BIPAP AUTO-SV SETTINGS HELP

Banned wrote:

Muffy wrote:

Trust Us. LOL!!

Banned

Well, not to offend either you or dsm... But you cited some basic logic that was broken in your quote below. Then dsm for some reason quoted it as an example of forthright acknowledgment of obvious truths---reminiscent of that truth-acknowledging boy amidst the foolish naked Emperor's timid court:

dsm wrote:

Guest wrote:

timbalionguy wrote:So this begs a slightly off-topic but pertinent-to-the-discussion question: If one finds that they will have to use a servo ventilator, how does one go about making the right decision the first time? Or is this something that your clinician pretty much has to decide? These are really expensive machines, and very few can afford one of each.

The right decision the first time would default to the VPAP Adapt SV. As seen in this thread where the BiPAP Auto SV has run into a brick wall.

Banned

Banned so often I read one of your comments & am reminded of the boy who (Emperor`s new clothes) points us to some basic home truths.

Read thee as thee will

DSM

So just how was your basic logic---your assertion and supporting statement---broken IMHO? Well, timbalionguy asked for general ASV selection guidelines. In direct response to that query for general ASV selection guidelines, you then submitted that Resmed ASV should be the "default". Then you went on to support that assertion only with CROWPAT's still unresolved mystery.

Absolutely amazing IMHO that anyone would quote that broken logical statement as any kind of supporting example of Emperor boy wisdom---the child who saw obvious truths. That may well be you at times, banned. But not regarding you broken statement above:

1) We have no idea whether CROWPAT would fare better or worse using the Resmed ASV. So citing CROWPAT's response to only one machine as comparative evidence that the other machine is generally superior is... badly broken logic IMHO.

2) Attempting to support either of those two ASV brands as either superior or the general "default" choice----with any one patient experience---neglects to factor the individual ASV outcomes having yielding a better opposite-brand experience. As soon as we acknowledge that patient A had a better experience with Resmed ASV while patient B had a better experience with Respironics ASV, then we must recognize the conclusion about superiority or best "default": choice lies in population-based numbers rather than individual anecdotes. Citing either single or a few message board anecdotes to make population based generalizations is... badly broken logic IMHO.

banned wrote:Trust Us. LOL!!

I may love you Sir Banned, but I think (or at least hope) I recognized your initial "default" Resmed statement in the spirit that I think you intended: a casual brand loyalty statement largely based on your positive experience.

And, banned, I definitely love your sense of humor and kind heart!

Interesting responses, and I do see a strong brand loyalty emerging here.

Maybe we need a new brand of ASV machine. It could be called a Respirmed or a Resmonics...take your choice

Carry on in this most fascinating discussion!

timbalionguy wrote:Maybe we need a new brand of ASV machine. It could be called a Respirmed or a Resmonics...take your choice

ROTFL!! Good one, timba!

I'll write the marketing blurb for the mixed-up machine:

Introducing the final answer to all sleep disordered breathing!!
The _______ (take your pick of names).

This innovative new machine is designed specifically to treat your patients if they have Complex Sleep Disordered Breathing. Or if they don't. It also specifically treats apneas, whether obstructive, central, or mixed. If none of the above, it will treat UARS and non-UARS just as effectively.

We recommend an attended full PSG titration night with this machine, but suggest titrating in the lab for no more than one hour, then let the patient take it home to finish out the night. The one hour titration should be performed by an RPSGT sleep technologist. But if none is available, a janitor can handle it. Just set the knob on the machine to "titrate/1hr."

Recommended settings:

No need to set PS, as the default is PS 1 and there are no other choices.
All other settings, including pressures, should be set for maximum comfort of the patient. That can be accomplished in the one hour titration. Studies have shown that "comfort" is the key. Setting therapeutic pressure levels has been shown in studies to be an outmoded concept.

Software will be released in 2020.

-SWS wrote:

Muffy wrote:Here's a challenge for -SWS. In that pile of data you have accumulated, find ANYTHING that says a pressure < 10cmH2O is DEFINITELY ineffective.

You mean that well-known statistical 10cmH2O threshold in epidemiology? That very same 10cmH2O threshold beyond which significant numbers of SDB patients begin to manifest central problems?

That same well-known 10cmH2O statistical threshold beyond which unnecessarily pressure-aggressive titrations can actually create more SDB problems than solve?

CROWPAT, I bet I threw that word "statistical" in there just enough times to pique your interest in Muffy's possibility of a pressure-aggressive titration being a plausible explanation for some of your sleep issues. Muffy, I'll go back and see if I can find a shred of evidence contrary to that hypothesis.

Well, Muffy has a perfectly good, lab-testable working hypothesis going---and has asked me to try and break that hypothesis by reviewing past data (which is not the same as that lab-testable part). So I shall attempt to do just that in Muffy's well-intended spirit of methodical inquiry. However, I won't sit down and make my earnest attempt to scour through CROWPAT's pile of data until tomorrow evening.

