ASV: Hypopnea Index Remains High

If I were *consistently* getting an HI around 4 of less, feeling good, and not showing large bands of periodic breathing, I'd be fine with it. However, conditions 2 and 3 aren't met, and this was the first night at a new experimental setting. So, continue it does.

BrianinTN wrote: So, continue it does.

Down the yellow brick road...

StillAnotherGuess, I'd think you'd be happy with where this is in the cycle right now. We've tried raising min EPAP, which didn't overall produce immediate better results and may have a side effect of its own (PB), although per JohnBFisher's comments, that not anything to get too worried about at this point in time. But, given that the increased EPAP alone wasn't a miracle silver bullet, per my earlier post, I'm going to try your original suggestion of experimentally tinkering with PS. If that turns out to be the silver bullet, great; if not, OK, I'll go back to the route of higher EPAP, perhaps combined with increases in PS. I simply don't want to tinker with *both* knobs early on in the experimentation. I'm not accepting or rejecting any particular course of action; rather, I'm just trying to gauge the impact from possible changes.

P.S.

avi123 wrote: p.s. Avi123, I agree. Thank you.

Isn't that josecpap's dog?

Hi Brian
I live in a differetn time zone - which is why I'm only responding now.
I saw your charts at EPAP=6 and didn't respond because I thought you were going to keep the settings like that in order to get more data.

Whichever setting you select, you really should keep it stable for a week, or 2. As you my have noticed, in that "to treat or not to treat" discussion, some people get used to therapeutic pressures after about 3 months (!). I think it is reasonable to assume that even those who need an ASV have to get used to their pressures and changes.

Of the three nights you showed at EPAP=6, the onel leakless night gives a 90th percentile for EPAP at 8, the leaky ones at less - a minimal EPEP of 9 may be too high.

I don't know what the periodic breathing means - I am neither a physician nor a sleep professional, and haven'r read enough about periodic breathing to contribute something rational. You assume its something not too good that happened as a result of the higher EPAP. And yet, when we see it at EPAP min = 9, its accompanied by two good things: 100% patient trigerred breathing, and no apneas or hypopneas. One night, as has often been said, does not trend make

I would consider a week or 2 at EPAP min =7 PS=3, I agree with Mr. Bills analysis. I would definitely use the way I felt as a guide to anything.


Do you have a pulse oximeter?

Hi ozij -- Thanks so much for weighing in again. What you said makes a good deal of sense. Obviously I'm being impatient. Since I feel neither stellar nor terrible, I'll give it a solid longer duration at the settings you suggested. I don't have a pulse oximeter, although frankly I have thought about purchasing one. In the lab, my oxygen numbers pretty much always remained high on both the ASV and BiPAP, although I know that's no guarantee they are doing so now (especially with the possible continuing periodic breathing). If the status quo keeps up, I may bite the bullet and make the purchase.

Thanks again. I'll of course show you all the results.

Brian

ozij wrote:Whichever setting you select, you really should keep it stable for a week, or 2.

Which also may be just more forum nonsense that you have bought into and continues to be perpetuated by the board. Respironics titration protocol calls for 20 minutes at any given setting. One night at any setting will give him more than enough data. But, Brian thinks your advice is the cats-meow, so maybe he will pursue 2 weeks at each setting. He probably has enough time for your 2 week window. Didn't he quit everything in his life just to do this for a year?

Should anyone happen to read this thread and wonder why I choose to ignore comments by the poster calling himself StillAnotheGuesS, here is a repeat of my post from about a week ago:

ozij wrote:Please note that "StillAnotherGuesS" is a

very very

new poster. S/He is not the poster known as "StillAnotherGuesT ".

<snip>
I would never trust a poster who registered 2 weeks ago on statements about what "has been demonstrated many times" or about "many forum users".

As a matter of fact, I would automatically distrust any posting by a poster who chooses a name so similar to a well known well respected other poster on the forum.

Caveat emptor.

BrianinTN wrote:
P.S.

avi123 wrote: p.s. Avi123, I agree. Thank you.

Isn't that josecpap's dog?

