BIPAP AUTO-SV SETTINGS HELP

Sir Banned wrote: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?

I personally don't know enough about sleep hygiene to give a good detailed answer to that, Banned. But I suspect your point is a good one: a variety of factors---that most of us don't normally associate with sleep deterioration----can probably adversely impact sleep.

Also the comment that if sleep maintenance is at the heart of an ASV user's central breathing problem, a rise time of 3 can sometimes arguably be better than a rise time of 5---but a rise time of 5 can in some cases arguably be better than 3. When would your suggested rise time of 5 be better than 3? I would suspect the answer is when 5 doesn't deteriorate ventilation in any significant way, but promotes better sleep by making the machine more comfortable----exactly as you suggested. I would guess trial-and-error is beneficial. And in many cases I think rise time should turn out to be acceptable either way.

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CROWPAT wrote: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 don't blame you for looking for that magic bullet. I think you should try to somehow fix sleep maintenance if that is your problem. Again, this is something that Muffy, who runs a sleep center, knows more about than any of us. So I'm personally staying tuned to hear anything that Muffy might have to say about sleep maintenance.

By the way, here is what Muffy (a.k.a. StillAnotherGuest) has already posted on this message board about Ambien/Zolpidem:
search.php?keywords=zolpidem&terms=all& ... mit=Search

I believe the reason for first focusing closely on sleep hygiene has to do with the fact that if it happens to be broken in cases like yours, it absolutely must be fixed. Additionally fixing broken sleep hygiene would be a non-pharmaceutical solution, which is generally always preferable IMO.

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JohnBFisher wrote: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, I've been reading your posts with great interest. I'm ecstatic to see how soon you received dividends from your Resmed ASV----and how soon your body began copiously paying back sleep debt.

I have noticed that ASV machines nicely fix that type of problem in some cases---perhaps most cases. Muffy has repeatedly mentioned cases in which ASV did not manage to algorithmically stabilize "ventilatory instability" where sleep onset and/or sleep maintenance problems were central. And, of course, we have read a few cases where switching from Resmed to Respironics, or switching from Respironics to Resmed finally did the trick.

I agree that successfully servo-ventilating through sleep-onset "ventilatory instability" can pay dividends---when it just so happens to algorithmically match well with a patient. And you're a clear example of that! So thanks for reminding us of that. And that, of course, means that experimental ASV machine tweaks---ideally with a knowledgeable medical team in the loop---can conceivably pay dividends in some cases. I would think that statement to be true especially if machine settings are inherently ventilation-inefficient or just plain sleep-disruptive.

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dsm wrote: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 ?

That nicely describes the crux of the algorithm's challenge IMO. Can it ventilate through the problem? And can it do so without getting out-of-step or being so uncomfortable as to wake the patient?

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As usual, I plan on tuning in very closely to hear what Muffy might have to say about CROWPAT's sleep...

CROWPAT wrote:Scored 16 centrals supine and 2 centrals non-supine.

Now (actually a long time ago) would be a good time to differentiate "good" (or at least "benign") central apneas from "bad" central apneas, how many one needs before they need to be addressed, and how to best go about addressing them.

Sleep-onset central apneas should be considered "normal" phenomena, but as we look at CP's data, he really doesn't have any in areas that we know are "sleep-onset"-- the beginnings of the downloads (DLs) and NPSGs. With that in mind, I think it would be difficult (although not impossible) to say that centrals in the middle of the DLs are of a sleep-onset nature.

There is another central apnea, a "post-arousal" central. There is a sleep disturbance, a brief hyperventilation, and then a compensatory pause (the central apnea). While the sleep disturbance may be abnormal, the response is not.

Neither of these centrals need treatment.

"Bad" centrals have a perpetuating pattern- central begets central. The pattern repeats at a rate greater than 20 an hour (AI > 20), with that rate depending on whether they are short cycle or long cycle. ASV technology is designed to fix a cyclical central pattern. It does not "fix" any singular central apnea per se.

Anyway, back to your story, your centrals are fairly isolated, so I think they're mostly, if not all, post-arousal in nature. Further, they are very sparse. Most sources say that treatment should be given if there is a persistent CAI > 5 (which means you'd need like 40 in a night with 8 hours of sleep time).

