BIPAP making my CSA worse

[Sleeprider]

Nearly 6-hours of use and entirely CA events. If your doctor won't help you, you need to find a different doctor or help yourself.

[ImAlwaysTiredd]

Not much of a choice, new doctor appointment for may 31
Heart echo in 8 days, next step to asv

I actually slept for 5 hours while on it though, this is a first. And under 5ahi at ps2, is significantly less than the 30+ a PS4 was giving me.

But there's a lot of leaks, not sure where those are at, mouth or nose. No dry mouth this morning, and no hypopneas

So that must mean the higher ipap is helping prevent those and too high causes more centrals. Ipap of 4.0 is the lowest I believe, so try that next? And after, would changing PS up or down be next?

[Sleeprider]

I know you're suffering through this, but the big picture is that you're on your way to appropriate therapy. I think you know how the system works, and now you're hitting all the marks.

[Sleeprider]

PS is 4.0
wont using a 1.0 make it do 6/7?  Or is the ipap really pointless anyways? Or is it to better acclimate?

They referred me to get a 2nd opinion which wont happen until May.
I reported my AHI and even sent OSCAR charts to my doc, with a response of:
"We have to use standard data and the most obvious so far is the result of monitored titration in the lab which documented success of BPAP."

titration study results from last year:
 

How is it so radically different? Was the titration study not using a PS setting? Titration study is odd too for the 11/5

Or is the bipap causing the apneas?
And the initial sleep study was a sham? They had lots of issues during that, and it wasnt during my normal sleep time, and I wasnt tired at all for it.

I'm still kinda in denial it's CSA, I wish it was anything other than, it really makes my lifestyle impossible. The cost of an ASV is a lot to me, but if it will actually help a lot, I might have to bite the bullet. No work at the moment. I'm still trying to consider if it's anything environmental, like caffeine/diet soda, or allergens, or poor sleep schedule.

I wanted to revisit this post and discuss your doctor's assertion the titration somehow demonstrated "documented success of BiPAP".  That is false. Titration is simply a method for challenging a patient with variable pressure settings and observing the result. As a scientific method, it is hypothesized that the incidence of apnea, SpO2 and REM sleep are correlated with efficacy. This may be true for most obstructive sleep apnea which is what the method intends to evaluate, but is certainly not consistently true of central apnea. To be a valid test, the result must be repeatable, and this test has non-linear (random) results and would not be repeatable.  First of all, the CPAP titration protocol method specifies that if the patient experiencing obstructive events that pressure be increased by 1-cm for OA, H, RERA and snoring, and recommends moving to bilevel if pressure equals or exceeds 15 cm.  However the protocol asks if events are central, and suggests if central events are incurred that pressure be REDUCED, and to move to ASV if central events continue.  

Based on this accepted titration protocol, your test was not performed corrected, and made the error of assuming that the reduction of events at 11/5 pressure was responsible for the demonstration of efficacy.  Your use of the prescribed pressure proved that the results of efficacy at 11/5 pressure were not repeatable.  Take a look at the CPAP titration protocol and count the errors of your test.  BiPAP to follow.



Now your test was a bilevel test and was initiated with CPAP then bilevel at 10/5, 11/5, 12/5 and 13/6.   Let's look at the recommended bilevel titration protocol and note that your test was started at a higher pressure and pressure support (5) than recommended.  In no case was PS 4 or less attempted.  During this test events were nearly all central with a single obstructive apnea. Note the protocol again calls for decreasing pressure when confronted with centrals, yet this technician did the opposite without regard to the type of events being recorded. The protocol contains the recommendation to move to ASV under these circumstances.  As I said at the beginning of this, your test showed that you randomly had a period that was free of central apnea for 72 minutes during which you had no REM sleep and several RERA.  On your most recent Oscar chart, you had a similar time that was free of events from 06:00 to 07:20. This efficacy is random, not a function of the settings and again, the titration results are demonstrably not repeatable.

[ImAlwaysTiredd]

lowered further to 4 with ps2, I have a lot of large leaks, I'm not sure where/how these happen



How/should I bring up the previous information to my doctor? It seems I cant really ever get past his nurse who just keeps gaslighting me.


I think part of the push for higher pressure was the initial study which states I had 7 obstructions, but I also noted they had a dehumidifier running at max, which instantly dried my face out, I had to drink at least a liter of water during my time there was so dry.

[Sleeprider]

At some point you should be having a face to face meeting with the doctor to discuss the therapy and you can come prepared with your concerns pertaining to the sleep study titration. Many doctors seem to disregard the device data because it lacks a number of critical channels used in PSG, but it is accurate and useful in grading therapy, and the same data is collected by the device used during titration supplemented by EEG and oximetry. Here is another fact most people don't know. An ASV titration is just letting the fully automatic machine run while EPAP pressure is changed. You don't need a titration test to titrate ASV. That's why we often help members to self-treat, then demonstrate efficacy to their doctor for future prescriptions. I have said many times, the best doctor for your sleep disordered breathing is usually not a sleep specialist.

[ImAlwaysTiredd]

this was the nurses last response "Since pt has repeatedly not used BPAP any longer than 1-2 hrs he will need another titration study in the lab to document if he will tolerate PAP treatment with a different interface.  Will order titration with BPAP, BPAP ST & ASV but to include ASV in the testing echoKG was requested ( to look at LV function). "

I sent the 5 hour chart at lower pressure as proof, I have a feeling I'll get some comment saying I wasnt prescribed that and it is invalid.

Scheduling another titration will probably push this testing out till june for me, so I guess I have to just buy my own it seems.

actually, I did a tele meeting with the sleep doctor last time, he was so concerned with his own ramblings, I really didnt get to ask anything I was concerned about

[Sleeprider]

For your consideration, Traveller10 informed us of a deal on the Resmed Aircurve 10 ASV at TheCPAPshop. The machine is marked down to $1776.00 USD and using the discount code "AIRCURVE" resulted in a further $477 reduction. With tax and free shipping he paid $1293 http://www.apneaboard.com/forums/Thread-...#pid466163

[ImAlwaysTiredd]

thanks for that, but it seems the link is broken, I asked them about it, and they require a specific asv prescription





So, I tried a pressure of 4 for ~3 hours and then of 5 later, at 5 and ps2 I had no apneas it appears, which seems really interesting, maybe too short of an interval to be of importance, maybe I wasnt really asleep, just in a groggy state
but I couldnt stay asleep, and not at all asleep at pressure of 4 earlier in the night. I notice a bursting of air when I wake up, like a leak, but I dont really know where it's coming from??

You can see where I changed it from a pressure of 4 to 5, the mask pressure chart shows a 6.5-8.5 then 5-6.8, I thought pressure would decrease?
I also notice that mask pressure stays higher after a high leak

I only got about 4-5 hours of sleep in total last night, and feel exactly the same as ~7 hours, still foggy and tired



and a closeup of the split

[Sleeprider]

In general, we use the lowest pressure and pressure support that is tolerated to minimize central events.

You might ask your doctor to approve an ASV delivery (prescription) from an online vendor. Your diagnosis and all therapy point to central apnea and that ASV would be much better. As long as he has the left ventricular ejection fraction there is no good reason to deny the prescription except to extract more testing and doctor visit fees from you. I see no reason not to try finding a doctor more enthusiastic about getting you good results and that knows how to treat central apnea.