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timbalionguy wrote:If one finds that they will have to use a servo ventilator, how does one go about making the right decision the first time? Or is this something that your clinician pretty much has to decide? These are really expensive machines, and very few can afford one of each.

TLG, that's a really good question IMHO. While a few posters have submitted "conclusion sounding" opinions over the last couple years, I personally haven't managed to come up with any definitive ASV model selection guidelines. Bear in mind that I tend to be picky about things like evidence, methodology, and scope-of-consideration when it comes to supporting population-based conclusions.

However, JohnBFisher and his medical team recently went through just those considerations. If I grasped the sketchy details correctly, John was successfully titrated in the lab on a Respironics BiPAP autoSV. However, his medical team then gave him a Resmed Adapt SV instead---which so far seems to work even better for John!

I am hoping that John might have an opportunity to eventually investigate and share with us which factors resulted in that change from one ASV model to the other. For all we know John's medical team might treat them as if they are functionally interchangeable. Based on what I've read, that seems to happen a lot.

PS @ rested gal and timbalionguy:

Muffy wrote:

-SWS wrote:So if the BiPAP autoSV refrains from administering its backup rate to singular central apnea events, I can't find that anywhere in literature. But I can find statements like the above describing "a central apneic event" (singular) receiving that algorithm's backup rate.

I didn't say it didn't, I said it shouldn't. My point is that not every central apnea needs to be bludgeoned to death.

Muffy

And Muffy is right about that, When the Resmed ASV sees a benign central - it bludgeons it to death (

DSM

(Hmmm shd that be moe ? curly ? Larry ? - perhaps Shemp

SWS

You read far to much into my comment about Banned. I repeat, at times he does come out with blunt remarks that hit the target & I enjoy his attitude at these times. My comment was general & not specific - hope that has been cleared up.

I always enjoyed his one liner to the effect that he never heard of anyone killing themselves by adjusting their cpap machine

DSM

-SWS wrote:... However, JohnBFisher and his medical team recently went through just those considerations. If I grasped the sketchy details correctly, John was successfully titrated in the lab on a Respironics BiPAP autoSV. However, his medical team then gave him a Resmed Adapt SV instead, which so far seems to work even better for John. I am hoping that John might have an opportunity to eventually investigate and share with us which factors resulted in that change from one ASV model to the other. For all we know John's medical team might treat them as if they are functionally interchangeable. Based on what I've read, that seems to happen a lot. ...

Well, I refrained from my own opinion, since it is just that. However, I also wondered how and why they chose the machine they did, when we obviously proved that the Respironics unit would work. I had the same fear that I would have a unit that we did not know would work.

First, this DME had proven to me over the course of a couple of months that they cared about their patients and that they were in business for the long haul. So, I was willing to work with them.

Second, they noted they perform two or three ASV titrations a month. From my reading, I was fairly certain that is fairly high based on the general averages. Why so high? Well, my sleep specialist / neurologist is very good. He tends to see some of the more difficult cases. He's developed a good relationship with this lab (and others), so they tend to see some of the more difficult cases in our metropolitan area. So, their experience base was obviously greater than mine. Until proven otherwise, I felt I could trust their experience.

Third, they observe that most patients do well on the ResMed ASV unit. They noted the way it works tends to make it easier for most patients. They also noted it tends to be easier to turn it on and turn it loose.

Fourth, since it is less expensive (for both the patient and insurance company) they start there.

Fifth, since they sometimes provide rental units if they need to move a patient to another unit, they will do so, taking back the unit and using it in the future as a rental unit. In other words they do not submit the paperwork for a couple weeks to allow the unit to prove itself.

So, I was willing to work with them on this. They proved their experience level exceeded mine. However, they admitted without any reservations that there is no pat answer, just a process that seems to lead to an answer that works for most patients. They went out of their way to help answer questions. I had a ton of them. They arranged a time for me to chat with the local ResMed representative! They helped me get into early appointments. They arranged to have very experienced sleep techs working with me. They were willing to work with me to determine which one is best unit for me.

I know not all DMEs are like this. I know that I am fortunate. But their process made a lot of sense to me. For my profession, I solve complex customer issues for my company. Everything my DME said rang true to me and indicated they had developed a process which helped identify the best balance between cost and value. No magic. No belief that the units were interchangeable. Rather a desire to get the most bang for the buck.

Hope that explains what happened and why I was willing to accept the change in machines.

PS @ rested gal and timbalionguy: Hey! Wait a minute! How did you get one of the pictures from my family album? !!

dsm wrote:I always enjoyed his one liner to the effect that he never heard of anyone killing themselves by adjusting their cpap machine

Yes, an enjoyable line.

But a few "naked truths" happen to strike me about that anecdote. The first "naked truth" is that ASV patients as a group might not carry the same cardiovascular stress risks as CPAP patents---that latter being the majority. The second "naked truth" is that banned has probably not "heard" a sufficient number of ASV patient outcomes to adequately evaluate risk assessment one way or the other.

