Why doesn't APAP respond to apneas?

OutaSync wrote:Echo,
Thanks for that info. I haven't tried Sonata. I should ask my Dr. if that would be better. I appreciate the link, too.

DMS,

Re: #4 in that article. As a child we used DDT a lot around the house for ants and roaches, even after it was banned in the US. We were also exposed to a lot of auto exhaust, direct venting for hours at a time. In those days we had leaded gas. My sister and I have wondered if that had any effect on our memory problems.

Bev

Bev,

I am prepared to believe there could be either a hereditary or environmental origin to your erratic respiration. The item I posted was just a clue and from what I can see is a consideration.

I sure hope one of your doctors looks into this possibility even if they later discard it. At the moment it is looking like a fair bet.

Doug

dsm wrote: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

Doug, can you give us any insight why you described the above PB occurrences as having felt significantly worse than AI-only nights? The above clinically successful AHI of 2.0 should have left you feeling pretty good. Yet you described an uncomfortable "heady" feeling associated with the above night at 14 cm while scoring PB.

We can also note from the above report that Respironics allows for: 1) PB scored without simultaneous apnea/hypopnea, 2) PB scored with simultaneous apnea/hypopnea, and 3) apnea/hypopnea scored without simultaneous PB. So Respironics PB scoring is neither a type of apnea nor hypopnea. And PB scoring does not require the presence of either apnea or hypopnea. Moreover, I think we can assume that some patients will experience irregular breathing that approaches but does not score as PB.

PB is associated with CompSA/CSDB in NREM. If frank PB can feel biologically uncomfortable, is it possible that marginal PB (less than frank PB and thus not scored as PB) might make some patients feel biologically uncomfortable as well?

Let's append that previous rhetorical question. Let's make those patients marginally CompSA/CSDB as Bev seems to be. If CompSA/CSDB is described in respected medical literature as entailing significant "biological discomfort", might it be possible that less-than-frank PB or simply irregular breathing can be involved in CompSA/CSDB as may be the case for Bev? If so, different amplitude-related statistical measures may be required than those employed for scoring frank PB. That is not to say that the amplitude oscillations are implicated as the pathogenesis or core of the problem---they may be merely symptomatic. And, of course, that is not to assume that benefit cannot be made by preventing or treating those amplitude oscillations.

SWS

The resulting day was pretty normal despite waking with a 'heady' feeling. It was not as good a night as normal. That is the worst PB data I have ever scored. But I can have a good nights data & still feel drowsy in the middle of the day on the odd occasion.

When I looked at that chart I expected a bad day but it didn't turn out that way.

Am still trying to figure out what matters & what doesn't in regard to the data from the machine.

DSM

Doug, thanks. I personally think there can be plenty going on in sleep-disordered physiology that is not reflected in APAP or SV-scored AHI---especially for CompSA/CSDB patients. And I happen to suspect that Bev is one of those CompSA/CSDB patients for whom disturbance-related mechanisms in physiology are not yet fully understood by sleep medicine.

SAG wrote: I would like to create a "Living Document" to determine an interpretive strategy for the variable breathing (VB) parameter, and would like to start out with:

< 5.0% Normal
5 - 15% Mild Disturbance
15 - 25% Moderate Disturbance
> 25% Severe Disturbance

I know one person, whom I consider to be quite "normal", with a VB of 0%.

I personally think this is an excellent area for exploration.

-SWS wrote:Doug, thanks. I personally think there can be plenty going on in sleep-disordered physiology that is not reflected in APAP or SV-scored AHI---especially for CompSA/CSDB patients. And I happen to suspect that Bev is one of those CompSA/CSDB patients for whom disturbance-related mechanisms in physiology are not yet fully understood by sleep medicine.

SAG wrote: I would like to create a "Living Document" to determine an interpretive strategy for the variable breathing (VB) parameter, and would like to start out with:

< 5.0% Normal
5 - 15% Mild Disturbance
15 - 25% Moderate Disturbance
> 25% Severe Disturbance

I know one person, whom I consider to be quite "normal", with a VB of 0%.

I personally think this is an excellent area for exploration.

SWS,

Just as a follow up comment, I used an S8 set with EPR for two nights (sat & Sun) just passed & based on the night on the SV at 14, I upped cpap to 13.8 & ran with EPR = 3.

That worked well enough but of course I don't have the same report as the SV data - but will extract those 2 nights data as they were on a Reslink & thus have some extra detail.

I believe that bad night at CPAP 14 on the SV was as much due to the change of mode. I am quite sure that big changes affect us and that we all are capable of and tend to adapt as we get used to a different setting. It is an interesting thing to hear so many members here talk of discomfort just from an AUTO as it adjusts.

DSM

dsm wrote:I am quite sure that big changes affect us and that we all are capable of and tend to adapt as we get used to a different setting. It is an interesting thing to hear so many members here talk of discomfort just from an AUTO as it adjusts.

CompSA/CSDB prevalence is estimated at more than 20%. And APAP modality is believed to be the worst modality for CompSA/CSDB. So based on the previous two scientific estimates or disclosures, I think we can expect to hear plenty of talk around hear about APAP-related discomfort.

