My first night on ASV

Snoredog wrote:
<snip>

Maybe this machine will help retrain your breathing over a course of weeks where it will settle down with very little change. Machine is doing its job, I just think it could do a better job at it. Would be interesting to see what happens when IPAP Min is increased say to 12, that is 2 cm pressure support, same you would get with a Bipap Auto at a minimum.

<snip>

This is what I am thinking too (I know banned would love you to have done it yesterday )

A few days of familiarization & getting used to it & like the others think, give it a try.

DSM

I wished he would have gone ahead with the nasal surgery, that could have improved his condition on this machine (or ruled it out).

My daughter had hers done at the end of October, she had some discomfort the first week or so but nothing but fantastic results ever since and her report of better breathing and sleep makes it all worth while. She just texted me she is in Oslo now for a couple weeks on Holiday.

If you read Dr. K's blog and what he says about resistance breathing, it makes sense, if that is the case with James, he is going to need much higher IPAP to overcome that resistance when inhaling. If you ask anyone that has the onset sleep events, they go through the routine when trying to fall asleep like when taking a nap, and breathing becomes really uncomfortable until you wake up (I call that period Stage I, yeah I know that can't happen supposedly, but they have been wrong before), when you live-in back up you find you are breathing rapidly, now this is only resting like on the couch watching TV (Roosters picture). The point is if you do this just falling asleep the same could happen during the night during sleep. It is mainly caused by resistance in the nose, I could breathe through my mouth but I trained myself NOT to do that. I've already had the turbinate reduction surgery years ago, so there is no more reaming they can do to the inside of my nose to improve that any. I know if I had a higher IPAP that would overcome that probably quite easily. Besides I'm not impressed with the medical care James has been getting up north.

Hey James I know a great ENT down in Sherman Oaks/Santa Monica, CA area, 36 years experience, good track record, great patient repore, uses latest laser surgery techniques. She says dry-nose syndrome is a thing of the past.

dsm wrote:

Snoredog wrote:
<snip>

Maybe this machine will help retrain your breathing over a course of weeks where it will settle down with very little change. Machine is doing its job, I just think it could do a better job at it. Would be interesting to see what happens when IPAP Min is increased say to 12, that is 2 cm pressure support, same you would get with a Bipap Auto at a minimum.

<snip>

This is what I am thinking too (I know banned would love you to have done it yesterday )

A few days of familiarization & getting used to it & like the others think, give it a try.

DSM

2cm between EPAP and IPAP Min is ridiculously close for effective SV pressure support. Remember the (automatic) gap on the ResMed Adapt SV is 3-6 cm between EEP and IPAP Min. Conversely, AVAPS states. "Do not set IPAP Min too low". An EPAP/IPAP Min gap of 3 cm would be rock bottom for SV mode to function properly. And if James truly does have upper airway resistance, as I do, he will be lucky if EPAP 10, IPAP Min 16 does the trick. Snoredog is correct to expect IPAP Min to be quite high with nasal restriction. My EEP/IPAP Min gap was 6 cm on the Adapt SV. On AVAPS the EPAP/IPA MIn gap is 4 cm but that's at EPAP 15 and IPAP Min 19. James will never make it sticking straws up his nose with his current mask. I think in the end, everyone one with upper airway resistance and currently on an SV needs AVAPS to get a decent breath. And remember, if those dials ain't spinn'in, I can't invoice!

Banned

Banned wrote:

dsm wrote:

Snoredog wrote:
<snip>

Maybe this machine will help retrain your breathing over a course of weeks where it will settle down with very little change. Machine is doing its job, I just think it could do a better job at it. Would be interesting to see what happens when IPAP Min is increased say to 12, that is 2 cm pressure support, same you would get with a Bipap Auto at a minimum.

<snip>

This is what I am thinking too (I know banned would love you to have done it yesterday )

A few days of familiarization & getting used to it & like the others think, give it a try.

