Why doesn't APAP respond to apneas?

dsm · Post by **dsm** » Mon Oct 20, 2008 3:20 pm

Bev
Scary isn`t it just how new and unexplored this area of xPAP use is.

What seems to be common experience here is how often we see within the profession, the blind leading the blind and that spills over into our own investigations here.

At times it seems like that infamous clarion call `every man for himself`
(now where did I put my dark glasses & cane )

DSM

dsm · Post by **dsm** » Mon Oct 20, 2008 3:32 pm

Bev,

One other bit of feedback re noise of the machine. Whenever I used a VPAP III machine my wife would go sleep in another room. Always it was the `whine` varing with epap-ipap.

With the Vpap Adapt SV, she asked what was wrong as she couldn`t hear any machine at all.

With the Bipap SV she got used to it because the noise was consistent & over time the machine got quieter. BUT, last night after I had done my experimenting, I left Ipap Max at 24 just to see how often it might get reached. When I woke wife wasn`t there - was in the spare room - asked her why & she said your machine sounded different - why did you change it.

Point being that we can get used to different noises but mostly if they are not fluctuating pitch sounds - the Bipap SV noise is very constant and in my experience easier than most to adapt to - for the average person.

DSM

Songbird · Post by **Songbird** » Mon Oct 20, 2008 10:10 pm

Y'know, there's a reason why my closest friend regularly reminds me that I'm the most gullible person she's ever known.... because I probably am. My pattern is to take whatever somebody says as gospel (uh.... that's with a little "g" -- NOT trying to get some kind of religious discussion started ) until something or someone proves it wrong.

So when

Snoredog wrote:Bev: Don't forget you are bifurcated too

don't feel bad, when I search up some of the words SWS uses, they show up under that Scolarly google thingee, when I search for words I've used, they show up under you really are dumber than a 5th grader google thingee.

I thought to myself, "You mean to tell me SNOREDOG needs to look up $50 words, just like me??? Whaddya know."

Nice try, Snoredog. Ya had me for a while there. And shining the light of blame on SWS for being the $50 word peddler. For shame!! Okay, okay, he is , but HE SURE AIN'T ALONE.

In an effort to find other places when some form of "bifurcate" was used (English class: get a better sense of a word from the context in which it was used), I ran a forum-wide search on "bifurc*." Guess what I found!!!!!! (I'm lovin' this) Hard as this may be to believe, some form of "bifurcate" has only been used in this entire forum a piddly 27 times, and four of those times were NOT in this thread. SWS used it once last month, and Birdshell quoted him two days later. The other two? What to my wondering eyes did appear.............

Exhibit A, from Fri Mar 16, 2007 8:47 pm:

Snoredog wrote:In my reading, injury at a bifurcation point was fairly common

Exhibit B, from Tue Nov 13, 2007 3:15 am:

Snoredog wrote:If it needs surgery depends on the degree of blockage, doctor most likely heard a "burr" which is why the further tests were ordered. The ultra sound is pretty accurate at detecting the blood flow. A burr can occur at a bifurcation point (Y branch) and it makes a swooshing or turbulent sound as the blood travels by it, sometimes that can be an indicator of a blockage.

BUSTED!!!!!

(Just funnin', Snoredog, NOT making fun.)

Marsha

Snoredog · Post by **Snoredog** » Mon Oct 20, 2008 11:29 pm

-SWS wrote:Speaking of bifurcation during Bev's two titration studies: she experienced no central dysregulation on CPAP; however she did experience central dysregulation on BiLevel. So the actual BiLevel pressure cycling itself may very well have been sufficient stimuli to cause central dysregulation. In light of that, I'm not surprised that Bev found the much larger and more erratic pressure pulsing of SV therapy even more disconcerting.

In my mind the big question will be whether a patient like Bev can eventually find BiLevel pressure pulsing to be comfortable. If so, then there's a chance that SV therapy may be able to correct episodic (a.k.a. bifurcated) central dysregulation when yet other disconcerting stimuli are presented. If so, SV may end up being the best modality for Bev after a certain adaption period. Could be entirely wrong about that "neurologically defensive" stimuli-based theory.