That brings us to the above assumption that everyone tends to adapt. A certain percentage of the patient population is guaranteed not to adapt IMO. And various degrees of both adaption and maladaptation are likely as well IMO. When it comes to environmental adversity, our species has historically adapted and genetically propagated. However, the same underlying genetic diversity that guarantees large-scale adaptive survival, also guarantees a certain spectrum of individual biologic success/failure relative to virtually any pathophysiologic stimuli (traditional PAP therapy in this case).

OutaSync wrote:Echo,
Thanks for that info. I haven't tried Sonata. I should ask my Dr. if that would be better. I appreciate the link, too.

DMS,

Re: #4 in that article. As a child we used DDT a lot around the house for ants and roaches, even after it was banned in the US. We were also exposed to a lot of auto exhaust, direct venting for hours at a time. In those days we had leaded gas. My sister and I have wondered if that had any effect on our memory problems.

Bev

Bev,

It is an interesting line of thought. As a youngster in NZ & Australia (esp Australia) we used DDT in hand pump devices for flies & other insects - in summer it was an essential. I am not clear on what level of DDT exposure matters or what that exposure might mean to us now mature post WW2 babyboomers.

DSM

StillAnotherGuest wrote:
2 isolated instances of PB composing 0% of the night is nothing to lose any sleep over. Knowing you like I do, I'd say those areas are either mixed or sleep-onset phenomena.

Or artifact.

SAG

Unless she has CHF.

Snoredog wrote:

StillAnotherGuest wrote:
2 isolated instances of PB composing 0% of the night is nothing to lose any sleep over. Knowing you like I do, I'd say those areas are either mixed or sleep-onset phenomena.

Or artifact.

SAG

Unless she has CHF.

But that hasn't featured at all in her checkups.

DSM

Having just extracted the data from my S8 Vantage - it allows me (using Rescan) to view data for varying periods of the night, right down to 30 mins across the screen that allows me to actually see every breath taken & event as it happened & to compare from line to line (pressure, event & duration, flattening index, snore index). Now I would very much love to have that granularity with the Bipap SV & get right down to seeing breath-by-breath what Bev's respiration is doing.

The bars hide far too much & leave us guessing a lot.

DSM

#2 a link to an example of the very granular data available in ResScan
http://www.internetage.ws/cpapdata/dsm- ... 1nov08.jpg

dsm wrote:

Snoredog wrote:

StillAnotherGuest wrote:
2 isolated instances of PB composing 0% of the night is nothing to lose any sleep over. Knowing you like I do, I'd say those areas are either mixed or sleep-onset phenomena.

Or artifact.

SAG

Unless she has CHF.

But that hasn't featured at all in her checkups.

DSM

Nocturnal Periodic Breathing can be common when we are infant babies, when it happens in babies it is most likely because the part of the brain which controls breathing hasn't fully developed yet. When that delicate balance of taking in oxygen and exhaling CO2 gets out of sync (hey Bev's handle) the baby will go into periodic breathing and they will blow off excess CO2 or flush it out. Parents watching this may freak out, but it is fairly normal in infants.

Advance to adult. Nocturnal Periodic Breathing may also be common. Only problem is when you are an adult it can also mean early signs of CHF and even Pulmonary Hypertension. Person may be breathing fine during the day never experience it at all. Then when they lay flat in bed things change, fluids in the body rush towards the trunk, hypertension increases. It is much easier for heart to pump blood to the legs vs. standing, but those fluids place extra pressure on the diaphragm making it more difficult to breathe, when that happens they may begin to hyperventilate to blow off excess CO2.

So the question becomes: Did she have PB and simply never knew she had it? or did the machine settings induce the PB? If the machine isn't the cause of the PB then if it was me I'd be getting my ticker checked out. Now SAG took a look at her raw data, I'm sure he would have checked what the heart was doing and said something if it was a problem.

But I still feel you should avoid any PB if at all possible. Part of what Bev indicates is when she attempts to fall asleep, I see a lot of professionals blow that off as nothing, yeah it is nothing if YOU don't have to experience it, but I'll guarantee you it will leave you with the most uneasy feeling you have ever felt. Now I have it when I'm not using the machine, she has it while using the machine. If her O2 levels are dropping her doctor may have to end up putting her on supplemental oxygen to prevent the PB. If it progresses it can turn into CSR and that is nearly always found with CHF.

It is why I asked you a week or so ago if you had your ticker checked out. Get your machine set so you can avoid that PB and there will be a lot less stress on your body during sleep. You have to have stable breathing before you can get quality sleep. I'd take a few apneas any day over PB.

Periodic Breathing is also found in mountain climbers at high altitude and pilots in non-pressurized airplanes but that is due to the lack of oxygen. What do they give those to stop it? Oxygen. PB is not so bad by itself its the load it puts on your heart which can be problem. I'd rather wake up
then put a load on my heart. It is why the SV and other machines like it come equipped with all these alarms. If it was no big deal they wouldn't have equipped them with alarms.

