs, such as alcohol and caffeine.

jnk,

They gave me Ambien before both studies. I don't drink alcohol (never have)and I have a cup or two of green tea in the mornings. I am very health conscious. Did I mention that I have had sleep problems ALL of my life and only a year ago got diagnosed because the doctors did not think that I "looked like the type ofperson who would have apnea" , i.e, tall and thin. I didn't know I snored and stopped breathing until a trip I took in 2006 where I shared a room with someone who commented on it. I used to wake up a lot thinking someone was in the room because I had woken to talking or animal like noises. It was just me.

But thanks for thinking that I might be a drug using drunk!

Bev

OutaSync wrote:jnk,

They gave me Ambien before both studies. I don't drink alcohol (never have)and I have a cup or two of green tea in the mornings. I am very health conscious. Did I mention that I have had sleep problems ALL of my life and only a year ago got diagnosed because the doctors did not think that I "looked like the type ofperson who would have apnea" , i.e, tall and thin. I didn't know I snored and stopped breathing until a trip I took in 2006 where I shared a room with someone who commented on it. I used to wake up a lot thinking someone was in the room because I had woken to talking or animal like noises. It was just me.

But thanks for thinking that I might be a drug using drunk!

Bev

HA! You green-tea addict and Ambien pusher you! No. I am in no position to cast that first stone! I'm the coffee, scotch, Benadryl-using sinner. (My name is jeff, and I chase my Irish Coffee with Bennies.) I don't even have anything against the idea of using Ambien before titration, or whenever needed, in principle. It's pretty common, I think. And it does its job amazingly well for some. And I may have completely misunderstood whatever it is the experienced poster was able to see in the titration data earlier. The only reason I mentioned it (as clumsily as I did ) was that in your case, I wonder if the Ambien may have affected the widely divergent titration data that are now being looked at by the big dogs for setting up the SV. Because of the drug-induced stupor, oops, I mean Ambien-induced sleep of your sleep studies, I wonder if the auto's results from day-to-day from right next to your bed may be much better data to use than those titrations, when it comes to setting up the SV. That's all I meant.

Still friends?

jeff (who thinks he may need to finish his second cup of coffee now and have a "drink")

Snoredog wrote:SWS: Her 10/16/07 PSG Respiratory events nearly mimics the Encore Pro report pulled 10/13/07. Clearly on that PSG the centrals are the bad guys with her SAO2. While there ARE NRAH's showing up on the 10/13 Encore report, you have to also conclude that many of the obstructive apnea seen on that Encore report are Central and a mix of obstructive, maybe they are mixed apnea I don't know.

Keep in mind when NRAH shows up that is 6 events and 3 pressure increases it takes to fire that off. If there were only 3 or 4 those would be counted by Encore as obstructive (when they were most likely central). So when you see those clusters across the page and compare to the 2 PSG's pattern they are nearly identical.

But if you erase those NR's that same pattern is what I look for when a person is experiencing central apnea along with obstructive. If I had a red pen, I'd circle each one of those clusters and tell you half of those tics seen are central.

The "chair" pressure probing is again seen between the quiet periods on that 10/13 report. No look at the 10/16 PSG titration, Zero events at 9.0 cm pressure. So if it was me looking for a baseline for the Adapt SV settings, I would follow recommended protocol and start with initial settings:

Auto SV mode
Set EPAP at 9.0
IPAP Min at 10 cm
IPAP Max at 25
Backup Mode = 10 BPM, IT=1.2 (if it cycles that should stop the CA's).

I would want to see the above results before increasing EPAP higher. If things are smooth and User initiated breaths are high you can use the BPM to set the backup mode, or if you set backup mode to auto it will set that for you from the Spontaneous finding.

The difference over everything we've seen is the SV will be able to automatically take care of everything on the Inspiration (IPAP) side and hopefully we can get some data to set up the backup mode. Maybe EPAP is set a bit high at 9, but any higher than that and centrals appear in her lab studies. She doesn't seem to have any spontaneous arousals that are of concern, 3.1 is nothing I'd be worried about.

PSG Question: Wonder why they don't give BPM information on a PSG?