Snoredog, the SV contraindication with hypoventilation has to do with the algorithm's downward skewing of running flow targets---which in turn generate under-treatment. Here, Bev is receiving the opposite algorithmic response: over ventilation via extended periods at IPAP max.

I agree with that, but can't we find settings that would avoid that condition? If central dysregulation is a problem, machine would be switching to backup mode, first night we didn't see much of that switching happening. Continue on with your thought process, I know you and DSM don't think the reports look all that bad, and that's fine you have seen many more of those than I, but I'll go on record as me thinks those (especially last night's) were a train wreck getting worse.

My concern and I think yours is too if you observe the 200712006-1.jpg Bilevel titration for similar pressures to where we are now (12/8 pressure especially), it is where she experienced the most severe desaturation down in the 70's, and since she is reporting the headaches, I have to assume she is also desaturating now and doing the same with current settings, the PB would seem to confirm that. My EPAP=9 cm initial experiment is over, I was wanting not only to see if that pressure produced any obstructive apnea component but how severe it was if any, I also wanted to know if her apneic threshold was below 10 or above it. Clearly from the last 2 nights her threshold is below 9.

Okay, I'll use your word again, it seems she either goes down that bifurcation point towards PB or central dysregulation. One is resolved with SV, the other with backup mode. I'm not too concerned with backup mode at this point. I think the BPM being Auto is taking care of that, so the overtargeting of IPAP we are seeing with IPAP appears to be from trying to correct the PB, in the process of it doing that it is causing the central dysregulation as SAG suggested.

Question: So is this aggressive IPAP movement and maxing we are seeing being applied to fill the waxing and waning of periodic breathing like we would typically see with CSR type breathing? That would explain the rapid up and down movement.

-SWS wrote: Did I ever tell you guys about the pirate who walked into a bar with a trifurcated-breathing parrot on his shoulder....?

[/quote]

Okay, I want to hear about the pirate joke, I'm a big fan of Jack Sparrow.

dsm · Post by **dsm** » Tue Oct 21, 2008 1:56 am

Songbird wrote:Y'know, there's a reason why my closest friend regularly reminds me that I'm the most gullible person she's ever known.... because I probably am. My pattern is to take whatever somebody says as gospel (uh.... that's with a little "g" -- NOT trying to get some kind of religious discussion started ) until something or someone proves it wrong.

So when
Snoredog wrote:Bev: Don't forget you are bifurcated too

don't feel bad, when I search up some of the words SWS uses, they show up under that Scolarly google thingee, when I search for words I've used, they show up under you really are dumber than a 5th grader google thingee.
I thought to myself, "You mean to tell me SNOREDOG needs to look up $50 words, just like me??? Whaddya know."

Nice try, Snoredog. Ya had me for a while there. And shining the light of blame on SWS for being the $50 word peddler. For shame!! Okay, okay, he is , but HE SURE AIN'T ALONE.

In an effort to find other places when some form of "bifurcate" was used (English class: get a better sense of a word from the context in which it was used), I ran a forum-wide search on "bifurc*." Guess what I found!!!!!! (I'm lovin' this) Hard as this may be to believe, some form of "bifurcate" has only been used in this entire forum a piddly 27 times, and four of those times were NOT in this thread. SWS used it once last month, and Birdshell quoted him two days later. The other two? What to my wondering eyes did appear.............

Exhibit A, from Fri Mar 16, 2007 8:47 pm:
Snoredog wrote:In my reading, injury at a bifurcation point was fairly common
Exhibit B, from Tue Nov 13, 2007 3:15 am:
Snoredog wrote:If it needs surgery depends on the degree of blockage, doctor most likely heard a "burr" which is why the further tests were ordered. The ultra sound is pretty accurate at detecting the blood flow. A burr can occur at a bifurcation point (Y branch) and it makes a swooshing or turbulent sound as the blood travels by it, sometimes that can be an indicator of a blockage.
BUSTED!!!!!

(Just funnin', Snoredog, NOT making fun.)

