BIPAP AUTO-SV SETTINGS HELP

Muffy wrote:Well, "IMHO", this old guy can really swing an axe...

Wow. That was GREAT!

-SWS wrote: Well that's refreshing. I thought it was going to be one of these:

And that was funny.

The forwarding has just been done.

Guest wrote:

Muffy wrote:

-SWS wrote:

CROWPAT wrote:O saturation remained about 90% throughout the night.

If saturation really remained at 90% throughout the titration night---and still remains that low---then I have to ask why the doctor(s) did not attempt to experimentally elevate CROWPAT's O2 baseline with supplemental oxygen.

Yeah, I thought at that point that was very significant information.

CROWPAT wrote:The oxygen number was all my fault. I should not have relied on memory, and made a mistake by saying it was about 90 when I meant to say above 90%.

Muffy's words "at that point" set the entire context of that reply you quoted...

I think the purpose of Muffy's comment was simply to say that my having focused so much on the 90% baseline at that point was not as nonsensical as it was portrayed. But at this point, who really cares?

rested gal wrote:The forwarding has just been done

Thanks for being the middle point so that CROWPAT can continue being this thread's center point...

Muffy wrote:Include the medication list and the times you take them (especially the nighttime stuff).

Don't forget the dosages, and what (if anything) you took during the portable study.

Muffy

15 mg Ambien during the 2007 study.
During portable: 50 mg Tambacor, 10 mg Zetia, and 80 mg aspirin - all in morning. 50 mg Tambacor in evening.
Current: 10 mg Tambacor, 10 mg Zetia, 10 mg Lexapro in morning, and 50 mg Tambacor and 80 mg aspirin in evening (1630 or so).
Started 2 sprays of Veramyst in the morning about a month ago with no obvious effects on sleep.
Generally drink 3/4 ounce of Nyquil just before bed for congestion and it helps me get to sleep faster.

Last spring I stopped each medication for two weeks in succession until I was only taking the aspirin - all with doctor approval. I did not notice any change in feeling or AHI from that experiment.

Based on the data, there is no definite evidence that any significant abnormal central dysregulation exists, so there does not appear to be indication that that an ASV algorithm would offer any benefit over conventional pressure therapy.

There is, however, significant evidence of sleep maintenance issues. Initial NPSG showed a sleep efficiency of 23%, and CPAP/ASV titration showed Sleep Efficiency of only 80.9% despite a hefty dose of Ambien. The CPAP/ASV titration was notable for a period of prolonged wake during the middle of the study. REM looks to be a little suppressed with some late-night rebound.

Unfortunately, the diagnostic study is a limited-channel portable study, so there are no measures of actual sleep. Further, those results are very confusing to me. The AHI is calculated at 20.7, yet oximetry suggests a number 3 or 4 times that. However, the quality of the oximetry channel looks suspect, so I would question the reliability of that data.

In reviewing the current D/Ls, respiratory events tend to be grouped in the middle of the night. Because of this, I believe a far more plausible explanation for their existence would be that they are related to Wake (and are artifact) and/or Sleep-Wake Transition, and Sleep Hygiene must be examined. How much caffeine and/or alcohol do you use, and when?.

An obvious exception would be the night at 13 cmH2O, when significant events occurred at the end of the night. This is odd in that the very aggressive pressure titration (which started at 13 cmH2O) showed virtually no respiratory events whatsoever. However, that particular D/L was also a very long sleep period, nearly 10 hours, so again the possibility of sleep maintenance issues comes into play. Almost all sleep times are consistently in the 9 hour range. I'd make sure that the Lexapro is doing what it's supposed to do.

The ASV titration data is incomplete. One is left to guess what the single documented number is, but I would certainly think that it would be EPAP. And if so, having no respiratory events at EPAP 5.0 - 7.0 cmH2O would certainly seem to open up a host of treatment possibilities.

IIWY, I would get back to the sleep lab and get a diagnostic study (or at least a split) to get an accurate diagnosis, including respiratory behavior in REM vs NREM. I would get a couple of weeks of sleep log, but I am still waiting to get back the logs of the last 4 people I gave them to. If you can prove that you have quality sleep, then do the MSLT. What'd you do in the Army? Ever have a significant head injury?

Muffy

Do not know what D/L means
Caffeine. Caffeine free diet Coke only drink. No known caffeine ingestion other than chocolate candy.
Alcohol. Virtually none except Nyquil as mentioned. Do have an occasional beer or glass of wine, but not daily or even weekly.
Army. Armor, but last 13 years of service in Operations Research with no field time.
Head Injury. None that I can remember.