Speaking of sleep time, there's 66 minutes of Wake TIme in this last sleep study with a Sleep Efficiency of 85.1% (the cut-off for a "good" Sleep Efficiency is 85%), so the Sleep Maintenance issue seems to persist here as well. You could even add, "Wow, that's even with Ambien", but Ambien doesn't last all that long. SInce Ambien is rapid acting and short duration, and you say that you have no problems falling asleep, then Ambien is probably not the best sleep aid if you choose to use one. There may not be any Ambien on board when your problem area starts.

Muffy

Buffy, thank you once again for all of your insight, experience, and attempts to diagnose and help me. Three doctors told me I had central or complex sleep apnea. Only one was honest enough to say that less is known about that version of apnea and how to successfully treat it.

It appears that they did not know what they were talking about. Nothing new for nice sounding and talking sleep doctors around my part of the country unfortunately.

I know from years of observation that I am subject to the placebo effect for almost any change in CPAP therapy. Consequently, I like to make changes for at least three days duration and preferably for seven days to be sure something is working or not working. Only when the effects of a change are clearly not good do I stop with that change and go back to the 12/14-22 that almost always yields good numbers for me even if it does not clear out the fog that inevitably shows up in the morning about 30 minutes to an hour after I awake.

Where do we go from here?

CROWPAT wrote:Where do we go from here?

To bed.

When you get up tomorrow, get out the bright sunlight for a good 30 minutes. And start your physician-approved exercise program.

Muffy

WILCO. Nothing else?

CROWPAT wrote:WILCO. Nothing else?

Pat,

Do you dream about sexy vampire slayers ???

Cheers

DSM

(a Buffy fan )

Muffy wrote:... but Ambien doesn't last all that long. SInce Ambien is rapid acting and short duration, and you say that you have no problems falling asleep, then Ambien is probably not the best sleep aid if you choose to use one. There may not be any Ambien on board when your problem area starts.

CROWPAT, I don't know much about selecting pharmaceutical sleep aides. My hunch is that you'll probably want to discuss a sleep-aide trial with your sleep doctor. I do know that more-expensive Ambien CR is the extended-release version of ordinary Ambien/Zolpidem:
http://www.ambiencr.com/what-is-ambien- ... en-cr.aspx (pardon the manufacturer marketing spin)

Also, Muffy's comments about that early-day sun exposure with exercise... the sun exposure helps entrain circadian rhythm----which can sometimes help with sleep maintenance problems. And regular physical exercise tends to improve sleep maintenance. Ever been "bushed" after a hard day's work? You probably slept well.

Muffy wrote:ASV technology is designed to fix a cyclical central pattern. It does not "fix" any singular central apnea per se.

I disagree with that statement. ASV is designed to administer a backup rate to address singular central apneas---as do other timed-mode BiLevel machines without a fluctuating IPAP amplitude.

Will do as I am told. Don't want meds unless necessary.
Concur with hard days physical work = good night's sleep.

dsm wrote:... 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)? ...

In fact, I found the Respironics ASV unit more disruptive. Since the ResMed ASV unit tries to identify the volume of ventilation, it starts to compensate as I start to drift off. It appears to gradually increase the pressure to compensate for my lack of effort to breathe. I feel as if I can "relax" and let the machine remind my body to keep on keeping on.

With the Respironics unit, I found it would play follow the leader. We all normally have a pattern to our breathing. Most of us normally take a few normal breaths and the one or two deeper breaths. The Respironics unit appeared to try to "follow the leader". If I missed a breath it would repeat what should come. Since it was often at the point of a deeper breath, I found it disruptive to have the unit suddenly increase the pressure.

So, for me, the gradual - although insistent - changes in the ResMed ASV unit appears to better conform to my needs and allows me to drift from sleep onset into sleep.

-SWS wrote:... I'm ecstatic to see how soon you received dividends from your Resmed ASV----and how soon your body began copiously paying back sleep debt. ...

The sleep debt is better. I am thinking MUCH more clearly and consistently. But it will require a long time of this increased energy to reduce the adverse impact (cardiovascular and metabolic) that the sleep debt had on my body. But I once again WANT to do the walking that will allow me to drop the weight.

-SWS wrote:... Muffy has repeatedly mentioned cases in which ASV did not manage to algorithmically stabilize "ventilatory instability" where sleep onset and/or sleep maintenance problems were central. And, of course, we have read a few cases where switching from Resmed to Respironics, or switching from Respironics to Resmed finally did the trick. ...

