Back up rate and not breathing.

[goodonya]

I was reading the fine print on my Respironics ASV Bipap and saw where they said the machine was not intended to be a breathing restarter. My prescription on that machine had the Backup Rate turned off. I could hold my breath and the machine would simply not pump any air.

I am now looking at buying a Resmed S9 Vpap Adapt. Is there a back up rate on these and if it is turned on will it push me to breath when I have stopped?

What is this all about where the machine does not pump air when you either hold your breath or stop breathing? I was under the impression that keeping us breathing is what these machines are for.

I could not help but wonder if it was a way for the whole system that took all my money to also provide a quiet exit strategy for me. Us baby boomers being kind of a glut on the system and all.

[robysue]

goodonya,

The Resprionics ASV machine has a backup rate feature. It can be set to OFF, AUTO, or a specific number of "breaths per minute" when the machine is run in ASV mode.

If your prescription did not include a back up rate or specified that the back up rate be turned off, then chances are that the DME set the machine up with the back up rate turned OFF because they were following the prescribing doc's orders.

And if you buy a brand new Resmed S9 Vpap Adapt (the Resmed ASV), and have the DME use the same prescription to set up the S9, then chances are the DME will turn the backup rate OFF on that machine as well.

In other words, the first thing you need to do is find out why the prescription has no back up rate. It could be that the sleep doc's office intended for the back up rate to be set to "Auto" instead of "Off", but the DME misinterpreted the script.

In other words, the first step may be to get your current machine set up with better settings rather than spending $3000 or more for the S9 VPAP Adapt. If I were you, I'd call the sleep doc's office and ask them to change the script so that the Backup Rate is set to AUTO rather than OFF. (If you're comfortable with changing your own settings, you could do this yourself through the clinical menu.)

I was reading the fine print on my Respironics ASV Bipap and saw where they said the machine was not intended to be a breathing restarter. My prescription on that machine had the Backup Rate turned off. I could hold my breath and the machine would simply not pump any air.

I'm pretty sure that regardless of what the back up rate is set to, if the apnea appears to be an OA based on the results of the PP algorithm, the machine will wait for you to start breathing on your own. And I'm pretty sure the Resmed S9 Adapt reacts the same way: If the apnea in progress appears to be an OA based on the results of the FOT algorithm, the machine will wait for you to start breathing on your own.

On both the Respironics ASV and the S9 Adapt, if the backup rate is set to OFF, the machine is NOT going to respond to an "CA apnea in progress". I'm not sure what each of these machines does if the apnea in progress appears to be a CA and the back up rate is turned ON. But I believe that if the backup rate is ON, on both the Respirionics ASV and the S9 Adapt, the ASV algorithm will kick in after several seconds of "no flow into/out of the lungs"---provided the apnea appears to be central in nature.

And it's also important to note that whether a machine will score an intentional holding of breath while awake as an OA or a CA seems to depend on exactly how you hold your breath. In my case, when I run that test, the fake apnea is more likely to be scored as an OA for some reason.

I am now looking at buying a Resmed S9 Vpap Adapt. Is there a back up rate on these and if it is turned on will it push me to breath when I have stopped?

If the back-up rate of either the S9 Adapt or the System One ASV is turned ON, then the machine will attempt to trigger inhalations when the breathing rate drops below the target number of breaths. The idea is to prevent the central apneas from happening in the first place by preventing the CO2 overshoot/undershoot cycle from developing. When the machine detects variations in the breathing pattern---including both slower than expected and shallower than expected breathing, the ASV algorithm kicks in and starts triggering inhalations by cycling between the IPAP and EPAP pressures AND increasing the IPAP (sometimes drastically) while leaving the EPAP alone.

But neither machine is going to respond to an OA in progress by increasing the pressure. Both machines will wait until the OA is over to respond by increasing the EPAP if they're run in AutoEPAP mode.

And, as I said before, I don't know what these machines do if a CA happens without any precursor "tell-tale" changes in breathing patterns. My impression is that if the CA lasts long enough and the back up rate is set to ON, then both the Resprionics ASV and the Resmed VPAP Adapt will try to trigger an inhalation by switching from EPAP to IPAP pressure. And if the CA continues, my impression is that both machines will continue trying to trigger inhalations by switching between EPAP and IPAP at regular intervals determined by the back up rate setting. And both machines will rapidly increase the IPAP pressure (but not the EPAP) as the pressure cycles back and forth between EPAP and IPAP.

