CPAPtalk.com

georgepds wrote:http://www.circ.ahajournals.org/cgi/con ... ll/113/1/9

Gives a better description

"In the 19th century, Cheyne and Stokes described a pattern of periodic breathing in patients with heart failure, but over the past few decades, particular attention has been given to the occurrence of periodic breathing during sleep. Central sleep apnea, also referred to as Cheyne-Stokes respiration, is an abnormal periodic breathing pattern in which central apneas and hypopneas alternate with periods of hyperventilation that have a waxing-waning pattern of tidal volume that classically has been associated with severe decompensated heart failure."

which brings up the question again.. should not PB set off alarm bells?

why not start your own thread and discuss it with yourself instead of hijacking this one?

Why are you asking a question, then googling the answer and posting it here?

Are you trying to create a manual like Bipap for Dummies?

Another attempt by Snoredog to control communication and terrorize a newbie.



Get your armor, cherish your kind heart, and ignore the attacks, George.
O.

georgepds wrote:http://www.circ.ahajournals.org/cgi/con ... ll/113/1/9

Gives a better description

"In the 19th century, Cheyne and Stokes described a pattern of periodic breathing in patients with heart failure, but over the past few decades, particular attention has been given to the occurrence of periodic breathing during sleep. Central sleep apnea, also referred to as Cheyne-Stokes respiration, is an abnormal periodic breathing pattern in which central apneas and hypopneas alternate with periods of hyperventilation that have a waxing-waning pattern of tidal volume that classically has been associated with severe decompensated heart failure."

which brings up the question again.. should not PB set off alarm bells?

Georgepds, welcome to the message board! I placed a link to the discussion you and dsm were having here:
viewtopic.php?f=1&t=36541&start=15#p316663

Feel free to add any of your thoughts or questions in that thread.

ozij wrote:

Another attempt by Snoredog to control communication and terrorize a newbie.

Get your armor, cherish your kind heart, and ignore the attacks, George.
O.

Hey I was asking a question, and I don't need to remind you of what we call the female dog either as I'm sure you already know it.

Snoredog wrote:

georgepds wrote:....

which brings up the question again.. should not PB set off alarm bells?

why not start your own thread and discuss it with yourself instead of hijacking this one?
...

I agree, it's bad form to answer your own question..

I'd like to better understand why PB are not a cause for alarm. As near as I can make out, they indicate a serious problem, and no one has here commented on it.

Banned wrote: I have never disputed James ability to write great SW. But with all due respect dsm and SWS, I cannot, for the life in me, figure how you two fairly knowledgeable individuals can look at James' charts and behave as if everything is fine.

Banned

I sorta agree, and my understanding he is only renting the machine for a few weeks, but I would make any change in small measured changes. I don't think he needs a week of baseline study, his rental will be up and he will be with CPAP data. I sent him the provider guides, manual and titration guide if he follows that he should be fine.

But I agree, I don't like seeing the PB on his report, that should be eliminated ASAP and if correct settings used it should take care of that without much tweaking. At the same time I also agree you have to follow guidelines in its setup. He already knows what the lab reported as long as he doesn't exceed those parameters he should be fine.

LOL, but the care he's gotten to date, could our suggestions be any worse? I doubt it, hey James give us a report dammit

Snoredog wrote:I doubt it, hey James give us a report dammit

http://james.istop.com/apnea/reports/AsvNov26.pdf

Yes I am anxious to start making adjustments as well. I wanted to take a bit of time and get used to the machine first. Also this is the first DME that has taken any interest at all in being involved in my therapy so I didn't want to make any changes until after I saw her again.

The first adjustment I plan to make is increase IPAPmin by 3cm. Will run that way for a few days and then I may try dropping EPAP by 1cm.

One thing that I have noticed is that Pressure Support kicks in shortly after I put on the mask and long before I fall asleep. Has anyone else experienced this?

I think you got a good baseline, you must have had a couple beers or glass of wine with dinner last night it is much worse the prior nights, if so I would ignore last night's data.