Again, just with my own experience, I firmly believe it is necessary to start with the sleep study. My first follow up to try to titrate my BiPAP pressure clearly indicated there were serious problems with central apneas. The Respiratory Information from that sleep study noted:

There were 67 respiratory events consisting of 6 obstructive apneas, 1 mixed apnea, 39 central apneas, 21 hypopneas, and 8 RERA’s. The overall apnea-hypopnea index (AHI) was 30.5/hr. The respiratory disturbance index (RDI) including RERA’s was 34.1/hr. The SpO2 nadir was 73%. Snoring was largely eliminated at 10/5 cmH2O, but tech noted snoring at 17/9. At BiPAP of 17/9 cmH2O, AHI was 14.6/hr. and the SpO2 nadir was 86%. Residual flow limitation episodes were seen despite BiPAP up to 17/9 cmH2O. The patient did sleep in supine position at this pressure setting.

And that was with only 132 minutes of sleep. My sleep was badly fragmented, with almost no REM sleep and it was fragmented:

Time in Bed (TIB) 361.0 minutes; Total Sleep Time (TST) 132.0 minutes; Sleep Latency 12.5 minutes; REM Latency 344.0 minutes; Sleep Efficiency 36.6%. Stage N1 Sleep 4.2% of TST; Stage N2 Sleep 57.6% of TST; Stage N3 Sleep 32.6% of TST; REM Sleep 5.7% of TST. There was 1 fragmented REM period.

Unstated was the fact that most of the central apneas occurred in stages N1 and N2 of NREM sleep. This of course makes it more difficult to attain deep sleep, let alone REM sleep. Not listed was also signfiicant issues with Restless Leg Syndrome and VERY bad cramping. That has not been completely eliminated, even with medication. Some nights (such as last night), I wake every hour or so with cramping. Nor does it appear to be lactic acid related. All I need to do is ignore the pain and "relax" my muscles. There is no correlation with any activity, food, stress or other factor during the day. It just comes and goes, though the frequency is increasing to about once a week. Still, bad sleep weekly is better than bad sleep every night.

-SWS wrote:... I agree that successfully servo-ventilating through sleep-onset "ventilatory instability" can pay dividends---when it just so happens to algorithmically match well with a patient. And you're a clear example of that! ...

And that's why I share my story. Not that this path is the one and only path. Rather that by working with a good medical team each of us should try to find what works for us. DSM finds the ResMed ASV to be a bit forceful. I find that same insistance to be very reassuring. It works for me. It might not work for others. As you note:

-SWS wrote:... that, of course, means that experimental ASV machine tweaks---ideally with a knowledgeable medical team in the loop---can conceivably pay dividends in some cases. I would think that statement to be true especially if machine settings are inherently ventilation-inefficient or just plain sleep-disruptive. ...

And what works for one of us might not work for another. I agree, I enjoy watching and learning from you, dsm, Muffy, banned and CROWPAT. I hope we find what helps CROWPAT to gain better sleep. He certainly has my empathy and best wishes. We, who find sleep so fleeting, value the blessing of sleep.

Again, please beware of the potentially biased manufacturer marketing literature below.

But this is what Respironics claims their machine does for a central apnea:

In addition to this breath-by-breath adjustment of pressure support, the BiPAP autoSV algorithm also calculates the patient's spontaneous breathing rate and will automatically trigger a breath should the patient have a central apneic event.

http://bipapautosv.respironics.com/how.aspx

While the PS-fluctuating algorithm is well-suited for cyclic peak-flow problems by design, the backup rate can do what an ordinary backup rate traditionally does for individual central apneas: commence timely ventilation.

JohnBFisher wrote:The sleep debt is better. I am thinking MUCH more clearly and consistently. But it will require a long time of this increased energy to reduce the adverse impact (cardiovascular and metabolic) that the sleep debt had on my body. But I once again WANT to do the walking that will allow me to drop the weight.

What a promising story, John.

It sounds as if your body needs to literally heal right now--- complements of that new-found sleep. Then, the prospect of physical recovery with exercise becomes possible for the first time in quite a while. One "hump" that you might struggle with is sleep drive or maintenance after sleep debt diminishes---since sleep drive sometimes diminishes a bit after sleep debt has been paid. In those cases it probably makes good sense to work at any sleep-impacting loose ends such as physical exercise, diet/biochemistry, circadian rhythm, potentially counterproductive medications, etc. Then, pharmaceutical sleep aides might become a sleep-stabilizing possibility in some cases as well.