With Bev's current settings on the Aflex, it is set up nearly like CPAP, using the minimum pressure at 14 cm and limiting to 17 cm there is not much movement in that range and the result is the lowest AHI out off all the titrations and reports seen.

If it was me, I'd like to see what the AdaptSV's auto mode comes up with. Hopefully the SV can manipulate her IPAP working pressure and inspiration volume to keep those centrals at bay. But EPAP will be fixed, it is my understanding that the same EPAP will be used when in backup mode. The SV protocol calls for using the EPAP pressure that eliminates the obstructive, but you CANNOT rely on the Encore reports we've seen for that information (because it includes both obstructive and central counts and you don't now how much of each). So I would rely on the 10/16/07 PSG titration for that and let the SV do its magic.

Out of everything I've seen here on Bev, if I only had a CPAP to use, I'd set it at 9 cm.

(2nd go at posting)

The suggested settings seem ok for epap but setting ipap 1 above epap when ipapMax is 25 does nothing. Bev has already pointed out that a gap of 3 gives her best data results. Setting IpapMAX to 25 probably doesn't matter on this machine as the chances of it going above about 21 are pretty remote. at least go for 9,11,25 then experiment with 9,12,25 also as a starting point risetime=3 (any faster may exacerbate aerophagaia). It may even be worth trying risetime out to 4 (400ms) as Bev's issues don't appear related to a need for higher volume. BPM=auto should be fine in Bev's case.

Also, one core benefit of an SV is its ability to correct irregular (variable?) breathing & setting the epap-ipap gap so low (e.g. to 1 CMs) is in all probability going to wipe out that machine benefit for no good reason. A Min gap of 3, on an SV, in this case may make more sense. I guess the balancing act here is good data vs aerophagia discomfort.

DSM

Okay, I think I got it. Now I just wait for my machine to come. I hope it uses the same software. BTW, since Encore saves as PDF, and Photobucket won't take PDF, what is the best way to transfer to photobucket?

You are all terrific for helping me sort this out. I'll be back soon with more questions.

JNK-THanks for the laugh. (and I love your music)

Bev

Have you talked to your doctor about this and the problems that you are having? I have had the same machine for a year and I was having problems with the blotting feeling etc. at about the 3 month level and the doctor had my settings changed to the lowest settings. I also had weight loss surgery with the band and that was causing some problems. When I talked to the doctor about it he suggested to go to a dentist who deals in sleep apnea and I was fitted with a herbest retainer and have been doing great with it. Iam also down over 65 lbs and had another sleep study and the numbers are all down. Will know more on Monday and might not have to use the machine. Will let everyone know what happens.

Chris

dsm wrote:The suggested settings seem ok for epap but setting ipap 1 above epap when ipapMax is 25 does nothing.

Recall that this machine can apply SV to either CPAP modailty or BiPAP modality. Recall that CSDB/CompSA patients tend to destabilize with all three of these modalities: 1) APAP (especially highly fluctuating APAP), 2) CPAP (not as destabilizing as APAP), and 3) BiLevel (usually not as destabilizing as CPAP). So APAP modality is the worst for CSDB/CompSA patients---especially as it's allowed to progressively fluctuate. So most of those CSDB/CompSA patients will find CPAP mode more destabilizing than BiLevel. But some of those patients are reported to find BiLevel mode a bit more destabilizing than CPAP!

In light of that last statement, I believe the Respironics design rationale is to allow the clinician to apply SV modality to either CPAP mode or BiPAP mode. Most CSDB/CompSA patients will obviously require BiPAP+SV. However, those CSDB/CompSA patients who found CPAP less destabilizing would be able to have SV modality applied to CPAP on an as-needed basis. Thus in that last case IPAP min would be set to match EPAP. The machine will stay in that CPAP mode until that CSDB-specific central dysregulation occurs. When it does CPAP mode is temporarily usurped by BiPAP SV mode with automatically fluctuating IPAP peak values (limited by IPAP max).

So I think the idea is that clinicians can apply SV to BiPAP modality (for most CSDB/CompSA cases) or they can apply SV to CPAP (far fewer CSDB/CompSA cases). And based on Bev's comment that she fares better with an IPAP/EPAP spread of 3 cm, I don't see the point in applying SV to CPAP either.

dsm wrote:chances of it going above about 21 are pretty remote. at least go for 9,11,25 then experiment with 9,12,25.