DSM

2cm between EPAP and IPAP Min is ridiculously close for effective SV pressure support. Remember the (automatic) gap on the ResMed Adapt SV is 3-6 cm between EEP and IPAP Min. Conversely, AVAPS states. "Do not set IPAP Min too low". An EPAP/IPAP Min gap of 3 cm would be rock bottom for SV mode to function properly. And if James truly does have upper airway resistance, as I do, he will be lucky if EPAP 10, IPAP Min 16 does the trick. Snoredog is correct to expect IPAP Min to be quite high with nasal restriction. My EEP/IPAP Min gap was 6 cm on the Adapt SV. On AVAPS the EPAP/IPA MIn gap is 4 cm but that's at EPAP 15 and IPAP Min 19. James will never make it sticking straws up his nose with his current mask. I think in the end, everyone one with upper airway resistance and currently on an SV needs AVAPS to get a decent breath. And remember, if those dials ain't spinn'in, I can't invoice!

Banned

then why not just put EPAP=4 and IPAP Max=30 then you cover the whole thing.

because doing that would be stupid.

Snoredog wrote: then why not just put EPAP=4 and IPAP Max=30 then you cover the whole thing.
because doing that would be stupid.

You may be on to something. And it may not be any stupider than Jame's current settings.

The interesting note is the only requirement for setting the ResMed Adapt SV is to set EEP and forget it, the device will set IPAP Min/Max with no more input.

I think you nailed it when you suggested raising IPAP Min may be higher than what we think.

Banned

Banned wrote:

Snoredog wrote: then why not just put EPAP=4 and IPAP Max=30 then you cover the whole thing.
because doing that would be stupid.

You may be on to something. And it may not be any stupider than Jame's current settings.

The inteseting note is the only requirement for setting the ResMed Adapt SV is to set EEP and forget it, the device will set IPAP Min/Max with no more input.

I think you nailed it when you suggested raising IPAP Min may be higher than what we think.

Banned

Actually his current settings is much better than what he had before on CPAP where AHI=55, you couldn't see the PB. He had a lab titration, they don't appear to have a clue based on the reported 20/10 fixed settings. WIth EPAP at 10, and working IPAP going to avg. 13 cm, he is already at a EPAP=10 and IPAP=13 if on a fixed bilevel machine. Would some of that settle down if IPAP settled at 13? ya don't know until you try it. Worst that could happen is IPAP working pressure would move up from there. What if a lot of those Hypopnea seen are central and from the rapid pressure changes? I just hope that EPAP is not a tad too high and he has already missed it from the start.

If he had a lab titration, why didn't they give him the pressure(s) to punch into the machine. If I was him, I'd call the sleep back directly and ask them what pressures where supposed to be punched into the machine, because it doesn't sound like the DME read those instructions correctly. What it sounded like to me is they punched in fixed Bilevel settings at EPAP=10, IPAPMin=20, IPAPMax=20, thought James said "no" but didn't want to argue with the DME, don't blame him we know those guys don't have a clue. What would have been nice is if they gave him the titration table to go by.

Snoredog wrote:

Banned wrote:

Snoredog wrote: then why not just put EPAP=4 and IPAP Max=30 then you cover the whole thing.
because doing that would be stupid.

You may be on to something. And it may not be any stupider than Jame's current settings.

The inteseting note is the only requirement for setting the ResMed Adapt SV is to set EEP and forget it, the device will set IPAP Min/Max with no more input.

I think you nailed it when you suggested raising IPAP Min may be higher than what we think.

Banned

Actually his current settings is much better than what he had before on CPAP where AHI=55, you couldn't see the PB. He had a lab titration, they don't appear to have a clue based on the reported 20/10 fixed settings. WIth EPAP at 10, and working IPAP going to avg. 13 cm, he is already at a EPAP=10 and IPAP=13 if on a fixed bilevel machine. Would some of that settle down if IPAP settled at 13? ya don't know until you try it. Worst that could happen is IPAP working pressure would move up from there. What if a lot of those Hypopnea seen are central and from the rapid pressure changes? I just hope that EPAP is not a tad too high and he has already missed it from the start.

