Varying AHI Readings on BiPap Auto SV Advanced

JIMCHI wrote: Any thoughts on what I should do if he wants another sleep study?

Tell him you will get back to him.
There is no reason your device cannot consistently give you 0 AHI and 100% Patient Triggered Breaths with some thoughtful self tweaking.

JIMCHI wrote: Any thoughts on what I should do if he wants another sleep study?

I'd suggest another sleep study IF they can get you in a lab both equipped and trained to titrate your BiPAP autoSV Advanced model. A sleep study scheduled several weeks down the road gives you time to tweak. If you tweak enough to get your residual AHI close to zero, then you have the option of canceling the study. If you tweak enough to get your residual AHI above 5 at your very best, then that gives them a chance to improve on your settings.

JIMCHI wrote:I can't really control sleep positions. Amazingly, I sleep quite well so I'm not aware of what goes on during the night. The few times I've been aware, I've been on my back or on right side.

Well, your sleep studies can yield that information. If it turns out that sleeping on your back or right side yields a disproportionate share of your residual AHI, then you might want to at least try to control your sleeping position. There are plenty of posts on this message board about people wearing devices to control sleep position. Some seem to pull it off with relative ease, while others don't.

[quote=""JIMCHI"]Any thoughts as to whether I should make a stand about another sleep study interpreted by the same sleep specialist?[/quote] I think I'd be tempted to call local sleep doctors and ask each how many CompSAS patients they treat. If one gets the lion's share of CompSAS patients---perhaps by good local or even national reputation---then I'd be tempted to give that sleep doc a try.

Banned wrote:There is no reason your device cannot consistently give you 0 AHI and 100% Patient Triggered Breaths with some thoughtful self tweaking.

I really admire that can-do sentiment, Sir Banned!! But I also think there are OSA/CSA pathophysiology scenarios that can result in PAP resistant/intractable SDB. And a severe iatrogenic effect in particular can supposedly make resistant CompSAS cases challenging to treat from what I've read. But I also think JIMCHI can likely achieve better residual AHI.

Kiralynx wrote:

Banned wrote:

JIMCHI wrote: One of my sleep studies indicated I did well at an EEP of 6. I did try an EPAP of 6 (min & max) on this new machine one night and I felt awful the next day, even though my AHI was 13. What do you think of my trying setting the EPAP min at 6..

CPAP and EPAP 6 and below, are non-settings.
Anybody with a CPAP or EPAP of 6 and below doesn't need CPAP therapy

With respect, that's just not true.

My ASV is set for an EPAP of 6, a MinIPAP of 10 and a MaxIPAP of 14. It was initially set for an EPAP of 10, and I could not, could NOT breathe out against it -- and it triggered apneas, as well as sending my leak rate through the roof. Once my EPAP was lowered to where I could breathe out, I was fine, and almost never have an AHI over 2, mostly 1.

Oops, sorry, gyrl,

I didn't think anyone with EPAP 6 was listening.
At least you are maintaining 4 points of separation between EPAP and IPAP.
Don't you find that 1 residual Apnea/Hypopnea annoying?
Is it an Apnea or a Hypopnea?
Lets go gunni'n for it.
Get your AHI down to 0.

-SWS wrote: I really admire that can-do sentiment, Sir Banned!!

I'm just hopping on your back and going along for the ride, SWS.
It has been your input that has changed this gentleman's CPAP destiny.
I like your idea of possibly lowering his EPAP Min to 7, if raising his PS Min to 6 does not bear any fruit.

Went to my pulmonary doctor today. He was actually very skilled in sleep medicine. I showed him all my data and he agreed that a sleep study might not capture all that's going on. He said my IPAP is too low. So he wants me to try the following settings for a few nights:

EPAP MIn 4
EPAP Max 15
PS Min 0
PS Max 15
Press Max 25
BiFlex 2
Backup Auto

He said I could up the Pres Max rate to 28 or 30 if I want to experiment further.

He said this is a complex case. Apparently Respironics has a Clinical Laboratory Service available for doctors to consult and he said he will contact them and see what they say.

So, I will try this for a few nights and see.

JIMCHI wrote:Went to my pulmonary doctor today. He was actually very skilled in sleep medicine. I showed him all my data and he agreed that a sleep study might not capture all that's going on. He said my IPAP is too low. So he wants me to try the following settings for a few nights:

EPAP MIn 4
EPAP Max 15
PS Min 0
PS Max 15
Press Max 25
BiFlex 2
Backup Auto

He said I could up the Pres Max rate to 28 or 30 if I want to experiment further.

You can compare his suggested settings to the ones we talked about HERE and also in the Respironics titration guide that we have been discussing.

JIMCHI wrote:He said this is a complex case. Apparently Respironics has a Clinical Laboratory Service available for doctors to consult and he said he will contact them and see what they say.

Well, so far I like your doctor a lot!

JIMCHI wrote: So, I will try this for a few nights and see.

Keep us in the loop with data and your observations... GOOD LUCK!

YOU ARE GOING TO CHOKE LIKE A GOAT ON THOSE SETTINGS.
But it is the BiPAP Auto SV Advanced titration protocol that SWS has been strongly suggesting.

When it all goes too hell-in-a-hand-basket and you decide you actually need to get some sleep, try:

EPAP MIn 8
EPAP Max 12
PS Min 6
PS Max 13
Press Max 25
BiFlex Off
Backup Auto

A few comments about the titration protocol your doctor suggested.

JIMCHI wrote: EPAP MIn 4
EPAP Max 15

This wide range grants the algorithm control to automatically address your obstructive component. This part of your machine's algorithm was borrowed from an ordinary Respironics APAP algorithm---the kind that treats ordinary obstructive sleep apnea.