Marsha

Marsha very impressed - so you too have worked out the SWS-Snoredog - good cop bad cop routine

D

dsm · Post by **dsm** » Tue Oct 21, 2008 2:00 am

This post is my attempt to translate some of the past discussion for us simple folk (esp those of us with dark glasses & canes )

What we are seeing with Bev is an unusual sensitivity to normal sleep patterning. There may be a neurological aspect to this disturbance but put simply Bev is an 'anxious' sleeper and her sleep gets disturbed by environmental factors combined with anxiety. The disturbances are showing up in her Apap and SV charts. Bev has been very forthcoming in explaining her anxieties.

In the original APAP chart there were the unusual 'steps' of pressure adjustments - the machine was adjusting pressure in a very unusual way in response to Bev's breathing.

In her SV charts we see two clear issues 1) is a very erratic breathing rate (breaths-per-minute) and 2) a somewhat erratic volume or flow (Periodic Breathing). Her PB is when the volume of air Bev breathes varies inconsistently (and Bev's is certainly doing that).

The breathing rate variation is usually associated with centrals (central dysregulation). The periodic breathing is more challenging, but it too can be associated with centrals. The SV Bev has, is currently set to use two of its mechanisms to deal with rate variations and periodic breathing fluctuations - av peak flow & bpm rate.

For centrals it adjusts the breathing rate by forcing epap-ipap-epap-ipap cycling at the rate the machine has chose as Bev's current target rate. The target when in BPM=AUTO mode is calculated based on Bev's breathing over a 4-min tracking window. Any variation above or below the target can cause the machine to change its cycling rate and pressure support level. The SV will add pressure support of 2CMs per each unsuccessful epap-ipap cycle when trying to push Bev's breathing back in line.

For periodic Breathing, it uses the pressure support as well - this is activated by the machine monitoring Bev's average peak flow over a 4-min window. Each breath the machine samples Bev's flow & decides if it needs to add pressure support (up to IpapMax in increments of 2 CMs per breath) in order to try to get breathing back on flow target. The machine attempts to normalize in 2-4 breathing cycles.

By using the SV and seeing the data, we are able to see just how erratic Bev's rate of breathing is. A timed machine such as the SV will be working flat out trying to stabilize Bev's breaths-per-minute rate because it is so erratic. Also the SV clearly shows the machine spending a lot of time trying to boost Bev's av peak flow. There are concerns at why the pressure support stays at max for so long. The implication is it is continually trying to boost Bev's breathing and that seems odd.

One question SWS, Snoredog and SAG are asking is, does the SVs response to her periodic breathing cause her to subsequently experience centrals. SWS has honed in on the split in stability of her breathing (unpredictably fine at times then wild at others - also referred to as bifurication). Snoredog has also been honing in on the periodic breathing aspect of the data. SAG is raising questions in regard to Bev's medication and to the interpretation of the original data. The erratic nature of the respiration could theoretically be from medication.

A question in regard to these two conditions is one the horse & the other the cart in regard to if one might be triggering the other. Also, is the whole invasive-ness of the bilevel machine triggering Bev's sleep anxiety which is then responsible for all or part of the symptoms shown in the data.

There are lots of questions.

Some ideas being floated include deactivating pressure support & setting the SV as a standard Bilevel - raising epap and setting ipap 4+ above epap. Another suggestion has been to also switch from BPM=AUTO to BPM=10 (or thereabouts). Hopefully Bev will find it easier to adjust to bilevel therapy if some of the variables are taken away. The SV can be set to be have like a stock standard Bilevel or a stock standard S/T Bilevel. This is done by removing the pressure support so it never gets activated (set IpapMax to the same value as IpapMin), and setting BPM=off or BPM=(4 to 30) then setting an epap and an ipap ipap being the IpapMin setting).

One suggestion I would offer is to set PS active but to the barest vale allowed which I think is IpapMax set to 1 CMs above IpapMin just to see how often the machine determines that Bev's flow is off target. (1 CMs would barely make any difference to Bev's breathing by way of inducing centrals when PS gets activated). It is the data showing how often the target is missed that we are after, setting PS to 1 CMs minimizes the effects of added pressure to a negligible number.

Then if the Encore data shows continued erratic BPM and volume with PS removed or reduced to 1 CMs, then some other strategy is needed.

Hope this helps explain in somewhat simple terms some of what has been discussed.

