ASV progress: born again and resurrected

deltadave wrote: However, given your current pressures and history of central disturbance, the likelihood of an obstructive event is small. More likely they are all central.

BTW, I do still have obstructives. Last night, I was awake to experience them and it kinda freaked me out. My first hour or so wasn't good. I turned over to my side like I always do. I noticed several times when I tried to take a breath, I felt my airway block up. It kinda shocked me because I had that initial reaction of ''i can't breathe". That only lasted a second until the machine pushed it's breath and opened my airway. I was curious what I would find in my report in the morning, and it turned out as I expected.

ameriken wrote:Is the BPM interfering with the machine's algorithm? I don't know, and as I said, I'm not sure why Respironic's would have a feature that would interfere with it's own algorithm.

They don't. Features have been manually overridden.

ameriken wrote:BTW, I do still have obstructives. Last night, I was awake to experience them and it kinda freaked me out. My first hour or so wasn't good. I turned over to my side like I always do. I noticed several times when I tried to take a breath, I felt my airway block up. It kinda shocked me because I had that initial reaction of ''i can't breathe". That only lasted a second until the machine pushed it's breath and opened my airway. I was curious what I would find in my report in the morning, and it turned out as I expected.

• One cannot have "Sleep-Disordered Breathing" if they are not asleep.
• Given their location and the possibility that this was a transitional sleep state, perhaps they were sleep-onset central events.
• That said, since the events are hypopneas, it cannot be determined from the available data whether they are central or obstructive in nature.

ameriken wrote:Here is why I went with the back up...after increasing my pressures in October, for the first time my AHI's dropped consistently to 4 and under. While I felt a bit better, I was still dragging, with occasional minor headaches in the morning. I don't have an oximeter at home, but my sleep study states my O2's during my sleep studies while on the machine were still in the 80's. I believe this is because I was also diagnosed last year with 'emphysematic changes' in my lungs due to my prior smoking history.

"IMHO", it may also be that elevation plays a role.

If the underlying issue is oxygenation, ventilatory dial wingin' is an extremely inefficient way to correct that. Even if you can, say in a very mild case of baseline drop, it done at the expense of creating hypocarbia. The treatment for low oxygen saturation baseline is oxygenation, not ventilation.

One cannot determine conclusively if their sleep is better without actually measuring sleep (OK, we can debate using something like the ESS, and I will be happy to make some concessions).

However, since the subject of surrogates has been brought up, as previously noted, Minute Ventilation does not suggest improvement in sleep quality.

If we are to concede that you are, in fact, better, and in order to achieve that have altered an ASV such that it behaves like a BiPAP S/T, it may be reasonable to explore that the underlying issue(s) are not SDB, but rather, some form of ventilatory insufficiency (and thus, hypercarbic rather hypopcarbic phenomenon); or, a combination os issues, such that you are an Overlap Syndromer.

deltadave wrote:or, a combination os issues, such that you are an Overlap Syndromer.

So we add 02, or more fun, plug the mask vents and add 02?

deltadave wrote:

ameriken wrote:Is the BPM interfering with the machine's algorithm? I don't know, and as I said, I'm not sure why Respironic's would have a feature that would interfere with it's own algorithm.

They don't. Features have been manually overridden.

ameriken wrote:BTW, I do still have obstructives. Last night, I was awake to experience them and it kinda freaked me out. My first hour or so wasn't good. I turned over to my side like I always do. I noticed several times when I tried to take a breath, I felt my airway block up. It kinda shocked me because I had that initial reaction of ''i can't breathe". That only lasted a second until the machine pushed it's breath and opened my airway. I was curious what I would find in my report in the morning, and it turned out as I expected.

• One cannot have "Sleep-Disordered Breathing" if they are not asleep.
• Given their location and the possibility that this was a transitional sleep state, perhaps they were sleep-onset central events.
• That said, since the events are hypopneas, it cannot be determined from the available data whether they are central or obstructive in nature.

ameriken wrote:Here is why I went with the back up...after increasing my pressures in October, for the first time my AHI's dropped consistently to 4 and under. While I felt a bit better, I was still dragging, with occasional minor headaches in the morning. I don't have an oximeter at home, but my sleep study states my O2's during my sleep studies while on the machine were still in the 80's. I believe this is because I was also diagnosed last year with 'emphysematic changes' in my lungs due to my prior smoking history.

