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ASV News Dated 5/15/17
#21
My viewpoint comes from someone recently diagnose with OSA(9 months), set up  with an Autoset, and sent home only to find out that my apnea was worse with treatment.
Did I buy the wrong machine? How can I afford the right machine? Will it be able to help? What is wrong with me? My brain is not working correctly?

It seems to me that there is a rush on Apneaboard to push ASVs on OPs in similar situations.

2 threads come to mind.
  
http://www.apneaboard.com/forums/Thread-...ght=marine         

http://www.apneaboard.com/forums/Thread-...light=lise      

My opinion is that not enough information is provided by the OP before we can say with any certainty that the ASV would provide a significant improvement over CPAP.
Is it treatment emergent complex apnea? Will time and/or adjustments to their machine resolve their issues.   

Can we take a bit more time, and consider the position the OP is in before we give them the $5000 solution that they may not be able to get.
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#22
(12-16-2017, 02:07 PM)Timur Wrote: Not sure if this has been posted here before but here's  an interesting analysis of the SERVE-HF study. 

"In this commentary, we consider methodological issues including the use of a previous generation ASV device that constrained therapeutic settings to choices that are no longer in wide clinical use. Patient selection, data collection, and treatment adherence as well as group crossovers were not discussed in the trial as potential confounding factors. We have developed alternative reasons that could potentially explain the results and that can be explored by post hoc analysis of the SERVE-HF data. We believe that our analysis is of critical value to the field and of particular importance to clinicians treating these patients."

http://journal.chestnet.org/article/S001...0350-5/pdf

Thanks; I believe it has, at least SERVE-HF has been danced around and through adnauseum.  That "The earlier ASV (now discontinued) had a 'fixed' EPAP" function and the newer models have a variable mode gives rise to the thought the ST probably has the functionality of the 'old' ASV?  Making the 'new' ASV off limits for LVrEF<45% but the ST is acceptable...
Go Figure Oh-jeez
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#23
(12-16-2017, 02:52 PM)zzzZorro Wrote: Go Figure Oh-jeez

Yeah, Lol ....

I'm going to wander over to that thread about alcohol and how it reduces AHI levels.  Cool
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#24
(12-16-2017, 01:51 PM)zzzZorro Wrote:
(12-16-2017, 09:15 AM)Shin Ryoku Wrote: In particular, I think there are a couple misconceptions here about the safety signal from SERVE-HF:  

First, people with CHF and EF < 45% are not on death's door.  As a physician, I have many patients with EF < 45% who live for many years.  Some of them even have a return to normal EF.  

Second, since the medical / scientific community does not know what caused the increased risk of death with ASV in CHF patients with reduced EF, we don't know what that safety signal means for ASV safety in other groups besides the one with that heart condition.  There seems to be an assumption by many in this forum that it is definitely safe except for people with that heart condition, but sleep medicine experts by and large do not agree with that assumption.  


Quote:As an aside, by extension many experts also have concerns about BPAP-ST safety - especially in patients with CHF and reduced EF - since it has in common with ASV the use of bilevel PAP with backup rate.

Shin;
Enjoyed your comments on ASV.  I am in the 40-45% LVrEF class. I do not believe I have CHF as there are no fluid retention issues, but instead CHD as it was a TAD M/I requiring two stents.  I continually study whatever I can find that applies to me and accumulate data trying to somehow get prescribed ASV, as the SERVE-HF study is wrought with irregularities- giving rise to much skepticism. That, now, has become pretty much a moot point.

I was condescending toward the sleep doctor previously because it took nearly three months, after being referred, before actually getting a face to face with the doctor himself.  Most of what instigated this feeling was how really disorganized and screwed-up the office and the whole sleep-study operation was around here.

Turns out he is very knowledgeable and spent the time necessary to address my issues. Reality is he is just ‘spread too thin’ and his assistant serves as his buffer. The moniker ‘Wizard of Oz’ is still applicable though due to the difficulty it has been to gain access beyond the curtain.