DSM

Snoredog · Post by **Snoredog** » Tue Oct 21, 2008 4:00 am

dsm: I was hoping the other night when you did your test video on your machine that you would have inserted a 1/2" PVC ballcock shut off valve between the mask and the hose, then you could have simply closed the valve to simulate for example; a 40 second central,

if the BPM=Auto, and your spontaneous rate was for example 14 as determined by the SV, when you cycled to backup mode it would/should have dropped that BPM from 14 to 12 (spontaneous rate -2), then we should have seen the pressure on the gauge cycle from IPAP working to IPAP Min and EPAP would have held at its steady rate. Maybe you did something similar to that but I wasn't paying attention at the time to which event you was testing, but I did see the gauge to rise from 10 cm (or the low value) to 25 cm or so on the high side (IPAP). Sorry, it was the angle of the gauge in the video I couldn't exactly make out if there was any delta on your settings.

Now, I have a different thought process as to how it handles central dysregulation and as you mention BOTH PB and CA are closely related. My understanding is it does not provide PS in backup mode. Centrals wouldn't seem to respond to any PS it may even make the condition worse. My understanding (and that understanding could be wrong) is that the machine takes avg spontaneous data for BPM, peak and volume flow over that 4 minute window and then when in SV mode subtracts from the sampling to deduce it by a fixed amount in the algorithm. You heard me mention the BPM=10 and IT=1.2 as Minimum, as you know that is in the protocol, I think they are more important than we realize. Here's why I think that:

Let's say Bev is beeboping along at 14.6 BPM and IT1.9 in SV mode. EPAP is in our left hand solid and steady at 9 cm, machine has IPAP working pressure in our right hand working between IPAP Min and IPAP Max. It is looking on a breath-by-breath basis at her target peak (inspiration). If half-way through that inspiration it determines she is not going to meet her target peak breath, the machine will increase IPAP working pressure until she does. The amount of time it takes to do this is the IT we cannot see in the reports. Now also built into the algorithm is the calculation for peak and tidal flows. It knows what ratio that should be. It will try and compensate those two to reduce PB, doing this should extend the tidal volume on exhale, it goes back to that balance SWS mentioned the other day. Remember it is using values from her own spontaneous breathing from that 4 minute window to establish values for backup when BPM=Auto. Now when things go awry and she starts having Centrals, the machine now has to take those same Spontaneous values and subtract from them if BPM is at 14 it may lower BPM to 12, Inspiration Time may have been at 1.9 (or higher) possibly inducing deep breathing, so the algorithm drops IT by a small amount say to 1.2 sec which then controls central dysregulation to a known value demonstrated to correct that condition.

Now there has to be a balance in the exchange of gases, if you are taking short rapid breaths, your peak and tidal volume will be lower than normal, BPM would also be higher because you are breathing faster. This rapid breathing condition is known to exhaust more C02 out of the patient and induce central dysregulation once the apneic threshold has been crossed. So my thinking is, we need to control the Spontaneous mode so it reduces that short rapid breathing (low peak, and volume) and also prevent deep breathing which is also known to contribute to central dysregulation. I think when she is landing in PB it is due to over targeting of the peak and tidal volumes with IPAP. My guess is that is what is leading to the waxing and waning and erratic breathing.

Now, since backup mode is what corrects central dysregulation, if we establish a base "settings" which simply corrects the central dysregulation, it should slow down her breathing, that slower breathing rate will carry over to spontaneous mode in the form of slower deeper breathing. This should bring both peak and tidal volumes up on their own.

In summary, she breaths too fast and shallow (something you'd expect to see with anxiety patients), which left unchecked quickly gets out of hand and turns into central dysregulation. When she lands back in spontaneous she is recovering from the central event. Spontaneous picks up and over-targets her peak and tidal volumes. Is it that IPAP Max is allowing this to happen or is she taking a deep breath taking IPAP up to the top? My theory is she is returning to spontaneous mode in recovery from central dysregulation and range set doesn't settle her down fast enough where the cycle repeats.

By establishing "fixed" backup values I "think" we would have better control over the PB and what happens with her breathing.