"IMHO", it may also be that elevation plays a role.

If the underlying issue is oxygenation, ventilatory dial wingin' is an extremely inefficient way to correct that. Even if you can, say in a very mild case of baseline drop, it done at the expense of creating hypocarbia. The treatment for low oxygen saturation baseline is oxygenation, not ventilation.

One cannot determine conclusively if their sleep is better without actually measuring sleep (OK, we can debate using something like the ESS, and I will be happy to make some concessions).

However, since the subject of surrogates has been brought up, as previously noted, Minute Ventilation does not suggest improvement in sleep quality.

If we are to concede that you are, in fact, better, and in order to achieve that have altered an ASV such that it behaves like a BiPAP S/T, it may be reasonable to explore that the underlying issue(s) are not SDB, but rather, some form of ventilatory insufficiency (and thus, hypercarbic rather hypopcarbic phenomenon); or, a combination os issues, such that you are an Overlap Syndromer.

You perhaps have a far better grasp of this machine and maybe even my breathing issues. Would you have any suggestions on how I can adjust it to maximize the therapy? Seriously...

Ameriken,
I'\n my reading, the patient initiated breaths are inverse to the BPM rate the machine is set at. Have you ever had your rate at 10? If your machine is functioning more as a ventilator, you don't want to mess with that too much...but I'll bet your patient initiated breaths would come up dramatically. Might be worth a one night test.

And I might add...something that I'm doing right now. I have a restrictive left chest wall and low O2 sats so I've added supplemental O2 at night and it has made a big difference in how I feel. My O2 is running mid 90s now instead if high 80s and I think I'm having fewer centrals (no data at present). I live at 6,000' asl.
Jamis

Prior to my setting it I had always set it on 'auto' which is a rate of 10. However, I've never taken it off auto and then set it at 10. I did post a question in the other ASV thread (no answer)...what is the difference between having it on auto which is a 10, and taking it off auto and setting it at 10?

Anyhow, my PTB's are higher when it is at auto. The only reason I set it to 12, is my average BPM is always around 13 to 14, and I figured having it at 12 minimum would be better than the 10 minimum when my PTB's drop. Been flying blind with this machine. But as mentioned, my AHI's are lower since I've increased my minPS and min EPAP, and set it to 12.

Ameriken,
I have heard that auto equals 10 on these machines...but that makes no sense to me. Perhaps it uses 10 as a baseline and then adjusts upward or downward from there. I had a Legacy asv machine for about a month and in the clinician's manual it said that the patients own breath rate was monitored and used to determine auto BPM. Probably set a few breaths shy of the patient rate.

Do you have the clinician manual? Just saying your understanding of the auto BPM may be incomplete. Why even call it auto if it's set at a fixed 10 bpm. Does that make sense to you?
Jamis

jamiswolf wrote:Ameriken,
I have heard that auto equals 10 on these machines...but that makes no sense to me. Perhaps it uses 10 as a baseline and then adjusts upward or downward from there. I had a Legacy asv machine for about a month and in the clinician's manual it said that the patients own breath rate was monitored and used to determine auto BPM. Probably set a few breaths shy of the patient rate.

Do you have the clinician manual? Just saying your understanding of the auto BPM may be incomplete. Why even call it auto if it's set at a fixed 10 bpm. Does that make sense to you?
Jamis

Jamis,

The reason I figured it was 'auto' is because it is not always pushing a 10 BPM...until it senses you are not breathing on your own. When you start again, then it backs off. Whereas setting it on 10 or 11 or 12, it is always trying to push the BPM you select. I'm probably wrong, I'm just taking a guess at it. I really don't fully understand this damned thing yet.

As for the manual, I have one for the AutoSV, but not the 'Advanced' version. Ken

Hi Ken,
Agreed that they are very complicated. Some settings may also impact other settings to further complicate things.