It seems he does not subscribe to the SERVE-HF study even though he says some of his very knowledgeable cohorts are solidly behind the conclusions. So, the truth is still somewhere up in the air.  That probably was 'why' he prescribed the VAUTO I'm on now instead of the ST that yielded the 'best' titration result at the sleep study, to be sure the VAUTO would not succeed.
 
I found it interesting that he had said when we met that the AirCurve 10 ST could well prove to have the same negative effect on LVrEF patients (if actually any) as ASV inasmuch as both have back-up. The same as you stated in your posting.  In my meager knowledge I would think the ASV 'safer' as it apparently has an 'intelligent' mode whereas the ST is 'dumb' in it's back-up function. [please feel free to correct me anyone if this is a misstatement]  With the VAUTO I continue having mixed apneas with consistent CHI and am waiting patiently for the new prescription; AirCurve10  ST to arrive at the DMS. It appears that back-up is the only thing to ‘kick’ the CA’s available to me, and I do not know at this time if they are treatment induced or not, I’m guessing not.  I’m gonna’ be findin’ out..
 
Thanks for your ASV comments, they were interesting and thought provoking.

You aren't being given an ASV, so it's a non-issue for you. The 2 one hour videos on ASV, as you scroll down the page here. I found is worth a week of reading papers 
https://www.youtube.com/user/emjreviews/videos
There is a 5 times death rate with those with low ejection, it should be taken seriously. As you know, for one difference, the ST doesn't resolve cheyne stokes breathing patterns and they think they are protective to low ejection. The ST will give a breath backup when needed, otherwise it just sits in the background. 

I think.The disadvantage is that you have the PS needed for that breath all the time. Where as the ASV is shaping every breath with variable pressure. based on the last few. The advantage is you still get to breathe next week with a ST Smile
new http://www.apneaboard.com/wiki/index.php...re_success
mask fit http://www.apneaboard.com/wiki/index.php...ask_Primer
From machine or charts for auto-cpap, set the min 1cm below median pressure, or 2cm below 90/95%. max at 20cm for now. Forum will help you fine tune settings
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#25
(12-16-2017, 11:50 AM)Sleeprider Wrote: Hojo, one quick question.

If not for the information and help you got on the forum, where do you think you would be now?

I had been suffering for at least 2 years trying to figure out why I wasn't sleeping and would many times a week in passing, tell my wife that I would do (almost) ANYTHING to get a good night sleep.  I was convinced that the only way to get any rest was to have (any) surgery just so that I could be put under to get some solid rest.

Without this forum I would be at a lost and have (basic) ENT doctor (I still respect him) guide my therapy.  With the help of folks here (especially you Sleeprider), I would have thrown the CPAP machine out the window and did just what I did after the BiPAP titration study; set my alarm for 3 am, 4 am, and 5 am, just to minimize the CA events.  Honestly, I doubt I could keep going on at work for much longer under those conditions, at least not safely.

While I think it is good to have open discussions on the different machines, I think the percentage of ASV users on this forum (as an example) is probably extremely low so no, I don't think that ASV is over used or pushed too much.  I think CPAP is good for some, BiPAP for others, and ASV for those that have a clear indications.
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#26
Mogy's examples, especially the one with Lise, are valid. I recognized that before this thread, and am going to go slower on ASV in favor of helping to make current therapy better. It is exciting and satisfying to see major life-changing success in some of the members I have had the privilege to help. It's hard to resist the potential outcome and patiently work through the process. Mia culpa. It is important that if you disagree with something I suggest that you say so. Mogy and Shin Ryoku recently did that in the thread referenced by Mogy, and I think I backed off. We're all here to help, and we're better as a group that develops consensus without condemnation. That is what sets this forum apart.
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#27
I actually enjoy and appreciate discussions such as this. This type of discussion is well suited to education of the subjects being discussed. I decided for myself via knowledge here and elsewhere that with the BiPAP PSG results I had, I was ASV bound. I made the call to push for it, as I was the one suffering from CSA. Others here, Sleeprider and no doubt others as well, shared knowledge that helped my research and education, but I myself made the call for pushing onto ASV after I passed the cardiac echo test. And I will not regret the better treatment as opposed to CPAP and BiPAP. Now, despite that above statement, if ASV were not my best choice, whatever that best choice would have been would have ultimately been what I had pushed for.