So what would happen is:

BPM=10
IT=1.2 sec

We know on her first night Encore that BPM=14.6, if you follow protocol ideally that would be 12.6 fixed BPM. IT we have no idea as the machine isn't outright telling us what that currently is, but I guess we could calculate it out. That BPM=10 equates to 6 sec breaths per minute, if you subtract the fixed inspiration time of 1.2 sec, that leaves 1.2 sec for inhale and 4.8 sec for exhale, hey isn't that the same values SWS came up with the other day

I'd like to get his consensus on the above assumptions and correct me if I'm all wrong (but you will have to explain it to me so I understand it, and Bev will also have to understand it).

So I'm in favor of using "fixed" backup values. I also don't have any problem with your suggestion of using a 1 cm delta from EPAP with IPAP Min, that is in line with protocol doing that we would end up with settings:

EPAP=9 (current value for 3 days)
IPAP Min=10 (maintain 1 cm delta)
IPAP Max=19 (standard protocol maximum of 10)
BPM=10
IT=1.2

Please see that 200712006-1.jpg Bilevel Titration chart for these similar pressures, we my be chasing something and it is because she is severely desaturating at these values. Of course with that titration we didn't have the moving IPAP pressure support to compensate on the fly as we do here.

dsm · Post by **dsm** » Tue Oct 21, 2008 5:00 am

Snoredog wrote:dsm: I was hoping the other night when you did your test video on your machine that you would have inserted a 1/2" PVC ballcock shut off valve between the mask and the hose, then you could have simply closed the valve to simulate for example; a 40 second central,

A good idea but I wanted the mask to vent as normal. The machine seems to behave very oddly if no venting is occuring. I have a video of that behaviour but can't make any sense of it (the pressure went to 28 then each ipap cycle dropped back by 2 CMs - bizzarre)

if the BPM=Auto, and your spontaneous rate was for example 14 as determined by the SV, when you cycled to backup mode it would/should have dropped that BPM from 14 to 12 (spontaneous rate -2), then we should have seen the pressure on the gauge cycle from IPAP working to IPAP Min and EPAP would have held at its steady rate. Maybe you did something similar to that but I wasn't paying attention at the time to which event you was testing, but I did see the gauge to rise from 10 cm (or the low value) to 25 cm or so on the high side (IPAP). Sorry, it was the angle of the gauge in the video I couldn't exactly make out if there was any delta on your settings.

I set rate to BPM=10 (manual) because I cant easily simulate varying the AUTO rate in a 4 min window. Machine went from epap 10 to ipap 12 then next cycle epap 10 to ipap 14, then next cycle epap 10 to ipap 16 etc: up to 22 (but it fluctuated around 21-24 at this point & that could be because I didn't have a tight enough seal)

Now, I have a different thought process as to how it handles central dysregulation and as you mention BOTH PB and CA are closely related. My understanding is it does not provide PS in backup mode. Centrals wouldn't seem to respond to any PS it may even make the condition worse. My understanding (and that understanding could be wrong) is that the machine takes avg spontaneous data for BPM, peak and volume flow over that 4 minute window and then when in SV mode subtracts from the sampling to deduce it by a fixed amount in the algorithm. You heard me mention the BPM=10 and IT=1.2 as Minimum, as you know that is in the protocol, I think they are more important than we realize. Here's why I think that:

I also thought what you say but a week or so ago thought I'd try simulating a centra - did it with machine running & me with mask on - after 5 mins I stopped breathing & then the machine cycled (in my case ) epap 11 - ipap 14, epap 11 - ipap 16 (at the time I wasn't using the guage & guessed it was bumping by 3 CMs but last nights test showed clearly it is 2 CMs. Using increased pressure shouldn't matter as it is the cycling that is supposed to get the central cleared & the machine does limit its PS to approx 10 CMs above IpapMin

