Why doesn't APAP respond to apneas?

OutaSync wrote:Good idea. I din't see where I could change modes. I was wondering about that in the middle of the night while I was awake and not wanting to turn on the light again to read the manual.

Bev

To turn it into a base bilevel set IpapMin = IpapMax

To turn it into a CPAP set epap = ipapMin = ipapMax.

Caution mode is to do the following ...
epap=9 or 10
ipapMin = epap + 2
ipapMax = IpapMin

DSM

When I line things up on the chart, it appears to me that the pressure went up first, then I had the hypopnea which dropped my peak flow and my BPM. All the dips in the Patient Triggered breaths line up with the increase in pressure. The same thing happened with the Auto M. That's why I had put a ceiling of 17 on it.

Bev, had another look - I'm using a ruler on the image on the screen - a bit of a challenge. In that 1st episode yes, appears it is the PS that went up 1st - it is hard to locate what the trigger for that was in the other data other than the PS is driven by current breath won't meet target peak flow so boost.

DSM

OutaSync wrote:My leak line looks good, but it says 56.1 and I usually have around 39 with the same mask. Why the big difference? I pushed inthe HH as far as it would go, it was a very tight fit. I think the sounds that kept me awake were the differences in pressure with every breath. It wasn't smooth and steady like my Auto M. It was a hard push and then a sudden drop. Wouldn't a difference between EPAP and IPAP Min of 2 be more comfortable?

These charts don't show centrals, either, right? It looks to me as though the Hyponeas occurred in the middle of the rise inpressure, maybe caused by the rise? The alarm was set to go off after 30 seconds of not breathing and it went off 3 times. I will turn that off, it was annoying.

I'll try to get some sleep tonight so we can have better data. That was a very rough night. I had some very bad nights when I was first on CPAP, too. Had a real hard time getting used to all of this stuff.

Bev

My opinion:
actually your report don't look all that bad, even with those initial settings you are at 99% Patient initiated breaths and that is what you want 100% even better. That machine is going to be more noisy than your M.

Um the Activa mask?......well not a great mask to use (in my opinion, bellows softens machine response too much). You should try your Soyala I bet you get better results.

But you will notice on your Encore report there is NO "obstructive" apnea using EPAP at 9 cm. Again, EPAP should ONLY be high enough to eliminate Obstructive Apnea. Your Spontaneous BPM was found to be 14.6 (if I make that out that report correctly). Your volume at 375.xml is a bit low but I don't know your height (height determines what your correct tidal volume should be), a chart for that is contained in the AVAPS manual, but I may not have sent you that one (I'll email it now, only use the tidal volume chart it contains as a guide no other settings from it). Notice at the start of therapy the higher your IPAP working pressure went up the higher the volume seen. Moving IPAP Min up from EPAP +4 should help that.

I would go by the titration chart for the SV I sent you and keep it in that mode. I do not recommend Bipap mode, if they couldn't get that right in the lab don't assume you can either. Give the Auto SV mode a chance.

I am assuming from your avatar picture you are a tall person, my guess at least 5' 10" probably taller. Based upon that height (69-71" you should be at 560 to 600 ml tidal volume).

I would leave EPAP=9, move IPAP min +4 to 13. Set IPAP Max according to the guide at 10+ any EPAP setting, so I would set it at 19 cm. I would leave backup mode in Auto for time being.

If you experience more problems in the middle of the night, you might also try setting the BPM mode from Auto to BPM=12.6 (i.e 14.6 -2=12.6) and IT=1.2 just like the manual says. If you experience variable breathing or clusters of centrals it will flip to backup mode and pick up those settings. Those manual settings are designed to stabilize your breathing. In the Spontaneous Auto SV mode those settings are taken care of.

Try and breathe naturally, let the machine catch up to you, don't try to match the machine.

So my next suggested settings would be:

EPAP=9.0 cm
IPAP Min=13
IPAP Max=19
BPM=Auto

If trying a different backup setting:

Same as above,
BPM=12.5 or 12.6 (2 cm less than Spontaneous BPM found on report).
IT=1.2

If you find the IPAP working pressure (line that moves in the report) bumping into the IPAP Max, move IPAP Max up by 2 cm.

Backup Mode=Machine initiated breaths
Spontaneous Mode=User Initiated breaths

The more time you stay in User Initiated breathing the better. If that drops from 99 to 89 then that means there are more central dysregulation. Bumping IPAP Min up for greater pressure support should improve your volume.

Snoredog wrote:My opinion:
actually your report don't look all that bad, even with those initial settings you are at 99% Patient initiated breaths and that is what you want 100% even better.