What is this all about where the machine does not pump air when you either hold your breath or stop breathing? I was under the impression that keeping us breathing is what these machines are for.

The PAP part of your therapy is NOT designed to make you breath when an obstructive event occurs. PAP works for obstructive sleep apnea by making it more difficult for the airway to collapse in the first place---in other words, PAP prevents the vast majority of the obstructive events from happening in the first place, but it is expected that a few events may still get by the defenses. When using a machine that is run in AUTO mode, the machine does NOT increase pressure during an obstructive event; rather the machine waits until the event is over and then increases the pressure to make it more difficult for future events to occur. That is how the machines are designed to work.

The ASV part of your therapy requires additional settings and careful titration. Again, the ASV part of the algorithm is designed to prevent the vast majority of central events from occurring in the first place. In other words, the ASV algorithm is designed to prevent the CO2 overshoot/undershoot problem from developing in the first place. (It is the CO2 overshoot/undershoot problem that is the main problem that leads to excessive numbers of CAs in the first place.)

In other words, even if an ASV machine is set up in ASV mode, it's only acting as a non-invasive ventilator that will help stabilize breathing by triggering inhalations when the breathing pattern becomes sufficiently ragged, but is still present. It's not going to blast a huge amount of air down an airway when the airway appears to be obstructed. And it's not completely clear what it's going to do for an isolated CA that is NOT part of an unstable breathing pattern.

The "holding your breath" tests mimic isolated events rather than genuine unstable breathing patterns, and that can explain why the machine doesn't "do" anything when you intentionally hold your breath while awake. And for some people, the way they hold their breath results in the machine scoring an OA not a CA, and that also can explain why the machine doesn't "do" anything when you intentionally hold your breath while awake.

I could not help but wonder if it was a way for the whole system that took all my money to also provide a quiet exit strategy for me. Us baby boomers being kind of a glut on the system and all.

Once more, the point behind the machine is to prevent the vast majority of the bad breathing from occurring in the first place. Even a completely normal person has a few OAs and CAs that occur each night, but these are NOT problematic because they are few in number and don't lead to serious O2 desats or fragmented sleep. The point of your ASV machine is to prevent the vast majority of your OAs, Hs, and CAs from happening in the first place rather than "treat" the events as they happen. If too many OAs, Hs, and CAs are occurring when you are using your machine, then the settings on the machine are not yet optimally set. In your case, if the Backup rate on your Respironics ASV machine is set to OFF, that may be interfering with the machine's ability to properly treat the central part of your sleep apnea. And that's why you need to talk to the sleep doc about why the DME thinks prescription says "back up rate = off."

[goodonya]

Hi Robysue I got a copy of the prescription sent to the DME clearly showing the back up to be off on the ASV Bipap from Respironics.
I have a new sleep doctor but am taking a new track as well where I learn what is going on on my own. I am going forward not backwards.

My sleep test showed I have 85% central apneas and have few obstructives in any case. I long since lost the extra weight and stopped the bulk of the inflammatory condition and sinusitis I had going on. Even untreated I rarely snore or choke or any of that. I do simply and quietly stop breathing.

I do when I have stress days do the Cheyne Stokes breathing.

I am just trying to sort out a reason to not have back up for a CSA person. I am also trying to determine if CSA people are involved in their back up rate and how it operates. I hear of people dying in their sleep and cannot help but wonder if a CSA person without their back up on could simply expire.
Finally I am interested in the S9 VPap Adapt and peoples experience with the back up on it. To me it makes no sense to not have it on, but maybe there is a viable reason that I should know about.

I am very appreciative of this board and you folks being involved in helping others. It is very cool, Thank you, goodonya

[robysue]

Hi Robysue I got a copy of the prescription sent to the DME clearly showing the back up to be off on the ASV Bipap from Respironics.
I have a new sleep doctor but am taking a new track as well where I learn what is going on on my own. I am going forward not backwards.

If the script said "back up rate OFF", then there's not much the DME could do: It had to set up your current machine with the back up rate set to OFF. The question is: Why did the doc tell the DME to set the back up rate to OFF? That's a particularly relevant question to be asking in light of:

My sleep test showed I have 85% central apneas and have few obstructives in any case.

The whole point of having an ASV with a back up rate is to treat the central apneas. But with the back up rate set to OFF, the machine can't properly treat the central apneas.

If I were you, I'd call the new sleep doc's office and give them a copy of the original script and ask the new doc for permission to turn the back up rate setting from OFF to AUTO. That will allow your current machine to behave like a proper ASV machine.