You think the chances of going past 21 are pretty remote based on...???? And Respironics recommends initially setting "IPAPmax 10cmH2O above the CPAP or BiPAP pressure".

So why do your recommendations defy your own logic? And more importantly, why do they also defy manufacturer recommendations, my friend?

dsm wrote:Bev's issues don't appear related to a need for higher volume.

How do we know the volume needs and variations?

dsm wrote:Also, one core benefit of an SV is its ability to correct irregular (variable?) breathing & setting the epap-ipap gap so low (e.g. to 1 CMs) is in all probability going to wipe out that machine benefit for no good reason.

Respironics documentation explicitly states that variable breathing ("periodic breathing") is corrected by how high or low IPAP peaks on each breath in compensation for those irregular amplitudes. That's the "SV" part of the algorithm. That "SV" part of the algorithm doesn't have anything to do with the gap between EPAP and IPAP min. A zero CM gap between EPAP and IPAP min (meaning CPAP mode + SV) doesn't even keep the machine from applying IPAP peak (bound by the IPAP max value) on an as-needed basis.

Great discussion! More thoughts from others as well are encouraged!

dsm wrote:The suggested settings seem ok for epap but setting ipap 1 above epap when ipapMax is 25 does nothing.

Geeze man, look at the titration protocol!!

It says to carry CPAP setting over to EPAP with a 1 cm delta for IPAP Minimum until obstructive events are taken care of. This is NOT a choice to use CPAP or SV, its how you set the frigging thing up if you read the Respironics instructions. There is even a flow chart decision tree which tells you what to change if Periodic Breathing or Central events exist. Sometimes you guys overanalyze things and make it a whole lot more difficult than it has to be.

If you are looking at CPAP info on the Adapt SV and wondering why they put that there, you haven't read far enough yet.

Snoredog wrote:Geeze man, look at the titration protocol!!

It says to carry CPAP setting over to EPAP with a 1 cm delta for IPAP Minimum until obstructive events are taken care of. This is NOT a choice to use CPAP or SV, its how you set the frigging thing up if you read the Respironics instructions. There is even a flow chart decision tree which tells you what to change if Periodic Breathing or Central events exist. Sometimes you guys overanalyze things and make it a whole lot more difficult than it has to be.

If you are looking at CPAP info on the Adapt SV and wondering why they put that there, you haven't read far enough yet.

Respironics clearly refers to their "SV" mode as "automatic pressure support". They clearly allow for that "automatic PS" to be applied not only to BiPAP mode (they call it "BiPAP + PS") but they also intend it to be applied to CPAP mode should etiology require (they call it "CPAP + PS"). And I explained that etiology would be a CSDB/CompSA patient who tends to destabilize less with CPAP modality than BiLevel modality.

Their marketing literature describes both "automatic PS" capabilities:


And their documentation clearly showcases their "automatic pressure support" (SV mode) applied to CPAP:


Thanks for the flattering characterization, Snoredog! When we finally catch up with you in China, egg rolls are on us!

-SWS wrote:[

<snip>

dsm wrote:chances of it going above about 21 are pretty remote. at least go for 9,11,25 then experiment with 9,12,25.

You think the chances of going past 21 are pretty remote based on...???? And Respironics recommends initially setting "IPAPmax 10cmH2O above the CPAP or BiPAP pressure".

So why do your recommendations defy your own logic? And more importantly, why do they also defy manufacturer recommendations, my friend?

SWS, I was being polite re the 25 IpapMAX suggestion. Also based on the data from Bev and my own experience I would 'guess' it won't. Do you believe from the data discussed this far that it will ? - if yes why ?

dsm wrote:Bev's issues don't appear related to a need for higher volume.

How do we know the volume needs and variations?

SWS, Volume didn't seem to be an issue up to this point. What makes you believe it is ?

dsm wrote:Also, one core benefit of an SV is its ability to correct irregular (variable?) breathing & setting the epap-ipap gap so low (e.g. to 1 CMs) is in all probability going to wipe out that machine benefit for no good reason.