Bev keeps getting complemented on all that wonderful sleep data she generated while lying there awake. If this isn't a supportive message board, I don't know what is.

dsm wrote:Re SWS's comment that the SV cycles at higher than IpapMin. Steve, it will only do that if there is an apnea - under normal operation it cycles between epap & ipapMin (which is what IpapMin is for).

Doug, I have to disagree with that "only" part in your statement. The SV machine can be unfriendly to the wake/stage-1 transition because it can and does cycle higher than IPAP min during wakefulness. It can and will cycle higher that IPAP min in response to nothing more than irregular peak-flow amplitudes during wakefulness.

Case in point: Bev claims she lied there awake most of that data session, and voila---we can clearly see that IPAP peak repeatedly going higher than IPAP min during her reported wakefulness. But what we cannot see are all 876 breaths worth of individual IPAP peak values displayed in each hour-long epoch---only rough averaged trends.

dsm wrote:Bev could deactivate the PS mechanism - that would help her get use to the basic bilevel but I would doubt that doing so makes any big difference as it is clear that Bev is thrown by the whole bilevel experience.

If Bev reduces to a fixed PS of 3 cm (the difference between IPAP and EPAP) then she may very well have a much easier time learning to breath on BiLevel. Wakeful anxiety/discomfort breathing can really make for an active IPAP peak while using autoSV, which can in turn make for one next-to-impossible transition from wake to sleep stage one.

Metaphor: learn to ride a gentle pony before you learn to ride a high-spirited horse.

Once autoSV's fluctuating IPAP peak is no longer perceived as disconcerting while awake, then IPAP peak should actually settle down for lack of that wakeful anxiety breathing. That in and of itself should make the transition into stage one much more manageable. Once asleep, SV can then go about straightening out those peak flow amplitudes, which may help with sleep architecture, Bev. But you first have to learn how to make a comfortable transition from wake to stage one. I suggest that you desensitize to BiLevel with a fixed, small PS of 3 cm first.

A successful transition into stage one sleep is a prerequisite for all the good experiments everyone has been talking about. So consider working on that challenging wake/stage-1 transition first. The machine's yours until you decide to sell it---if you ever decide to that is. So you have all the time in the world to desensitize to the whole experience. That's a luxury "one-nighters" in the lab just don't have!

-SWS wrote: If Bev reduces to a fixed PS of 3 cm (the difference between IPAP and EPAP) then she may very well have a much easier time learning to breath on BiLevel. Wakeful anxiety/discomfort breathing can really make for an active IPAP peak while using autoSV, which can in turn make for one next-to-impossible transition from wake to sleep stage one.

Metaphor: learn to ride a gentle pony before you learn to ride a high-spirited horse.

Once autoSV's fluctuating IPAP peak is no longer perceived as disconcerting while awake, then IPAP peak should actually settle down for lack of that wakeful anxiety breathing. That in and of itself should make the transition into stage one much more manageable. Once asleep, SV can then go about straightening out those peak flow amplitudes, which may help with sleep architecture, Bev. But you first have to learn how to make a comfortable transition from wake to stage one: desensitize to BiLevel first.

My guess:

Those were simply sleep onset artifacts causing the IPAP working pressure to rise from Minimum set. IF IPAP Min is moved up for more pressure support that may make it more comfortable for her. Think she was at IPAP Min=11 and EPAP=9 when she restarted, that is only 2 cm PS, darn near CPAP

If she moved IPAP Min up by 3-4 cm that should make it more comfortable for her. I suspect when she finally does relax just before entering Stage 1 that she forgets to breathe OR is shallow breathing (about same place that hypnic jerks also happen). This causes most machines to go buzzerk. I think that machine has a Ramp setting, wonder if you enable that if it wouldn't settle that down.

Notice in the beginning of that session how when IPAP working pressure went up near 20 cm that her volume went way up too? I think she will end up with a higher PS than 4 but might as well go in baby steps to get there.

Hey her AHI for that night was only 1.0, she's already doing better!!

oh she was awake all night... gotta work on that

Hey Bev: Got any ear plugs?

Snoredog wrote:Hey Bev: Got any ear plugs?

A good set of blinders (horse blinkers) might be more useful, so Bev can stay focused on -SWS's excellent advice.

-SWS wrote:

Snoredog wrote:My opinion:
actually your report don't look all that bad, even with those initial settings you are at 99% Patient initiated breaths and that is what you want 100% even better.

Bev keeps getting complemented on all that wonderful sleep data she generated while lying there awake. If this isn't a supportive message board, I don't know what is.

dsm wrote:Re SWS's comment that the SV cycles at higher than IpapMin. Steve, it will only do that if there is an apnea - under normal operation it cycles between epap & ipapMin (which is what IpapMin is for).