Let's say Bev is beeboping along at 14.6 BPM and IT1.9 in SV mode. EPAP is in our left hand solid and steady at 9 cm, machine has IPAP working pressure in our right hand working between IPAP Min and IPAP Max. It is looking on a breath-by-breath basis at her target peak (inspiration). If half-way through that inspiration it determines she is not going to meet her target peak breath, the machine will increase IPAP working pressure Within 2-4 cycles bumping at 2 CMs per breath until she does. The amount of time it takes to do this is the IT we cannot see in the reports Yes the reports have no granularity - in fact this brought home to me why Resmed in ResScan allow the viewer to expand time out so you can start to see actual points in time - I must go check this aspect just to see how granular their data can get - I have a Vpap ResScan report . Now also built into the algorithm is the calculation for peak and tidal flows I think alg only tracks av peak flow . It knows what ratio that should be. It will try and compensate those two to reduce PB, doing this should extend the tidal volume on exhale, it goes back to that balance SWS mentioned the other day. Remember it is using values from her own spontaneous breathing from that 4 minute window to establish values for backup when BPM=Auto agreed but testing AUTO is too difficult that is why I used BPM=10 as the mechanism should be identical except the INSp will be what is set in the param & I set it to 1.7. Now when things go awry and she starts having Centrals The moment Bev has a central her BPM drops to (essentially zero) & the CA mechanism kicks in - that is what I was trying to test & am satisfied it will take current ipa (as you say) and cycle epap to curripap but will also boost by 2 CMs if the does not generate greater than 100ml of flow , the machine now has to take those same Spontaneous values and subtract from them if BPM is at 14 it may lower BPM to 12, Inspiration Time may have been at 1.9 (or higher) possibly inducing deep breathing, so the algorithm drops IT by a small amount say to 1.2 sec which then controls central dysregulation to a known value demonstrated to correct that condition. This aspect is beyond what I can guess - as mentioned I got the patents off the machien & tried to locate the one describing this mechanism but thus far - no luck

Now there has to be a balance in the exchange of gases, if you are taking short rapid breaths, your peak and tidal volume will be lower than normal, BPM would also be higher because you are breathing faster. This rapid breathing condition is known to exhaust more C02 out of the patient and induce central dysregulation once the apneic threshold has been crossed. I believe the SV drops its PS the moment the CA sufferer breathes more than 100 ml, then it applies PS if needed to meet the past av peak flow target So my thinking is, we need to control the Spontaneous mode so it reduces that short rapid breathing (low peak, and volume) and also prevent deep breathing which is also known to contribute to central dysregulation. I think when she is landing in PB it is due to over targeting of the peak and tidal volumes with IPAP. My guess is that is what is leading to the waxing and waning and erratic breathing. Waxing & waning is a classic CHS description but Bev's respiration is simply erratic - CHS is cyclic - I need to think about this aspect a bit

Now, since backup mode is what corrects central dysregulation, if we establish a base "settings" which simply corrects the central dysregulation, it should slow down her breathing, that slower breathing rate will carry over to spontaneous mode in the form of slower deeper breathing. This should bring both peak and tidal volumes up on their own. That makes sense to me - but backup mode does appear to use PS bumped 2CMs every failed cycle. It would be helpful to locate the patent desc of the backup controller

In summary, she breaths too fast I didn't think she had breathed too fast, I have a chart of myself at 44BPM and that was plain hyperventilation (broght on by the settings I was using that night on a VPAP III S. Bev rarely goes above 17 BPM - I would say her breathing rate overall is not as bad as I 1st thought. and shallow (something you'd expect to see with anxiety patients), which left unchecked quickly gets out of hand and turns into central dysregulation. When she lands back in spontaneous she is recovering from the central event. Spontaneous picks up and over-targets her peak and tidal volumes. The SV will drop all PS if Bev is on target. But if Bev were to breathe too rapidly yes, but the more I look at her data the less that seems an issue ? Is it that IPAP Max is allowing this to happen or is she taking a deep breath taking IPAP up to the top? My theory is she is returning to spontaneous mode in recovery from central dysregulation and range set doesn't settle her down fast enough where the cycle repeats.

By establishing "fixed" backup values I "think" we would have better control over the PB and what happens with her breathing. Setting a BPM would allow us to eliminate doubts about what is happening in AUTO mode plus would allow us to set INSP to a safe know number.