So if you've already had it on auto, why not try the 10 setting? It may not be any different from when running auto BPM...if your theory is correct. But it could increase your PTB. I don't know why I feel this way, but I just don't like the idea of giving up my respiratory drive to a machine.
Jamis

edited to correct thinking error...

jamiswolf wrote:Hi Ken,
Agreed that they are very complicated. Some settings may also impact other settings to further complicate things.

So if you've already had it on auto, why not try the 10 setting? It may not change anything...if your theory is correct. But it could increase your PTB. I don't know why I feel this way, but I just don't like the idea of giving up my respiratory drive to a machine.
Jamis

My theory was, even on auto my PTB's were were 65 to 90%, so I was still hitting the basement every night, breathing at a mere 10 bpm on auto when my body normally wanted 13 to 14 when it worked right.

I figured since auto was 10, and my average was 13 to 14, then perhaps I'm getting less air than I needed, thus, maybe a lower O2. So I thought if I upped the BPM to 12 instead of the 10 on auto, I'd have a higher baseline and could perhaps get more breaths in.

Unfortunately, no one seems to really know enough about these machines and the associated breathing issues and how to maximize the therapy for one's individual issues. It's an awesome machine that does a great job for the most part, but I think if we can find the right tweaks, we can make it better and get where we really need to be.

Ken,
Sorry I edited that post after you quoted it. We're going in circles here. I disagree with your idea that auto equals 10 and so was trying an end run to get you to try a 10 setting on manual.

There are so many other issues that affect whether you get enough oxygen. A faster BPM rate isn't the only variable by any means. I assume you have some tidal volume limitations with your emphysema. Ti is definitely a factor but 1.5 seconds seems to work with you. I used a much longer setting. You start messing with all that and the whole shabang can fall apart.

Sorry Dude, out of ideas tonight,
Jamis

No prob, it was the RT at the DME that told me auto was minimum of 10. And I should state that 10 appears to be a minimum, the auto rate can go higher as well. Also, on all my reports...when my PTB's bottom out, the BPM flatlines at 10 when set to 'auto'.

Anyhow, I don't know how or why we got down this road anyway. My AHI's are far better now than they ever were, the fog has lifted, and my energy levels are coming back. That was the whole purpose of this thread to begin with.

ameriken wrote:Unfortunately, no one seems to really know enough about these machines...

What, you mean the rate?

Yeah, that one can be tricky. Advanced uses a multi-layered approach, involving:

• Respiratory rate;
• Expiratory time; or
• Cycle time

Further, the algorithm is specifically designed to avoid overdriving the patient, encourage spontaneous breathing and promote respiratory synchrony.

So in the "yes, you are/no, I'm not" discussion in re: FingU the algorithm, 75%+ machine breaths aren't in the Decision Tree.

ameriken wrote:Anyhow, I don't know how or why we got down this road anyway. My AHI's are far better now than they ever were, the fog has lifted, and my energy levels are coming back. That was the whole purpose of this thread to begin with.

Fine.

Thanks so much for sharing.

StillAnotherGuess wrote:

deltadave wrote:or, a combination os issues, such that you are an Overlap Syndromer.

So we add 02, or more fun, plug the mask vents and add 02?

In re: the mask vents, probably not.

If this boy's got CO2 retention (there is hx of chronic narcotic use (methadone), restrictive lung dz (scoliosis), and obstructive lung dz (emphysema)), this is the ONE time you could've suggested AVAPS and at least be on topic.

Now leeme alone, I gotta get ready for FB. I need the Ducks to pull this one out in order for the Master Plan to work.

Good Morning Ameriken,

Ameriken wrote: No prob, it was the RT at the DME that told me auto was minimum of 10

Whoah, a minimum of 10 is way different then 10. Your breath rate has been running in the mid teens...like 16 so the auto rate was probably running 12 at least.

Ameriken wrote: Anyhow, I don't know how or why we got down this road anyway

Basically I was responding to DDs suggestion that you were using the machine as a ventilator and suggesting a way to explore and possibly back off on that. But if you're feeling better, perhaps it's not such a bad thing.
Jamis