Respironics documentation explicitly states that variable breathing ("periodic breathing") is corrected by how high or low IPAP peaks on each breath in compensation for those irregular amplitudes. That's the "SV" part of the algorithm. That "SV" part of the algorithm doesn't have anything to do with the gap between EPAP and IPAP min. A zero CM gap between EPAP and IPAP min (meaning CPAP mode + SV) doesn't even keep the machine from applying IPAP peak (bound by the IPAP max value) on an as-needed basis.

SWS, agreed that a zero gap won't stop PS working (good point), the point I would make is that PS when activated = a new Ipap (limited by IpapMax) which is still followed by epap even if epap is set to same as ipapMin (machine runs as a Bilvel rather than a Trilevel). Are you are saying that periodic breathing is *only* corrected by PS setting & nothing to do with cycling ? if yes I would like to see more info (you may well be right) but I for the life of me can't see how the SV can bring errant irregular breathing back inline (see SV specs - I believe it says within 3 breathing cycles) by increasing Ipap unless it is making use of the PS gap between epap and now IpapMax (when epap=ipapMin) to manipulate the sleeper back to the correct breathing rate. Also it will from what I see keep upping the PS until it works (and within its 3 cycle target). Are you mixing VB with Irregular Breathing in this regard ? - just to restate, I understand your point that CPAP mode may suit some people and that CPAP mode still offers PS & the PS can bring irregular breathing under control, but that has everything to do with the gap ! (which is cpap setting (epap=IpapMin) + PS as it gets applied ever incresingly, to bring the user back to the target rate.

Bev says her best numbers are from Bilevel mode - so following that, why disable it in her case & just use PS (which creates a bilvel mode as soon as PS (IpapMax) starts getting exercised) .

Great discussion! More thoughts from others as well are encouraged!

SWS, as always, you really trigger thinking about the topic at hand. Thanks DSM

SD wrote
"It says to carry CPAP setting over to EPAP with a 1 cm delta for IPAP Minimum until obstructive events are taken care of. This is NOT a choice to use CPAP or SV, its how you set the frigging thing up if you read the Respironics instructions. There is even a flow chart decision tree which tells you what to change if Periodic Breathing or Central events exist. Sometimes you guys overanalyze things and make it a whole lot more difficult than it has to be.

If you are looking at CPAP info on the Adapt SV and wondering why they put that there, you haven't read far enough yet. "

SD,

The titration process uses CPAP as the starting point to eliminate obstructive apneas. Then when that phase appears to be stable they have a baseline, then they say carry the CPAP setting over to epap (with a variance of 1 CMs (delta) to begin the next phase of the titration.

Your original suggestion of ipap being set to epap+1 still makes no sense - even in that context - it looks to me like a misreading of the titration process ?.

Cheers

DSM

-SWS wrote:to complicate matters, those poor daytime symptoms can be entirely unrelated to CPAP therapy.

I think something, or several somethings, unrelated to CPAP therapy are most likely what's accounting for Bev's daytime EDS (excessive daytime sleepiness.) There can be soooo many health or sleep hygiene issues besides sleep disordered breathing that can cause problems..even if OSA therapy is doing its part of the job well.

Bev, I could be very, very wrong about this, but I really don't think you need to be concerned about the average length of time your supplemental data showed for the few (and scattered) apneas you had on the recent graphs ozij posted in this thread. But I may be being too blase' about those.

My edit was to make the quoted statement appear correctly. No words added or taken away in the post.

SWS,

I think I can see a divergence between our thinking re irregular breathing.

I guess I am focusing on (perhaps too much) the variation in rate whereas you are focusing (perhaps too much) on just flow.
Correcting the BPM rate AFAICT is only done with cycling, I agree though that flow fluctuations (via Peak Flow), are corrected
with PS. So I am thinking we are both right within the line we are pushing. I am sure we both agree on how Target Peak Flow
works.

The Vpap SV will almost frog-march a CHS sleeper back into line within one breathing cycle (volume support). The Bipap SV leads the sleeper
more gently (3 breathing cycles).

Both flow (PS) and rate (cycling) are the mechanisms the Bipap SV has at its disposal to deal with such situations. Are we talking about these two different mechanisms as if they are one

DSM

dsm wrote:SWS, I was being polite re the 25 IpapMAX suggestion. Also based on the data from Bev and my own experience I would 'guess' it won't. Do you believe from the data discussed this far that it will ? - if yes why ?