Sleep maintenance. If this means my body's ability to keep me in sleep then I am very suspicious that you are on to something. I often feel like I am on the verge of sleep or wake during the last hour of sleep. Could my brain be working overtime on something during the night?

2002 sleep study based on VERY little sleep. Too many wires and uncomfortable surroundings.

Found another NPSG - 2006. Graphs not good quality. Huge number of arousals (130) with centrals above 13. Scored 16 centrals supine and 2 centrals non-supine. Minimum SaO2 was 94%. SaO2>89% was 98.1.

Can scan report to bmp if you want me to. How can I get it to you?
Pat

CROWPAT wrote:Can scan report to bmp if you want me to. How can I get it to you?

Pat, I'd be more than happy to be your courier pigeon or pack mule with those BMPs. Any method of getting more info to Muffy is worthwhile IMO.

Muffy wrote:There is, however, significant evidence of sleep maintenance issues. Initial NPSG showed a sleep efficiency of 23%, and CPAP/ASV titration showed Sleep Efficiency of only 80.9% despite a hefty dose of Ambien. The CPAP/ASV titration was notable for a period of prolonged wake during the middle of the study. REM looks to be a little suppressed with some late-night rebound.

Unfortunately, the diagnostic study is a limited-channel portable study, so there are no measures of actual sleep. Further, those results are very confusing to me. The AHI is calculated at 20.7, yet oximetry suggests a number 3 or 4 times that. However, the quality of the oximetry channel looks suspect, so I would question the reliability of that data.

In reviewing the current D/Ls, respiratory events tend to be grouped in the middle of the night. Because of this, I believe a far more plausible explanation for their existence would be that they are related to Wake (and are artifact) and/or Sleep-Wake Transition, and Sleep Hygiene must be examined.

I don't suspect what Muffy just described as one possibility for your symptoms is exactly news to you, CROWPAT. So please pardon me while I attempt to fill in some missing pieces for any new readers who might be wondering how all those "scored" central events can possibly fit in with Muffy's working hypothesis that ordinary sleep-related central dysregulation might not be the problem at hand:

New readers attempting to follow CROWPAT's mystery should probably note that for some people, much more than others, Ventilation Is Unstable During Drowsiness Before Sleep Onset. Again, that particular ventilatory problem related to sleep onset can be MUCH more pronounced for some of us than others. And if that wake-to-sleep based "unstable ventilation" is very pronounced in any given individual, then repeated wakefulness throughout the night---even very brief interludes of interrupted sleep----can repeatedly produce that same "unstable ventilation" throughout the night.


Muffy's working hypothesis would corroborate this observation about following-day symptoms that CROWPAT is hoping to fix:

CROWPAT wrote:The one thing I have noticed on the BiPapAutoSV is that when my "Breathing on my Own" number is 99.9% I feel better even if some of the other numbers are not as good as usual.

Poor sleep architecture with repeated brief wakefulness throughout the night can explain a less than 99.9% spontaneous breathing machine score (via the "unstable ventilation" mechanism linked above), as well as that following-day mental fog and any drowsiness that might occur.

2006 report sent to SWS for Muffy. Waiting to hear more about what to do next. Can find Encore data for time on APAP if needed, but it is about two years old. How would I know that I was having disruptive breathing that resulted in significant arrousals during the night? I don't question that it could be happening and may be the root of the daytime tiredness/fog feeling. The obvious question is what can I do about it?

CROWPAT wrote:2006 report sent to SWS for Muffy

Got it and passed it along to our Guru of all gurus of a sleep pro.

In contrast to your previous studies, that PSG shows:

1) comparatively little wakefulness (a likely Ambien effect),
2) central apneas during sleep above 13 cmH2O (supporting ASV as a viable modality), and
3) no mention of periodic breathing during all that stable sleep

That might be more of a lung-inflationary Hering-Breur Reflex type effect going on with those sleep-related central apneas that were scored above 13 cmH2O. And I believe ASV can effectively address those while also addressing your obstructive SDB component---which often seems to require a higher pressure.

But the lack of breathing periodicity during all that stable sleep sure seems to support Muffy's working hypothesis in no small way. Fixing sleep maintenance rather than tweaking ASV pressure sure is starting to look like a very promising path from where this layperson sits.

-SWS wrote:Muffy usually comes up with some very useful advice.

I may have to rethink that statement. I'll have to go back to our various PSG sleep-study threads to see if there was ever an instance when our refreshingly quirky-humored Muffy/StillAnotherGuest/sleepydave ever failed to offer useful advice. I can't think of an instance off the top of my head...

dsm wrote:
<snip>

I hope to do a summary of CROWPAT's status from the input we have & hopefully we can get into a diagnostic phase & I think
SWS has already offered some excellent & easy to try steps.