Sorry that I read too much in your response as you quoted banned's response about "default" ASV selection. I still don't understand the point of quoting broken logic of all things to praise someone's ability to cite "naked truths". For that matter, I'm a bit confused whether you view banned's casual actuarial one-liner as a "naked truth" for ASV patients or as insufficiently-supported implied advice.

Because if I was a newcomer contemplating ASV pressure experiments, and I read banned's implied advice, I'd probably assume that highly-experienced banned just gave me the ASV-experimentation "go ahead" based on low risk assessment. And when highly-experience dsm lends credence to banned's ASV risk assessment, I'd assume that dsm has also garnered numerically sufficient ASV outcomes to endorse that implied low-risk assessment of banned's.

Again, not to offend either of you two. Risk assessment is always a worthy topic of discussion---and especially among the scant few ASV users we have.

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John, thanks for that input! I resonated in no small way with why you felt comfortable placing your trust in your medical team. And I found these two anecdotes to be particularly helpful:

they observe that most patients do well on the ResMed ASV unit.

they admitted without any reservations that there is no pat answer, just a process that seems to lead to an answer that works for most patients.

I didn't realize you had already chased that question down. But I'm glad you did. Thanks!

http://chestnet.org/education/online/pc ... rint10.php

Conclusions

CompSAS is a syndrome of mixed central and obstructive events with short cycles of obstruction, minimal disease in rapid eye movement sleep, and incomplete response to CPAP therapy. It is likely that, in patients with CompSAS, there is an interplay of multiple pathogenic factors. There is no uniformly effective medical therapy, but improvement in sleep hygiene and positional therapy may be effective in reducing CompSAS. The syndrome cannot be consistently treated with oxygen or CPAP therapy. BPAP and ASV are the only consistently well-documented forms of therapy. Both may be equally effective, but ASV appears to be better tolerated by patients. The efficacy of a particular modality of therapy should clearly be demonstrated in the sleep laboratory in an individual patient before its use.

Those multiple pathogenic factors mentioned above are probably why there is no cookie-cutter best single treatment for CompSAS/CSDB.

And I would even wonder if that multifactorial pathogenic progression ("patient unique" disease-factor sequence) can sometimes cause CompSAS onset years after successful adaptation to CPAP therapy...

Does Pat have CompSAS?

Muffy

-SWS wrote:

they observe that most patients do well on the ResMed ASV unit.

Isn't that what I said?




Banned

Muffy wrote:Does Pat have CompSAS?

-SWS wrote:No conclusions or even generalizations based on CROWPAT's unknown physiology at this point.

viewtopic.php?f=1&t=46945&p=427430&#p427430
And while John mentioned that his PSG team did not spot any CompSAS events during his sleep study, there seem to be some disease-unique pathogenic factors that still manage to bring John to some pathophysiological commonality with CompSAS/CSDB.

banned wrote:Isn't that what I said?

Well... actually it is not. The clinicians said that most of their patients do well on Resmed ASV. By contrast you said that Resmed ASV should be the "default" choice---citing CROWPAT's who has never even tried Resmed ASV as your comparative proof. I consider clinical anecdotes based on 2 or 3 ASV titrations per month to be more useful than a message board anecdote. But I still consider the clinical anecdote that John provided to be insufficient to support which ASV model should be the best "default" model---in light of so many other clinicians having arrived at an opposite-brand preference.

But banned, let's pretend that we somehow have a clear understanding that you actually submitted the correct answer about which ASV model should be "default". Rhetorically: did you arrive at the right answer by a viable method? Or did you do what Aunt Weeza did as she hastily discarded the road map and told me to turn 'left" at the "lake" because they both begin with the letter "L"? The answer is correct no thanks to her flawed methodology. She gloated at correctly getting us to the Lakeside Tavern despite a flawed method. Crazy thing, those 50/50 propositions are...


Above: Aunt Weeza's Road Trip Buddies

RE the posts about brand vs brand. I don`t believe I have seen anyone really making that kind of comparison of ASVs. I can see that Banned`s comment (that seems to have triggered such colorful interaction above) may be interpreted that way but Banned has used & experimented with Respironics Bipap AutoSV, Respironics Synchrony AVAPS plus has used the Resmed Vpap Adpt SV.

If anyone asked me which one I thought might be the most advanced ASV I`d lean toward the Weinmann SOMNOvent CR. It has some incredibly innovative features but without the chance to use it or read other peoples comment`s on it, my comments about it are based on what I read of its method of operation. It is very clever.

DSM

dsm wrote:I`d lean toward the Weinmann SOMNOvent CR.

I've got to have it. Could be a good travel ASV.

Banned

Banned wrote:

dsm wrote:I`d lean toward the Weinmann SOMNOvent CR.

I've got to have it. Could be a good travel ASV.

Banned

Banned it is very expensive but also has a fantastic software program that provides what looks like the best data I have ever seen that can come off cpap.

The humidifier is essential as well.

The challenge will be finding where to buy it. A company here in Aust who are Weinmann agents offered to import one for me but there wasn`t ny way I could justify the price.

DSM