Yes, this poster kept shadowing my posts copying them and adding silly remarks like this:


[quote="josecpap




I Agree. Please, do not Stop Breathing.[/quote]


Or this:

Please work on Those AHI's. I will work on My AHIs too. Please, do not Stop Breathing at Night. I will Look at my Flows and AHIs more.[/quote

So, I made it easier for this poster by saving him/her time and efforts.

Do you think that it will solve the issue?

Brian, going back to our discussion about your ASV setting, I don't think that you can do it optimally without a full PSG set-up. You need the RIP, EEG, ECG, Oximeter, sensors, etc. to distinguish those sleep disorder events during the actual sleep stages. Those PAP machines that we are using including the ASVs don't have the signal to noise ratios needed to do it properly.


Even at the PSG, it could be a problem if you got a patient with irregular and unpredictable respiratory pattern.


******************************
Brian, IMO, you should be satisfied with your achievements so far!

Your AHI components' values are low and your Periodic Breathing is only 1% of sleep.

Tinkering wrongly with the setting could make it worse.



p.s. what's your opinion about this thread:

viewtopic.php?f=1&t=60687&st=0&sk=t&sd= ... ing+on+asv

BrianinTN wrote:Hi ozij -- Thanks so much for weighing in again. What you said makes a good deal of sense.

I'm very glad to see that ozij is helping you Brian. She's a very intelligent person offering good advice, imho.

StillAnotherGuess wrote:

ozij wrote:Whichever setting you select, you really should keep it stable for a week, or 2.

Which also may be just more forum nonsense that you have bought into and continues to be perpetuated by the board. Respironics titration protocol calls for 20 minutes at any given setting. One night at any setting will give him more than enough data. But, Brian thinks your advice is the cats-meow, so maybe he will pursue 2 weeks at each setting. He probably has enough time for your 2 week window. Didn't he quit everything in his life just to do this for a year?

The 20 min period is also in the Resmed's titration instructions for the VPAP Adapt SV :



Link:

http://www.resmed.com/us/documents/1011 ... otocol.pdf

Hi Avi --

avi123 wrote:
p.s. what's your opinion about this thread:

viewtopic.php?f=1&t=60687&st=0&sk=t&sd= ... ing+on+asv

I know this thread goes on and on (and on!), so it's really easy to lose track. However, waaaay back on page 2, you'll find this comment from me:

BrianinTN wrote: -SWS had helped JIMCHI in another thread by dictating a matrix of possible settings to improve his luck with the ASV. Ultimately, that's what I'm trying to get at here as well -- where should I go first?

What I was hoping for with my thread really was a proposed experimental design with a theoretical backing behind it. That caveat is really important; it's the reason why I really want to avoid the "turn this, change that" approach that can make drawing conclusions specious at best.

As for your other comments: you're certainly right that there are limitations to the data I can collect at home. I'm sure this is part of why ozij recommended a pulse oximeter. As for the 20 minute stuff, thanks for pasting that; I'd familiarized myself with the titration protocols from both manufacturers weeks ago, but I'm sure people stumbling upon this thread will find it useful. The reason why it's not terribly relevant to the discussion is that the protocol is about stabilizing patients. There are two reasons why it just doesn't end up being relevant in my case:
(1) I don't have the home ability to make changes on my own during the night. I can only count on the ASV to make changes and witness the next morning what they were and how they happened.
(2) The logic is backwards. In the titration, if there are events (instability), then you make the appropriate changes to obtain stability (low AI, low HI, etc.). There's no reason to spend much time on a setting that isn't working because, since the ASV is making adjustments using its sliding window (4 minutes in the case of the Respironics ASV, if I recall correctly), you've let it run its course so to speak. Once you've narrowed the EPAP and PS parameters for it and reached a stable end point, you're "done." In my case, however, I'm not stable! And what makes it worse, I'm not stable over the course of an entire night -- and a whole night has an awful lot of data variability in it. At what point(s) in the night were the settings not ideal, and what would have been the responses to changing certain settings at that time? Indeed, it's tough to answer these questions.

It's also worth noting that the titration protocols are intended for precisely that -- titration, which is usually a one night ordeal. People's numbers at certain settings can and often do improve over time, despite starting out with a high AHI at those very same settings. Similarly, I'm not the first person on these boards to be "stabilized" in the lab multiple times during the titration, only to discover that those settings didn't work out in the long-term. This is, I'm sure, why ozij was encouraging me to give it more than just one night at any given setting before completely giving up.