Doug, I have to disagree with that "only" part in your statement. The SV machine can be unfriendly to the wake/stage-1 transition because it can and does cycle higher than IPAP min during wakefulness. It can and will cycle higher that IPAP min in response to nothing more than irregular peak-flow amplitudes during wakefulness.

Case in point: Bev claims she lied there awake most of that data session, and voila---we can clearly see that IPAP peak repeatedly going higher than IPAP min during her reported wakefulness. But what we cannot see are all 876 breaths worth of individual IPAP peak values displayed in each hour-long epoch---only rough averaged trends.

dsm wrote:Bev could deactivate the PS mechanism - that would help her get use to the basic bilevel but I would doubt that doing so makes any big difference as it is clear that Bev is thrown by the whole bilevel experience.

If Bev reduces to a fixed PS of 3 cm (the difference between IPAP and EPAP) then she may very well have a much easier time learning to breath on BiLevel. Wakeful anxiety/discomfort breathing can really make for an active IPAP peak while using autoSV, which can in turn make for one next-to-impossible transition from wake to sleep stage one.

Metaphor: learn to ride a gentle pony before you learn to ride a high-spirited horse.

Once autoSV's fluctuating IPAP peak is no longer perceived as disconcerting while awake, then IPAP peak should actually settle down for lack of that wakeful anxiety breathing. That in and of itself should make the transition into stage one much more manageable. Once asleep, SV can then go about straightening out those peak flow amplitudes, which may help with sleep architecture, Bev. But you first have to learn how to make a comfortable transition from wake to stage one. I suggest that you desensitize to BiLevel with a fixed, small PS of 3 cm first.

A successful transition into stage one sleep is a prerequisite for all the good experiments everyone has been talking about. So consider working on that challenging wake/stage-1 transition first. The machine's yours until you decide to sell it---if you ever decide to that is. So you have all the time in the world to desensitize to the whole experience. That's a luxury "one-nighters" in the lab just don't have!

SWS,

Wise words & well put.
PS in normal use is driven by target peak flow. One point I would question is did Bev remain awake all night ? maybe but I think she managed some stages of sleep.

But yes, there is absolutely no doubt that this pony is more spirited than the rider is used to (as would be any bilevel with similar epap-ipap placed in this same situation) .

Bev absolutely needs to take this slowly as you suggest.

DSM

rested gal wrote:

Snoredog wrote:Hey Bev: Got any ear plugs?

A good set of blinders (horse blinkers) might be more useful, so Bev can stay focused on -SWS's excellent advice.

Are you sure she shouldn't increase EPAP just for good measure? I mean there is like zero apnea being seen, on her report.

Are you sure she shouldn't increase EPAP just for good measure? I mean there is like zero apnea being seen, on her report.

Smarty canine pants!

If she manages to makes it into REM she just may have to.

dsm wrote:PS in normal use is driven by target peak flow

That's what happens during sustained wakeful anxiety breathing as well.

So in the case of wakeful anxiety, a target peak flow is averaged from wild ups and downs. That target is now a single running value based on that averaged moving window.

But the wild ups and downs of anxiety breathing continue. So that single-value target then gets applied with countering IPAP pressure, to each wild up and down that continues during wakeful anxiety breathing. IPAP peak fluctuates between IPAP min and IPAP max in the process. If the awake patient happens to find that up and down IPAP peak response disconcerting, they continue the anxiety breathing that further perpetuates that up-and-down IPAP peak action. That's why SV can be wake/Stage-1 unfriendly to some patients.

Then we only see a very rough averaged trend of all that minute up and down action plotted in Encore--- rather than 876 individual IPAP peak variations discretely displayed per hour. Regardless of that more minute up and down action occurring at finer undisplayed epochs, the rough trend still manages to show sustained deviation from IPAP min as well.

-SWS wrote:

dsm wrote:PS in normal use is driven by target peak flow

That's what happens during sustained wakeful anxiety breathing as well.

So in the case of wakeful anxiety, a target peak flow is averaged from wild ups and downs. That target is now a single running value based on that averaged moving window.

But the wild ups and downs of anxiety breathing continue. So that single-value target then gets applied with countering IPAP pressure, to each wild up and down that continues during wakeful anxiety breathing. IPAP peak fluctuates between IPAP min and IPAP max in the process. If the awake patient happens to find that up and down IPAP peak response very disconcerting, they continue the anxiety breathing that further perpetuates that up-and-down IPAP peak action. That's why SV can be wake/Stage-1 unfriendly to some patients.