Ask yourself, now why did they pick 10 seconds as the magic number for a hypopnea along with 3% drop in oxygen to classify an event?
That is because brain cells begin dying in as little at 10 seconds deprived of oxygen rich blood. Got any memory problems?

Snoredog,

In 8 months of data I can pull up about 10-15 charts that show 1 to 2 tiny PB scores. The chart that SWS reposted was the worst I have ever seen of all the data & occurred after I significantly altered my machines mode & settings to illustrate how my machine's data looked when compared to Bev's.

See the above granular data I pulled off rescan & s8

Doug

dsm wrote:Snoredog,

In 8 months of data I can pull up about 10-15 charts that show 1 to 2 tiny PB scores. The chart that SWS reposted was the worst I have ever seen of all the data & occurred after I significantly altered my machines mode & settings to illustrate how my machine's data looked when compared to Bev's.

See the above granular data I pulled off rescan & s8

Doug

One or two tics worth across the page is not a problem as the machine is correcting the PB and that is what is should do. But when you have solid red PB resembling your Large Leak tic scores that is not good (period in report looks to be nearly 15-minutes long). The part to understand is the PB is a result of irregular breathing it is akin to hyperventilating during the day, same load on the heart. Now do you think you will be getting quality sleep during that period of irregular breathing? I doubt it.

It is when we look at a report "what is really good"? Peak and tidal volumes and compare them to a chart? I don't think so. With plain jane OSA it is easy, just get AHI down. Now if you feel great with those settings then it doesn't matter what the report says, but I don't think that is the case. In other words what I'm saying is if you have your machine adjusted and truly working, you won't have PB or CA and no need for backup mode. It is already assumed from the start that OA is taken care of by EPAP.

I know your case is as complex as Bev's is and there is no doubt you have tried every machine down to a shop vac. How does your SAO2 look with those settings? I think they should for the price of that SV include a pulse oximeter in the box.

[quote="Snoredog
It is why I asked you a week or so ago if you had your ticker checked out. Get your machine set so you can avoid that PB and there will be a lot less stress on your body during sleep. You have to have stable breathing before you can get quality sleep. I'd take a few apneas any day over PB.[/quote]


Sorry, Snoredog, I missed that question. The problem with my memory is that if I read some of these posts while I'm at work, and don't get a chance to answer right away, I will forget that there was a question asked. I have to take notes at work, notes at home, write notes on rubber bands that I wear on my wrist if there is information going from work to home or vice versa. I can't remember what I have read, here. I think that I will be able to go back to find the information, but this thread is so long. I've taken pages of notes and printed out pages, trying to re-read and understand. Y'all confuse me, and believe me, it's not hard to do.

What is involved in checking out the ticker? In the past I've had to run on a treadmill (felt like I ws going to die) and been hooked up to a 24 hour harness. They have taken my blood pressure and always told me that I was "fine", even though I have irregular heatbeats and chest pain (could it be the GERD?)

Bev

OutaSync wrote:[quote="Snoredog
It is why I asked you a week or so ago if you had your ticker checked out. Get your machine set so you can avoid that PB and there will be a lot less stress on your body during sleep. You have to have stable breathing before you can get quality sleep. I'd take a few apneas any day over PB.

Sorry, Snoredog, I missed that question. The problem with my memory is that if I read some of these posts while I'm at work, and don't get a chance to answer right away, I will forget that there was a question asked. I have to take notes at work, notes at home, write notes on rubber bands that I wear on my wrist if there is information going from work to home or vice versa. I can't remember what I have read, here. I think that I will be able to go back to find the information, but this thread is so long. I've taken pages of notes and printed out pages, trying to re-read and understand. Y'all confuse me, and believe me, it's not hard to do.

What is involved in checking out the ticker? In the past I've had to run on a treadmill (felt like I ws going to die) and been hooked up to a 24 hour harness. They have taken my blood pressure and always told me that I was "fine", even though I have irregular heatbeats and chest pain (could it be the GERD?)

Bev[/quote]


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Bev,

Snoredog was referring to a suggestion to me that I get my ticker checked. I replied that I had done a full stress ECG & come up absolutely fine.

My point to Snoredog is that if everyone used an SV and in CPAP mode at their normal or perhaps higher than normal settings, eventually they will probably produce a chart or two with similar red PB scores. The issue is if the PB scoring is consistent and repeated.

Periodic Breathing as defined in the Respironics manual for the Bipap SV is really referring to Cheynes-Stokes respiration which is identified as a 'rythmic' waxing and waning of breathing volume. It is associated with CHF (Chronic Heart Failure). Neither you nor I are exhibiting that. Respironics also defines a pattern of fluctuating breathing called Variable Breathing. You are doing that & those 'chairs' in your original AUTO charts are the machine trying to iron out your VB. The SV also shows your Vb and it is why the SV stays so long at IpapMax.

DSM

#2 If anyone is really interested in what Variable Breathing is and how the standard Respironics AUTO tries to manage it, read this thread. It contains an extract from the patent.

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