Okay...I see. I didn't quite follow where that 25 cm value came from. The machine is capable of 25 cm. And some neuromuscular closures are in excess of 25 H20 column pressure. What did Dllfo's BiPAP SV machine max out at?

Rather than assign a probability to an unknown, I would personally be tempted to initially go with the manufacturer's recommendation on IPAP max---and then cautiously tweak up. We can look at considerably more volumes of Dllfo's data and not notice his prolonged times spent at IPAP max. And yet, it happens to him on an episodic and infrequent basis. Again, we don't know Bev's etiology, so this should be assigned a unknown status rather than any given high probability status IMO.

And thank you for being polite!

dsm wrote:

-SWS wrote:How do we know the volume needs and variations?

SWS, Volume didn't seem to be an issue up to this point. What makes you believe it is ?

Please read my statement again, my friend. I don't believe that volume is a problem. I also fail to believe that volume is not a problem. If we don't know Bev's volume needs and variations, then how can we know either way? So, why, then, do you believe that volume is not a problem on certain nights if there are moderately wide night-to-night variations here? Is volume not a problem on the nights when Bev has central and mixed apneas? Or is volume not a problem on nights when she experiences no central dysregulation?

dsm wrote: Are you are saying that periodic breathing is *only* corrected by PS setting & nothing to do with cycling ?

Not at all. Recall that periodic breathing was treated for many years, with much less success, using ordinary BiLevel. It's the fluctuating gap ("automatic PS" amplitude ) that Respironics view graphs attribute to being the primary treatment for periodic breathing. The older conventional BiLevel parameters (namely pressure frequency cycling) helped and still do.

Not to confuse the benefits of fluctuating gap (SV or "automatic PS") with the benefits of static gap (fixed PS). Let's take the case of a CSDB/CompSA patient who destabilizes slightly more with BiLevel than CPAP. That patient thus gets IPAP min set to EPAP (CPAP mode). Like all CSDB/CompSA patients, they go from a steady-state of regulation, to a triggered and transient state toward dysregulation, and finally on to a short-lived steady state of oscillatory dysregulation. Of those three states, CPAP is advantageous in the first----simply because it induces that second stage less frequently. Then onto that third oscillatory state they go, where the offsetting pressure fluctuations now become the most advantageous machine modality until state one is restored. Specifically the pressure fluctuations entail offsetting pressure magnitudes to minimize that time spent in dysregulation.

So I agree that Bev is not likely the CPAP+PS case. Interesting none the less IMO.

rested gal wrote:

-SWS wrote:to complicate matters, those poor daytime symptoms can be entirely unrelated to CPAP therapy.

I think something, or several somethings, unrelated to CPAP therapy are most likely what's accounting for Bev's daytime EDS (excessive daytime sleepiness.) There can be soooo many health or sleep hygiene issues besides sleep disordered breathing that can cause problems..even if OSA therapy is doing its part of the job well.

I agree wholeheartedly. See?

earlier -SWS wrote:Any PLMs, bruxism, GERD, arthritis pain, medications, etc. that might be thoroughly trouncing that sleep architecture?

earlier -SWS wrote:My hunch is that simply fixing those isolated straggler apneas may not sufficiently fix up your sleep problems and daytime energy issues. I have a hunch that you may have a variety of sleep issues that need to be collectively addressed. Perhaps it's time to find a more cooperative sleep doctor.

Now with that said, am I the only one who thinks Bev's bifurcation of central dysregulation may be a salient clue here? Some nights she has central dysregulation and other nights she does not. Do we think bumping up pressure a teensy bit is going to fix that? It might, but I doubt it. That bifurcation is potentially a central clue (pun intended) and it seems to be getting little or no consideration in this thread.

I'm thinking that a patient with that kind of central bifurcation tendency probably has an unresolved SDB problem that accounts for her daytime symptoms. Am I the only one in this thread who seems to think along these wacky lines? What's the nature of that central bifurcation? Snoredog suggested that an inexperienced sleep tech might not have been looking for centrals, but the respiratory effort belts and automatic scoring software are really the ones that look for those.