So what would happen is:

BPM=10
IT=1.2 sec

We know on her first night Encore that BPM=14.6, if you follow protocol ideally that would be 12.6 fixed BPM That seems viable and fits the vendor recommendation . IT we have no idea as the machine isn't outright telling us what that currently is, but I guess we could calculate it out. That BPM=10 equates to 6 sec breaths per minute, if you subtract the fixed inspiration time of 1.2 sec, that leaves 1.2 sec for inhale and 4.8 sec for exhale, hey isn't that the same values SWS came up with the other day

I'd like to get his consensus on the above assumptions and correct me if I'm all wrong (but you will have to explain it to me so I understand it, and Bev will also have to understand it).

So I'm in favor of using "fixed" backup values. I also don't have any problem with your suggestion of using a 1 cm delta from EPAP with IPAP Min The suggestion was 1 CM between IpapMin and IpapMax just to have the machine tell us when Bev is not meeting flow target but without the PS disturbing Bev , that is in line with protocol doing that we would end up with settings:

EPAP=9 (current value for 3 days)
IPAP Min=10 (maintain 1 cm delta)
IPAP Max=19 (standard protocol maximum of 10)
BPM=10
IT=1.2

I'd go epap=10 (Bev showed enough AI for me to bump by 1) -- IpapMin=14 (using industry guidelines) -- IpapMax=15 (to turn on av flow tracking & reporting but not disturb Bev) -- BPM=10 -- IT = 1.2

Please see that 200712006-1.jpg Bilevel Titration chart for these similar pressures, we my be chasing something and it is because she is severely desaturating at these values. Of course with that titration we didn't have the moving IPAP pressure support to compensate on the fly as we do here.

Cheers Doug

StillAnotherGuest · Post by **StillAnotherGuest** » Tue Oct 21, 2008 5:33 am

Hey Bev, what version of software are you running on the AutoSV (the first number when you boot up, should be a 1.x something.

Consider cataplexy very carefully. Have anything that resembles this?

Cataplexy is a sudden loss of muscle tone that leads to feelings of weakness and a loss of voluntary muscle control. Attacks can occur at any time during the waking period, with patients usually experiencing their first episodes several weeks or months after the onset of EDS. But in about 10 percent of all cases, cataplexy is the first symptom to appear and can be misdiagnosed as a manifestation of a seizure disorder. Cataplectic attacks vary in duration and severity. The loss of muscle tone can be barely perceptible, involving no more than a momentary sense of slight weakness in a limited number of muscles, such as mild drooping of the eyelids. The most severe attacks result in a complete loss of tone in all voluntary muscles, leading to total physical collapse in which patients are unable to move, speak, or keep their eyes open. But even during the most severe episodes, people remain fully conscious, a characteristic that distinguishes cataplexy from seizure disorders. Although cataplexy can occur spontaneously, it is more often triggered by sudden, strong emotions such as fear, anger, stress, excitement, or humor. Laughter is reportedly the most frequent trigger.

SAG

OutaSync · Post by **OutaSync** » Tue Oct 21, 2008 8:53 am

Last night I used my APAP because I couldn't deal with another bad night. I had an AHI of 3. Headache is better today. I figured out that the chest pain I had all day yesterday was my "silent" GERD deciding not to be silent any more. I had to get some more Prilosec and hope that will feel better in a few days.

SAG,

If you mean Encore version, it's 1.8.49. If there is another number from the SV, I can't check it right now from work. Yes, I have had what is described as cataplexy. Who knew that they had names for all of this stuff?

Bev

-SWS · Post by **-SWS** » Tue Oct 21, 2008 10:12 am

Songbird wrote: Exhibit A... Exhibit B... BUSTED!!!!!

(Just funnin', Snoredog, NOT making fun.)

ROTFL! Busted him good!

Plus Snoredog is the one who emails many of us our weekly vocabulary lessons. He calls 'em Twenty $50 words for only $11.95" The shrewd entrepreneur keeps reminding us that's a weekly savings of $988.05!

------------------------------------------------------------------------

Snoredog wrote:I agree with that, but can't we find settings that would avoid that condition?

If that dysregulated breathing is exacerbated by nothing more than the pressure cycling of BiLevel, then there may be some other neurologically defensive implications---such as partial defensive airway closures. If this is happening then I still think the best strategy is to allow for a comfort or adaptation period to fixed BiLevel with a fixed PS=3. Then after adaptation, titrate with those initial counter-productive effects of pressure-cycling based stimuli out of the way. And I agree that fixed backup rate and IT may, indeed, be the best way to go.