The benefit of the holistic approach is to look at life & circumstance matters as they can and do play an important role & again
it may be that CROWPATs machine is already doing its best job (but with careful evaluation we can hopefully work out if it can
be improved on).

DSM

I guess the simple explanation that is emerging is that the machine may already be doing the best it can ?

DSM

CROWPAT wrote:The obvious question is what can I do about it?

Muffy wrote:I believe a far more plausible explanation for their existence would be that they are related to Wake (and are artifact) and/or Sleep-Wake Transition, and Sleep Hygiene must be examined.

Muffy wrote:IIWY, I would get back to the sleep lab and get a diagnostic study (or at least a split) to get an accurate diagnosis, including respiratory behavior in REM vs NREM. I would get a couple of weeks of sleep log

CROWPAT, here are Muffy's past posts mentioning the search terms "sleep" and "log":
search.php?keywords=sleep+log&terms=all ... mit=Search

And here are Muffy's past posts mentioning the search terms "sleep" and "hygiene":
search.php?keywords=sleep+hygiene&terms ... mit=Search

dsm wrote:I guess the simple explanation that is emerging is that the machine may already be doing the best it can ?

Something even better than a highly-broad preliminary explanation or guess is emerging IMHO: good, substantiating details that CROWPAT's doctors can now work with. Vague predictions: potentially gratifying. Multiple vague predictions: a virtual guarantee. Highly gratifying none the less...

Ok. So let's assume CROWPAT is a dirty sleeper and chooses to keep Sleep Hygiene Log for 2 weeks. Shouldn't he also document when he takes a puff of his cigar (and doesn't inhale), how much time he spends breathing his own second-hand smoke, and when he takes a hit of chocolate?

Banned

SWS, thanks for the feedback and forwarding. Read all of the relevant posts by Muffy. Believe sleep hygiene (I printed it) is pretty good: bed at 1115 but not up until I wake, no late night snacks, have limited chocolate and do not eat other caffeine products, bedroom is dead quiet and dark and cool.
Sleep but no asleep is likely, but don't know what to do to fix that. RX for something? - Yes, I am looking for a magic bullet.

I did notice that I had great feeling sleep during the 2006 and 2007 sleep studies when I requested Ambien to help me endure the study surroundings.

-SWS wrote:... New readers attempting to follow CROWPAT's mystery should probably note that for some people, much more than others, Ventilation Is Unstable During Drowsiness Before Sleep Onset. Again, that particular ventilatory problem related to sleep onset can be MUCH more pronounced for some of us than others. And if that wake-to-sleep based "unstable ventilation" is very pronounced in any given individual, then repeated wakefulness throughout the night---even very brief interludes of interrupted sleep----can repeatedly produce that same "unstable ventilation" throughout the night. ...

SWS, that is me to the "T". I certainly am not saying that is CROWPAT's problem. Rather I affirm your note this can be a very difficult problem.

As I start to fall asleep, my respiratory drive completely fails. I no longer even make the effort to breathe. I do not have heart failure. Though badly overweight, I fall below the point where Obesity Hypoventilation Syndrome (OHS) is normally a factor. I just seem to suffer breathing and sleep dsyregulations as I try to sleep.

My sleep specialist / neurologist thinks it may be a progression of the Sporadic OPCA impacting the brain stem. The central apneas would get long enough that my Remstar BiPAP (M Series) would think I was no longer connected to the machine. It would turn off. Time after time after time. When you realize that the machine takes 60 seconds before it automatically turns itself off, you begin to realize how bad the apnea had become.

Plus, as note, I would awaken during the night - for whatever reason - and face the same problem all over again.

I still dread going to sleep. That dread will not go away quickly. But as I fall asleep it is now very, very clear how much ventilation support I need as I fall alseep. Plus, based on the machine data it appears during my light stages of sleep my respiratory drive is none too good. After an hour or so I seem to reach a much deeper, smoother breathing pattern. This is all conjecture (admittedly) based on the cyclic pattern that I see in the data and the timing of those patterns.

My sleep specialist / neurologist described this as "sleep onset central apnea with arousal".

So, yes. I affirm this can be a horrible issue to face.

John,

Seeing you have a Vpap Adapt SV (that I humorously called the 'Respiratory Nazi' - do you find that it 'whips you into line' quickly

Any other comments re how you perceive it ? - have you ever done battle with it over when & how deep to breathe ? (& lost )

DSM