Good evening all,
Dave
lots-o-coffee
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#28
(12-16-2017, 07:31 PM)Sleeprider Wrote: "...We're all here to help, and we're better as a group that develops consensus without condemnation. That is what sets this forum apart."

Agree 100%. That by itself is one thing I like about the AB. We each can and do express our own opinions and beliefs, yet still maintain being in the same boat. With a hose. And mask. And blower...

AND COFFEE! lots-o-coffee Dave B

Great Weekend y'all Sleep-well
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#29
(12-16-2017, 01:51 PM)zzzZorro Wrote: I found it interesting that he had said when we met that the AirCurve 10 ST could well prove to have the same negative effect on LVrEF patients (if actually any) as ASV inasmuch as both have back-up. The same as you stated in your posting.  In my meager knowledge I would think the ASV 'safer' as it apparently has an 'intelligent' mode whereas the ST is 'dumb' in it's back-up function. 


I agree with you.  Intuitively, I would have thought ASV was safer.  And there was no BPAP-ST comparison group in SERVE-HF.


ajack Wrote:You aren't being given an ASV, so it's a non-issue for you... As you know, for one difference, the ST doesn't resolve cheyne stokes breathing patterns and they think they are protective to low ejection. The ST will give a breath backup when needed, otherwise it just sits in the background.


It not known whether diminishing CS respiration was the cause of increased deaths with ASV.  That is one of several theories.  A couple excerpts from recent reviews by different authors from UpToDate.com (subscription required):


M Safwan Badr, MD, Professor and Chief of Pulmonary Critical Care and Sleep Medicine, Wayne State University School of Medicine Wrote:The use of bilevel positive airway pressure (BPAP) with a back-up respiratory rate in patients with CSA due to heart failure with reduced ejection fraction should also be approached with caution and on a case-by-case basis. One reason for concern is the analogous mechanism of effect between ASV and BPAP with a back-up rate, the relative paucity of data on the effectiveness of BPAP on patient-important outcomes, and the data that ASV may cause harm in these patients. Given the limited available therapies in this patient group, however, BPAP with a back-up rate may be the only available option for some patients.


Tomasz J Kuzniar, MD, PhD and Neil Freedman, MD, Division of Pulmonary, Critical Care, Allergy, and Immunology, North Shore University Health System, University of Chicago Wrote:There is an increased mortality in patients with CSA and heart failure with low ejection fraction treated with ASV, but no similar quality data on BPAP-S/T [14,22]. Our personal practice is not to offer BPAP-S/T in this patient population, because its effect and therefore risk may be similar to that of ASV. In patients with persistent CSA who are on maximum medical therapy, we typically treat with CPAP or CPAP with oxygen. Sometimes oxygen is used alone without CPAP. Rarely, some patients have less frequent central apnea events in the non-supine position such that positional therapy including elevation of the head of bed and/or avoiding sleeping in the supine position is advised for selected patients [34].


(12-16-2017, 07:31 PM)Sleeprider Wrote: It is important that if you disagree with something I suggest that you say so.  Mogy and Shin Ryoku recently did that in the thread referenced by Mogy, and I think I backed off.


Thanks, I appreciate yours and everyone's thoughtful responses to those concerns.
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#30
Thanks Sleeprider,
I can see that you have assisted numerous people with their treatment. I have used your suggestions with good results.
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