If he had a lab titration, why didn't they give him the pressure(s) to punch into the machine. If I was him, I'd call the sleep back directly and ask them what pressures where supposed to be punched into the machine, because it doesn't sound like the DME read those instructions correctly. What it sounded like to me is they punched in fixed Bilevel settings at EPAP=10, IPAPMin=20, IPAPMax=20, thought James said "no" but didn't want to argue with the DME, don't blame him we know those guys don't have a clue. What would have been nice is if they gave him the titration table to go by.

What the Dr. punched in (or what James thought she would punch in) is probably less important than just getting the machine. Like you, I don't think Jame's Dr. has a clue about the workings of an SV. Remember, she only grabbed the SV to accommodate James bizarre mask preference. Jame's lucked out! All he needed was the machine.

I don't think anything is going to settle for James at IPAP Min 13. I think when he gets to IPAP Min 15 he may start to see some improvement in PB and Hypopneas.

What I do like about James Encore reports is that it is the first time I have actually seen PB scored. I never owned a Respironics SV but it it would have been interesting to see if I scored PB. I doubt dsm has even scored a PB, but I could be wrong.

I'm thinking EPAP 10 is probably ok. I'm ready for James to pick up his game, tonight. I think we got the drift of where he's at with his current settings.

Banned

Banned,

I have several charts with small PBs - but in the overall scheme of things my therapy has improved so much since the Bipap AutoSV I have not worried about the few that occur from time to time. I took the view (right or wrong) that as they only showed when some other situation had occurred that day so they were not in any way the norm.

Bev's charts tended to have a few PB scores when she was on full BipapSV settings - one reason we should be careful about push James to wing his dials so early in his adaptation phase.

DSM

Banned wrote: I'm thinking EPAP 10 is probably ok. I'm ready for James to pick up his game, tonight. I think we got the drift of where he's at with his current settings.
Banned

Right now at EPAP=10, he has zero Apnea, that is what you would want to see on this machine, if EPAP was 9.0cm and I then seen a couple AP's show up I'd say he could be confident that 10 was a good working pressure to use. IF 10 is slightly high for him, it only makes for more unstable sleep the farther up he goes. Things will change rapidly when he starts applying Pressure Support so we will see. Think he already has the reports, if the pressure was checked on each machine with a manometer and you got 10 from CPAP, then that would be okay, but I've seen these machines be off on pressure by 1.5 cm from the LCD, luckily that was only on a 420e and you could correct it.

It is just a matter of anticipating what is going to happen next when you move pressure one-way or another. If you look at the HI's on his report (if by chance they were obstructive hypopnea), IPAP working pressure should have eliminated them, it didn't in fact IPAP working remained far from reaching IPAP Max. Since IPAP pressure did not eliminate those, you are pretty much guaranteed they are central hypopnea, dropping from Patient Triggered breathing would also indicate that but I see a few that it didn't see that way.

James is a tough guy, it will just wake him up

Snoredog wrote: Right now at EPAP=10, he has zero Apnea, that is what you would want to see on this machine,

I see your point about trialing James at EPAP = 9.

dsm wrote:Bev's charts tended to have a few PB scores when she was on full BipapSV settings - one reason we should be careful about push James to wing his dials so early in his adaptation phase.
DSM

Doug, I'm not sure what he needs to adapt too. The guy is on CPAP. Hasn't he done that before?

Snoredog wrote: Things will change rapidly when he starts applying Pressure Support so we will see.

So, let the games begin!

But, it appears James has left the area.. We're preparing the party and he's a no show?

Banned

James was smart enough to design Encore Analyzer. I'm sure James is smart enough to ask for help when he wants it. The repeated implication that James needs advice about settings, despite never having asked for it, is both condescending and insulting IMO.




James, our accomplished and benevolent author of Encore Analyzer, deserves a whole lot more respect than that. In my opinion his accomplishments demand more respect than insistent armchair quarterbacking. Sorry to clear the air in your thread that way, James.