Then we only see a very rough averaged trend of all that minute up and down action plotted in Encore--- rather than 876 individual IPAP peak variations discretely displayed per hour. Regardless of that more minute up and down action occurring at finer undisplayed epochs, the rough trend still manages to show sustained deviation from IPAP min as well.

SWS,

I can buy that
I guess the moral is, don't use an SV while awake & anxious

Now, you should see the PS fluctuations in my charts - but I do have the benefit of being in deep restful sleep .

Thanks for that insight - Doug

Now here is an example of very hefty PS activity - possibly the worst night for unstable data even though I slept like a log through it all (a typical good night).

My wife's comment to me was 'dearest, your mask leaked a lot last night"
my reply
"oh , did it, I must check the data 1st thing"

Now, for anyone wondering about how some machines handle bad leaks - check this



DSM

-SWS wrote:

Are you sure she shouldn't increase EPAP just for good measure? I mean there is like zero apnea being seen, on her report.

Smarty canine pants!

If she manages to makes it into REM she just may have to.

I was ignoring that train wreck in the beginning of her report. But it is pretty hard to ignore:

at EPAP=9.0 she had zero apnea,
at IPAP avg=14 cm she ended up with an AHI=1.0,
at those settings her avg. tidal volume was 375ml, that is low either that or Bev is really short, if she is tall, that is still low.

But that 1st night was initial settings, that was to be expected, we basically wanted to learn if lower pressure kept obstructive events away, that it did show. So with EPAP at 9 cm, and avg. IPAP at 14cm that is 5 cm Pressure Support as determined by the SV.

So when you look at that Encore report and initial settings, what needs to be fixed?

-AHI=1.0 is certainly acceptable AHI, only one aspect of this person's sleep.
-99% Patient initiated breaths is good, can it be better? I think so.
-Avg Tidal Volume seen is 375ml, low unless you are a midget, dangit Bev how tall are ya anyway?

Soo armed with that info, where do you go next? Well I see it as:
Can't increase EPAP quiet yet as there are no Apnea seen (give me a reason why it would need to be increased), machine reported it wanted to use 14 cm as IPAP avg, meaning the SV thought 5 cm pressure support was adequate for that session. Well let's decrease the work IPAP working has to do, move IPAP Min higher, should add more breathing comfort and it would only have to move 1 cm to avg out with what it did last night.

Sure If we wanted to control/lower where IPAP was heading or rising too, we could increase EPAP but I suspect things will only fall apart faster as they did during her lab titrations. But it might eliminate those residual 3-5 Hypopnea seen during that 8.5 hr period. Actually, I see those 3-5 HI's a bit high for the SV, most the reports I've seen it completely eliminated HI's.

The SV pegged her BPM at 14.6. You will notice on her Encore report where those 3 sets of Hypopnea showed up her BPM (in auto mode) went down to 10 BPM, IPAP working pressure went up about 19 cm to address those Hypopnea. So there that BPM=10 shows up again even in the SV algorithm.

I'd still like to see her find settings that increase her tidal volume closer to 500ml cause I know she's not a midget

Bev, out of that third session of 6.5 hrs did you land any sleep in that period at all? I know you don't feel like it, but I suspect you were in some kind of sleep during therapy hour 5 thru 8?

I think once we get some pressure support built-in she will start feeling better. Her pressure support may even have to go higher than what
the SV wants to almost address UARS, now ain't that complex.

So SWS, does the SV protocol consider those HI's seen on Bev's report as "obstructive" events? ...meaning do they want EPAP to also completely eliminate those? and IPAP then only targets peak flows and tidal volume? I could believe that, but I don't think its the case.

dsm wrote:Now here is an example of very hefty PS activity - possibly the worst night for unstable data even though I slept like a log through it all (a typical good night).

My wife's comment to me was 'dearest, your mask leaked a lot last night"
my reply
"oh , did it, I must check the data 1st thing"

Now, for anyone wondering about how some machines handle bad leaks - check this

DSM

Looks like that leak didn't help that Periodic Breathing seen. Was that mouth breathing that caused that leak?

With that amount of leak, you have to wonder WHY you felt so good after that session. Was it because the leak exhausted out more CO2? Periodic breathing period would suggest that.

That Large Leak would almost indicate a broken barb inside the machine on the main outlet port, it comes from twisting on the hose directly to the machine in warm weather. On that side of the machine there is only 1 screw in the center, this allows the lid of the machine to actually separate from the bottom case (you have to pay attention to the side of the machine to see it happen), but the small clear hose on the inside don't have a lot of free play, it doesn't take much tension by twisting that port to "crack" the barb, the result can be an internal leak which of course would present a Large Leak. If your LL continues, that is what I'd look for.