I still think you need to avoid that PB. You only had 1 or Apnea for the week, but HI is way too high for this machine, this machine should be killing all HI's. Since IPAP working pressure is NOT moving up to resolve them says it is central hypopnea, so I still believe you are a tad too high on EPAP.

If it was me I would try:

Lower EPAP to 9.0 cm (to reduce HI's seen, but if more AP's show up you have to go back up to 10 cm).
Move IPAP Min +4 to 13 cm (you are avg. 13 now)
Leave IPAP Max=20 (unless you start bumping into it)
BPM=Auto

I would ignore the Pressure support seen at the beginning of sleep, it seems it does that with most people that I've seen to date, must be the machine trying to establish where you want to be breathing at. Those could be onset artifacts causing the machine response (to be expected).

georgepds wrote:

Snoredog wrote:

georgepds wrote:....

which brings up the question again.. should not PB set off alarm bells?

why not start your own thread and discuss it with yourself instead of hijacking this one?
...

I agree, it's bad form to answer your own question..

I'd like to better understand why PB are not a cause for alarm. As near as I can make out, they indicate a serious problem, and no one has here commented on it.

Periodic Breathing IS a cause for alarm in my opinion. And yes it will set off alarms, but alarms are expected at this stage of the game. Most turn them off until settings are established. He is on his first week on this machine, he has to first get settled into breathing with the machine. Goal would be to eliminate all therapy flags as those items are residual events and you also have to be careful at what you are looking at, those could either be central or obstructive events. Set correctly this machine should take care of PB. His SDB traits are more in line with CSDB as opposed to CSR. I haven't seen anything in his past history reports that suggest Mixed apnea is present.

But even with the baseline settings, it is an improvement over what he had before. But with his prior machines you could not see the PB and/or tell what was central vs. obstructive. As we have seen here in the past, things can quickly turn into a train wreck by making too aggressive moves. You first want a baseline so if that does happen you can revert back to baseline settings that worked better.

While it still may look bad its not that bad, hopefully he is getting "some" rest and that can also influence things. It is like your body has to get used to sleeping again.

Snoredog wrote:I think you got a good baseline, you must have had a couple beers or glass of wine with dinner last night it is much worse the prior nights, if so I would ignore last night's data..

Yeah last night wasn't good. The only change I made was that I changed rise time from 4 back down to its default of 3. That shouldn't have an effect should it?

jskinner wrote:

Snoredog wrote:I think you got a good baseline, you must have had a couple beers or glass of wine with dinner last night it is much worse the prior nights, if so I would ignore last night's data..

Yeah last night wasn't good. The only change I made was that I changed rise time from 4 back down to its default of 3. That shouldn't have an effect should it?

No actually that shouldn't have come into play at all. Rise time is only applicable when you are in back up mode then backup mode has to be set from BPM=Auto to BPM=Fixed settings, then you input Rise Time and IT timed values. IF BPM=Auto it completely ignores any values input.

IF BPM=Auto is not correcting your breathing when landing in the backup mode, then you input those Fixed values. The goal with this machine is to get EPAP taking care of Obstructive Apnea (not necessarily obstructive hypopnea). Then the moving IPAP pressure adjusts Pressure Support to eliminate any Periodic Breathing. If any Central events show up it switches to the Backup Mode where those settings (in your case it is set to Automatic) slow breathing down (i.e. BPM) which brings the central dysregulation under control. Once spontaneous breathing returns (2 to 6 breaths supposedly) you breathe back on the spontaneous side of the machine.

You almost have to look at this machine like 3 machines in one. SV side corrects breathing, if it does that it can eliminate PB and Centrals. Central dysregulation is caused by erratic breathing or periodic breathing. So main function of the SV side is breathing. Backup mode (i.e. BPM=xxx) is another machine type that uses settings to control breathing from the Automatic side of the machine. If you understand the logic behind how they do titration decisions its easy to understand.