Snoredog wrote:Okay, I want to hear about the pirate joke, I'm a big fan of Jack Sparrow.

Joke? That's Aunt Weeza's new boyfriend. He sails the high seas of Wyoming as well. I just thought it was ironic that my respiratory-disturbance inclined Aunt Weeza would have landed a pirate boyfriend with a pet that can't breathe all that well either. My understanding is that dsm's going to send the trifurcated parrot a trilevel machine...

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dsm wrote:Marsha very impressed - so you too have worked out the SWS-Snoredog - good cop bad cop routine

We mix it up at times... When we're in a thread with Slinky, for instance, it becomes the good COPD bad COPD routine.

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OutaSync wrote:If you mean Encore version, it's 1.8.49. If there is another number from the SV, I can't check it right now from work. Yes, I have had what is described as cataplexy.

Cataplexy is pretty much exclusive to narcolepsy. And yet you don't seem to display rapid sleep onset REM periods (SOREM periods)---which are usually highly characteristic of narcolepsy. Could be that you often do, and that the PSG was anomalous or highly atypical of your usual sleep patterns.

Would you mind describing in detail what just may be symptoms of cataplexy, Bev?

StillAnotherGuest · Post by **StillAnotherGuest** » Tue Oct 21, 2008 10:27 am

OutaSync wrote:If you mean Encore version, it's 1.8.49. If there is another number from the SV, I can't check it right now from work.

The SV itself. After you plug it in and it does the LCD check, the number that appears, like 1.2 or 1.3.

SAG

StillAnotherGuest · Post by **StillAnotherGuest** » Tue Oct 21, 2008 10:32 am

-SWS wrote:And yet you don't seem to display rapid sleep onset REM periods (SOREM) periods.

Unless they were suppressed by the Lexapro.

SAG

OutaSync · Post by **OutaSync** » Tue Oct 21, 2008 11:15 am

My sleep Dr. called me. He wanted to know why I had requested the raw data from the PSGs. I told that i suspected that the BiLevel titration was flawed because I had so much disturbance from the ill fitting mask that I was awake most of the night. He agreed, but said I was doing fine now. He said my tidal volume was fine and he would prefer that I set the SV to a Back-up of 8 or 9 because he did not understand how the auto worked.
He said "why don't you bring your machine in and we'll tweak it here".
I said "you mean an overnight titration?"
He said, "No, just bring it in and we'll adjust it.
" I said, "if I'm awake how are you going to know what to adjust it to? Can't you just give me the number and I can adjust it at home. The thing is huge and I don't want to move it"
He said, "All right, I'm just shooting in the dark here, but let's set the EPAP to 4."
I said," I thought the EPAP was supposed to be set to eliminate all apneas. "
He said ,"Well that would take 16/12."
I said, "Don't you think I should have a proper tiration?"
He said, "Yes, but I don't think your insurance will pay for it." Try these settings for a month and call me back to set up a face to face meeting. EPAP and IPAP at 7, Max IPAP 17"

They agreed to give me my data.

SAG, I'll check the number when I get home.

SWS, I'd rather not go into detail as to when this happens "complete loss of tone in all voluntary muscles, leading to total physical collapse in which patients are unable to move, speak, or keep their eyes open"

Bev

-SWS · Post by **-SWS** » Tue Oct 21, 2008 11:36 am

OutaSync wrote:SWS, I'd rather not go into detail as to when this happens "complete loss of tone in all voluntary muscles, leading to total physical collapse in which patients are unable to move, speak, or keep their eyes open"

Oh my goodness... please do go into great detail! Just kidding!

Bev, If that truly is cataplexy you're experiencing, then it's by far the most significant piece of information presented in this mammoth thread. I would suggest reviewing that symptom in great detail with your doctor. If you're experiencing genuine cataplexy, then SAG in all likelihood hit the nail squarely on the head by entertaining the possibility of narcolepsy.

Why doesn't APAP respond to apneas?

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Another Day, Another Dime...

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