Snoredog wrote:What was the pressure on your Cflex that produced the lowest AHI vs. Pressure curve report?

It was 9cm. See chart below:

Snoredog wrote:Only looking for the Cflex pressure that eliminated the obstructive apnea OA. I know you
ran your machine in CPAP mode so that would be what I would want to see. It is absolutely critical on this machine you get
EPAP nailed.

I had been running at strait CPAP at 8.5 the past month or so trying to avoid centrals (which seemed to get a lot worse around 10cm).

Snoredog wrote:You will notice when you start off with the machine that peak and tidal volumes are way up there at 41 peak, breaths per minute at 21 then you settle down, are you breathing that deeply or rapidly when you are starting out?

Wasn't aware that I was. Keep in mind that after an hour or so I get more congested and find it harder to breath, not sure if that is a factor in this change?

Snoredog wrote:I don't have a lot of confidence in what they came up with in your lab report, sounded to me like they wanted you on fixed 20/10 instead of 20/10/10, your avg. so far is 20/13/10 on avg.

The lab tech wrote 20/10/10. It was the RT at the DME that messed up due to a poorly written prescription and set the machine at 20/20/10.

Snoredog wrote:my first move would be to move IPAP Min to 12 cm adding 2 cm minimum Pressure Support and see what happens.

Yeah I think I will go try IPAP Min at 12 or 13 once I have been on the machine about a week or so.

dsm wrote:
A few days of familiarization & getting used to it & like the others think, give it a try.

DSM

Agreed.

Snoredog wrote:I wished he would have gone ahead with the nasal surgery, that could have improved his condition on this machine (or ruled it out).

Yes it was a mistake to not get that done in June of 2007. I now have it scheduled for Jan 9 in Ohio by Howard Levine (http://www.clevelandnasalsinus.com)

Snoredog wrote:Besides I'm not impressed with the medical care James has been getting up north.

Amen to that. It might be free up here but its terrible... it maybe a case of you get what you pay for.

Banned wrote:James will never make it sticking straws up his nose with his current mask.

Please keep in mind I am not using my nose at all at night, zero.

Snoredog wrote:If he had a lab titration, why didn't they give him the pressure(s) to punch into the machine.

http://james.istop.com/apnea/reports/ASVTitration.pdf

Banned wrote: What the Dr. punched in (or what James thought she would punch in) is probably less important than just getting the machine. Like you, I don't think Jame's Dr. has a clue about the workings of an SV. Remember, she only grabbed the SV to accommodate James bizarre mask preference.

A few points:
- It was the DME that punched in the wrong values
- The Dr told the lab to use either the Auto SV or the CS2
- It was the lab tech that choose the SV. She had both in the lab and said she would switched to the CS2 if necessary
- My 'bizarre mask preference' was due to the fact that my nose doesn't work. Zero air though my nose at night. It was a big step forward when I got it as I had been unable to use CPAP for 6 months due to extreme nasal irritation. I'm going to try and get a Quottro on Thursday, maybe you will stop bitching about it then?

No disrespect intended, James. Just mess'in.
I'll go mess with my own therapy and tone it down.

Thanks!
Banned

-SWS wrote:James was smart enough to design Encore Analyzer. I'm sure James is smart enough to ask for help when he wants it. The repeated implication that James needs advice about settings, despite never having asked for it, is both condescending and insulting IMO.




James, our accomplished and benevolent author of Encore Analyzer, deserves a whole lot more respect than that. In my opinion his accomplishments demand more respect than insistent armchair quarterbacking. Sorry to clear the air in your thread that way, James.

yeah we all know your perfect.

I appreciate everyone suggestions (some more than others )

Its fun to watch everyone banter back and forth a bit as it make me think more about each of the suggestions.

I take it all as meaning that everyone cares and wants to help. That's a good thing in my mind. I've said it before and I will say it again, this group has been a great help to me the past two years. Thanks

There are a handful of regulars that I have really grown to respect.