-SWS wrote:

Muffy wrote:ASV technology is designed to fix a cyclical central pattern. It does not "fix" any singular central apnea per se.

I disagree with that statement. ASV is designed to administer a backup rate to address singular central apneas---as do other timed-mode BiLevel machines without a fluctuating IPAP amplitude.

I disagree with your disagreement. The CompSAS cycle is perpetuated by overshoot, so the key is not how it blows through the CA, but how pressure support drops back during the hyperventilatory period immediately after. That is the critical area. If this were not the case, then simple BiPAP with a backup rate would be successful in treating CompSAS and there would be no need for ASV.

Further, singular (or more specifically, isolated) central apneas are nearly always benign, and should be left alone.

Muffy

CROWPAT wrote:Buffy, thank you once again for all of your insight, experience, and attempts to diagnose...

Buffy does not diagnose.

-SWS wrote:CROWPAT, I don't know much about selecting pharmaceutical sleep aides. My hunch is that you'll probably want to discuss a sleep-aide trial with your sleep doctor.

Right, Buffy does not prescribe, either (although you're certainly welcome to try):

"Hi! Buffy from the internet said that you should give me some AmbienCR."

BTW, eszopiclone might also be just what the doctor ordered (or should) IF it turns out that middle of the night sleep maintenance is the issue.

CROWPAT wrote:Where do we go from here?

Try to figure out how much sleep you're getting and how much sleep you need. Your DLs are suggesting you're sleeping 9+ hours a night, and that could actually be too much and the cause of the "fog". That needs to looked at carefully, to see if

1. You are truly a "long sleeper" and that's just how it's going to be (and if you were only sleeping 5.5 hours back when you were working, then that must have been hell)(Hey! Hell On Wheels! Wasn't that the nickname of an armored division?)(Or maybe it was a Rock 'n Roll Band, I forget);
2. You are "oversleeping" and it's too much. Statistically, long sleepers tend to have the same morbidity/mortality as short-sleepers;
3. You have a sleep maintenance issue, and that 9 hours of DL time is really like 7 hours of sleep;
4. You have another medical issue(s) (like uncontrolled depression).

Can you get a clear copy of the graphs from 2006?

Time for a sleep log:

http://www.sleepeducation.com/pdf/sleepdiary.pdf

The directions are right there.

Do you take naps? Do you feel better afterwards? Make on a note somewhere on the log how you feel after the night's sleep and any naps.

See the receptionist for another appointment in 2 weeks.

Muffy

1. You are truly a "long sleeper" and that's just how it's going to be (and if you were only sleeping 5.5 hours back when you were working, then that must have been hell)(Hey! Hell On Wheels! Wasn't that the nickname of an armored division?) 1st or 2d AD, I forget.
2. You are "oversleeping" and it's too much. Statistically, long sleepers tend to have the same morbidity/mortality as short-sleepers;
3. You have a sleep maintenance issue, and that 9 hours of DL time is really like 7 hours of sleep;
4. You have another medical issue(s) (like uncontrolled depression).

Can you get a clear copy of the graphs from 2006? I will try to get one.

Time for a sleep log:

http://www.sleepeducation.com/pdf/sleepdiary.pdf I downloaded it.

Do you take naps? Never.

See the receptionist for another appointment in 2 weeks.

Muffy[/quote]

Got up, went out in 24 degrees, and walked for 30 minutes. Fog returned shortly after I got home, but no worse than usual.

1. You are truly a "long sleeper" and that's just how it's going to be (and if you were only sleeping 5.5 hours back when you were working, then that must have been hell)(Hey! Hell On Wheels! Wasn't that the nickname of an armored division?) 1st or 2d AD, I forget.
2. You are "oversleeping" and it's too much. Statistically, long sleepers tend to have the same morbidity/mortality as short-sleepers;
3. You have a sleep maintenance issue, and that 9 hours of DL time is really like 7 hours of sleep;
4. You have another medical issue(s) (like uncontrolled depression).

Can you get a clear copy of the graphs from 2006? I will try to get one.

Time for a sleep log:

http://www.sleepeducation.com/pdf/sleepdiary.pdf I downloaded it.

Do you take naps? Never.

See the receptionist for another appointment in 2 weeks.

Muffy[/quote]

Got up, went out in 24 degrees, and walked for 30 minutes. Fog returned shortly after I got home, but no worse than usual.