PS Min 0
PS Max 15

And this wide range grants the algorithm control to automatically address your central component and all hypopneas. This part of your machine's algorithm is based on classic adaptive/auto servo ventilation----whereby BiLevel IPAP automatically varies, as-needed, and on a per-breath basis. PS Min of 0 implies that CPAP is your base modality---with proportional BiLevel (ASV) kicking in on an as-needed basis.

JIMCHI, your problem is variability. Your doctor now has you testing the algorithm's ability to automatically address both your obstructive variability and central variability. In the course of automatically doing all that, Respironics ALSO attempts to keep your EPAP and IPAP as low as needed----to avoid exacerbating/triggering the CompSAS central component. At least you'll know after tonight whether the algorithm can successfully: 1) automatically address your obstructive and central variability, and 2) avoid triggering iatrogenic central problems by increasing EPAP and IPAP only on an as-needed basis.

BTW, what were last night's settings and AHI? And patient triggered breaths?

Banned wrote:YOU ARE GOING TO CHOKE LIKE A GOAT ON THOSE SETTINGS.
But it is the BiPAP Auto SV Advanced titration protocol that SWS has been strongly suggesting.

When it all goes too hell-in-a-hand-basket and you decide you actually need to get some sleep, try:

EPAP MIn 8
EPAP Max 12
PS Min 6
PS Max 13
Press Max 25
BiFlex Off
Backup Auto

Banned, you have always taken a pass on treatment protocols and manufacturer recommendations in the past.... Who would expect you to want to go back to the beginning---where JIMCHI and his autoSV Advanced should have started?

Yes, I also think it's possible that JIMCHI and his doctor may have to take control away from the algorithm----and continue with those same manual PS tweaks he already started per our peanut gallery recommendations...

sws- My settings last night were the same as the night before: EPAP Min 8, EPAP Max 12, PS Min 5, PS Max 10, Pres Max 22, Backup auto, Biflex off.

My readings were: AHI 11 (vs. 7 the night before) and patient triggered breaths were 97.9% (vs 98.2% the night before).

Jim

-SWS wrote: Banned, you have always taken a pass on treatment protocols and manufacturer recommendations in the past.... Who would expect you to want to go back to the beginning---where JIMCHI and his autoSV Advanced should have started?

Yes, I also think it's possible that JIMCHI and his doctor may have to take control away from the algorithm----and continue with those same manual PS tweaks he already started per our peanut gallery recommendations...

Well, maybe I was a bit brash, however..

my point is that the titration protocol for the BiPAP autoSV Advanced assumes a second interested party will "Monitor Patient PSG, Wait... Watch... Observe... Think" and tweak the device accordingly, in real-time.

The doctor is asking this gentlman to stay on the titration settings for 2 days, as if these settings will automatically self-medicate him. I don't think the device, with-out some manual manipulation in real-time, will yield him very good results, is all. Hence my suggestion for his alternate plan.

The gentleman could do a at-home split-night study, with one half of the night at the doctor recommended BiPAP autoSV Advanced titration protocol, and the other half of the night at at the new tweaked setting of Min PS 6.

Obviously there was allot of data that was probably presented to the doctor. I think the doctor should have asked, "Show me the best data you have".
Your suggestion and the doctors determination that IPAP needs to be increased, is exactly what we were already tweaking, before we stopped moving forward with increasing PS Min.

I presume "tweeking" was what was done when I had my last two sleep studies. And despite all the tweeking, the two studies revealed radically different recommedations. That's what makes my case so complicated. It's as though every night is a totally new scenario; I might as well be a completely different patient. What gives somewhat good results one night yields terrible results the next.

I brought a lot of data with me today but I knew he couldn't go through all of it. So I used Excel and created a big line graph that dramatically showed the variances, night by night, in my AHI's. It was far superior to the graph shown on the Encore reports as their graph is so small. Then I created a spreadsheet that grouped my results by EPAP max and min settings, so he could clearly see that with stable settings, my AHI's were all over the place. He was quite impressed and kept those to show to Respironics. Who knows how long it will take for him to get information to and back from Respironics; I think he has to go through his sales rep. I suspect it will be weeks.

So we will see tonight. If I can't tolerate the settings, I will tweek the settings during the night using Banned suggestions. I think I'll go to bed early !

Banned wrote: Oops, sorry, gyrl,

I didn't think anyone with EPAP 6 was listening.
At least you are maintaining 4 points of separation between EPAP and IPAP.
Don't you find that 1 residual Apnea/Hypopnea annoying?
Is it an Apnea or a Hypopnea?
Lets go gunni'n for it.
Get your AHI down to 0.

I was also listening. But I figured maybe mine was that low because it is mostly central.

Banned wrote:Your suggestion and the doctors determination that IPAP needs to be increased, is exactly what we were already tweaking, before we stopped moving forward with increasing PS Min.

That was moving forward with manually increasing IPAP via the PS min increments. But the key is that those were manual changes we implemented and at some pressure-titration midpoint---without ever going back to see if the new Advanced algorithm could work as designed. Banned, you don't know how many hypopneas were primary and how many were iatrogenic---and which machine parameters might have exacerbated the iatrogenic component versus leaving the primary component under treated. There was probably some dynamic intermix causing all that variability.

JIMCHI wrote: So we will see tonight. If I can't tolerate the settings, I will tweek the settings during the night using Banned suggestions. I think I'll go to bed early !

Well, at least you're willing to give it a try, JIMCHI. You can resume the previous PS min experiment if those fully-automated settings are intolerable as you say. At this point I wish you the very best of luck with your ASV experiments.

-SWS wrote:But the key is that those were manual changes we implemented and at some pressure-titration midpoint---without ever going back to see if the new Advanced algorithm could work as designed.

Nicely said. Let's hope he can tolerate the titration protocol long enough to verify the algorithm as designed.