The periodic breathing is a series of breaths where there is a pattern of over shoot and under shoot. It is like after you have an apnea you gasp and take a deep breath (similar to holding breath under water in a swimming pool). But that deep recovery breath over shoots your oxygen/CO2 ratio and it continues. The target of this machine is catch your inspiration as it begins and apply Pressure Support by IPAP to bring the inspiration up so you avoid that recovery breath and overshoot. Many times you will see a deep breath before a central event (seen by peak volume increasing rapidly).

We have all seen what CSR breathing looks like, it is a series of 10 breaths with varying degrees of inspiration followed by periods of no breathing followed by series of more breathing. This machine targets all inspiration breaths by looking at the prior 4 minute average. With PB it will stair-step up/down in peak volume. If that inspiration peak line is up it increases IPAP pressure with every breath to meet its target, if that trend is down, it decreases IPAP, this avoids the "deep" breath and overshooting your target peak inspiration. The machine wants to see consistent inspiration breaths, it actually treats every inspiration breath the same. Next thing it looks at is timing between inspiration to inspiration. The closer that is the higher your RR/ BPM will be. All they mean by BPM is the fixed backup mode because that is where you input those settings in.

From my understanding of how this machine works, you leave BPM=Auto until you get EPAP set correctly, get IPAP Min and Max set correctly, then you only change it if you cannot eliminate PB or Central events. Your most fail-safe mode is to keep BPM=Auto. I also believe you should follow basic guidelines established elsewhere and not exceed the 10 cm Pressure Support limit, that limit is to prevent unnecessary lung damage. You don't want to do any harm with the machine.

Here are some interesting thoughts on Periodic Breathing.
http://www.ncbi.nlm.nih.gov/pubmed/6819 ... rom=pubmed

Worth reading the abstract.

DSM

dsm wrote:Here are some interesting thoughts on Periodic Breathing.
http://www.ncbi.nlm.nih.gov/pubmed/6819 ... rom=pubmed

Worth reading the abstract.

DSM

I like the graphical display of it, pretty much tells what is happening, the up and down squiggly lines in the graph are your inspiration breaths, the non-breathing solid line periods is the central apnea that follows. SV is going to capture that inspiration peak and boost it up and/or add boost as it drops to keep breathing consistently up across the board.

http://global.respironics.com/UserGuide ... 042299.pdf

jskinner wrote:

Snoredog wrote:I doubt it, hey James give us a report dammit

http://james.istop.com/apnea/reports/AsvNov26.pdf

Yes I am anxious to start making adjustments as well. I wanted to take a bit of time and get used to the machine first. Also this is the first DME that has taken any interest at all in being involved in my therapy so I didn't want to make any changes until after I saw her again.

The first adjustment I plan to make is increase IPAPmin by 3cm. Will run that way for a few days and then I may try dropping EPAP by 1cm.

One thing that I have noticed is that Pressure Support kicks in shortly after I put on the mask and long before I fall asleep. Has anyone else experienced this?

James,

Interesting how your PB scores show up anywhere in the night. From reading the charts you appear to have some 'good' nights with a couple not so good.

But the important things like consistency in tidal flow & volume seem to be ok.

There are a few occasions when the machine spends some time trying to control your breathing rate but the average looks fine to me.

DSM

Snoredog wrote:
<snip>

From my understanding of how this machine works, you leave BPM=Auto until you get EPAP set correctly, get IPAP Min and Max set correctly, then you only change it if you cannot eliminate PB or Central events. Your most fail-safe mode is to keep BPM=Auto. I also believe you should follow basic guidelines established elsewhere and not exceed the 10 cm Pressure Support limit, that limit is to prevent unnecessary lung damage. You don't want to do any harm with the machine.

Two nights back I set BPM=OFF (was =AUTO) just to see what would happen. The nights data was worse than normal but of course the patient triggered breaths line was flat

So I promptly reverted to BPM=AUTO - at least I know when I see an AP scored in the data (typically 6-10 for the whole night) & there is a blip in the patient triggered breaths line, I know the machine is probably just trying to tidy up an arousal breathing pattern - esp when my SpO2 pulse data shows a blip at the same time.

DSM