Anyway, back to the original quote of yours, JIMCHI and I do have a bit in common, which is why I'd keenly eyed his thread. Indeed, the high amount of variability -- one night that's quantitatively good and the next night that's quantitatively bad, even with the same settings -- is what is most vexing and frustrating about this. I wish he had continued responding on his thread, because I would have loved to have seen how it played out.

avi123 wrote:I have used the Fisher & Paykel #432 full face, as you do, for a few weeks and had high leak rates with it like you (above 30 L/min). I think that the solid foam under the Silicone cushion caused it. So I changed to full face #431 (without the foam), in medium size, and it works much better. The leak dropped to below 10 L/min. But I keep the headgear straps quite tight. Especially, the lower ones. I can slide my index finger between the strap and my cheek easily but not my thumb. After switching the pressure ON, I adjust the mask by lifting it off my self severel times.

HI
I'm a new user of this forum but had cpap's for 10 years.
this mask that leaked is the one that I'm having trouble with the #432.
I'm at pressure 16 up from a 10 since the new study was done.
I don't know the difference between the cpap and the bi pap? Can someone give me a quick explaination?
Also would like a machine with the print out. Mine has a card it it. if you take it out does it give the print out to the dr. There is just so much to learn as in 10 years i've never had problems like this. I guess since moving to CA and having new standards and finding new Dr etc it's just all so overwhelming.
I'm now a mouth breather and went from the nasal pillows to this one and hate it as air blows out the side and i snore with it
thanks for any help

Judy in CA wrote:

avi123 wrote:I have used the Fisher & Paykel #432 full face, as you do, for a few weeks and had high leak rates with it like you (above 30 L/min). I think that the solid foam under the Silicone cushion caused it. So I changed to full face #431 (without the foam), in medium size, and it works much better. The leak dropped to below 10 L/min. But I keep the headgear straps quite tight. Especially, the lower ones. I can slide my index finger between the strap and my cheek easily but not my thumb. After switching the pressure ON, I adjust the mask by lifting it off my self severel times.

HI
I'm a new user of this forum but had cpap's for 10 years.
this mask that leaked is the one that I'm having trouble with the #432.
I'm at pressure 16 up from a 10 since the new study was done.
I don't know the difference between the cpap and the bi pap? Can someone give me a quick explanation?
Also would like a machine with the print out. Mine has a card it it. if you take it out does it give the print out to the dr. There is just so much to learn as in 10 years i've never had problems like this. I guess since moving to CA and having new standards and finding new Dr etc it's just all so overwhelming.
I'm now a mouth breather and went from the nasal pillows to this one and hate it as air blows out the side and i snore with it
thanks for any help

Hi Judy, a few days ago I posted this reply about these F&P masks:

viewtopic/t63861/viewtopic.php?f=1&t=64 ... 61#p599761

I never went to an inspiration pressure as hi as 16 cm H2O. Only up to 13. But many posters are at pressures close to the top of 20 cm. However, I may need to increase the pressure somewhat b/c of my existing Obstructive events. Doing so will increase the mask leak. But, as long as the leak is kept below 25 Liter/Minute, for a Resmed machine, ( I read the value in the machine window) then the reading of events should be accurate. Otherwise, it can't distinguish the events correctly.

As to CPAP vs BiPAP I suggest that you enter this sentence in the above search box and also click on the BULB icon to search more. If you need more info just start a new post with a heading of the full question.

As to your question: Also would like a machine with the print out. Mine has a card it it. if you take it out does it give the print out to the dr. The answer is yes. But my Doc would rather get the answer via my DME and not directly from me.Whenever I go to the DME I take the Flow Generator section with me and they download the data and report to my Doc.

Hey BrianinTN, what did your doctor set you up with for an 'Inspiratory Time'? I noticed you have a pretty high BPM, around 17. As you see in my sig, they set my I.S. at 1.2 seconds. I was wondering if that is why my BPM ends up being 17-19? Does everybody breath this quickly when on ASV?