I am just trying to sort out a reason to not have back up for a CSA person. I am also trying to determine if CSA people are involved in their back up rate and how it operates.

In my humble opinion, the scrip should NOT have said "back up rate OFF" since the back up rate is a critical part of how the ASV algorithm treats central sleep apnea.

From what I've read here and elsewhere from folks who are using ASV machines to treat CSA, the back up rate has to be set to something other than OFF. When the back up rate is set to OFF, the ASV is essentially turned into nothing but a very expensive bi-level machine rather than being allowed to work as a full-fledged ASV machine.

Finally I am interested in the S9 VPap Adapt and peoples experience with the back up on it. To me it makes no sense to not have it on, but maybe there is a viable reason that I should know about.

I'm simply trying to point out two things:

1) You might be able to save yourself quite a bit of $$$ and still fix your current problem by turning the back up rate on your current Resprionics ASV machine ON. The question is whether to set the back up rate to Auto or to a fixed breaths per minute. And that's a decision you need to get some input on from the new sleep doc.

2) If you bought an S9 VPAP Adapt with the current prescription, the DME you buy it from will set up the S9 with the back up rate set to OFF because that's what the script says to do. And they have to set the machine up according to the script.

Finally some questions: Are you using a Respironics System One ASV or are you using an older Respironics M-Series ASV? Have you got the Encore software you need for seeing what's going on each night?

[goodonya]

Hi RobySue, I have a new prescription from the new sleep doctor with the backup clearly marked "auto" on the BPM Rate line.
I showed him the old prescription after I got the copy from the DME showing the back up as marked "off".

I had began going to a different branch of the DME and they were more helpful and I appreciated that. That is where I found out a new sleep doctor was in town with excellent credentials and was a neurologist rather than a pulmonologist. My insurance when I still had it had my old sleep doctor as a preferred provider. They dropped that but for a while there was no other doctor.
I was not happy with the old doctor because he was simply signing off on the patient/ physician assistant system he had going. The physicians assistant while helpful absolutely refused to prescribe any setting changes on the machine. The 24 pressure setting brought me to my knees. I am a strong man. They had me whupped.

I had nothing but trouble with the Bipap Auto SV Advanced from Respironics. I do understand completely that the DME sets the machine to the prescription, okay? The first machine I had was brand new with warrantee. When it began being a problem heating up and I was still experiencing times waking up not breathing.

I finally took a day off and drove the 300 miles to the DME office to try and resolve the problem. I was at a very low point in my life working full time totally exhausted from lack of sleep my treatment was not helping me in fact I felt like I had been consigned to Hell.

In all of that was the need for compliance to keep being treated. I was compliant by a slim margin. I was determined to get help. The Boss at the main branch DME helped me by giving me what I thought was a new machine. It was not until later I learned there was another branch of the DME in a town closer to where I actually live. I went to them - they were the ones who when I told them my new machine was not working right again; checked their files and found the Boss had given me a re-certified machine. We called my insurance, and they(the branch DME) also called their main office and learned that my warrantee was voided. They tested the machine and said it was fine.
It got worse. I was down to 3 hours of sleep a night. Some where in there I was no longer able to have enough cognitive function to safely do my occupation. As my insurance expired I found out about the new doctor in town and paid out of pocket. Even at that point I did not sort out the back up rate situation until later. The machine by the way besides heating up became completely dysfunctional, pulsing the mask on my face searching the algorithm all night which finished me. They tested it again and it was fine.
As I said before I am looking forward. Back was a system failure. I will at no time recommend either that DME, the original sleep doctor or the Respironics Bipap Advanced ASV that cost my insurance company $5,500 dollars.
The Sleep Study people were awesome and I have no complaints other than I cannot afford another $4,000 dollar study until I get central sleep apnea treatment and am able to work and get my insurance back.
I have cashed in an IRA and and paid the penalty so I can get a new machine. Believe me I want that new machine and I want a two year warrantee. When I am back on the job and insured the warrantee will carry me to the 5 year mark that my insurance requires to buy a new machine.
I need a new beginning RobySue I have floundered through the old situation for three years. I did the best I could. I went from being an exhausted hardworking guy with a darn good job to a stay at home on an internet forum on no form of social service or insurance or income. Another words, teachable. Sometimes life just makes us hit a wall and then we lurch forward again. That is me lurching forward.

[robysue]

Hi RobySue, I have a new prescription from the new sleep doctor with the backup clearly marked "auto" on the BPM Rate line.
I showed him the old prescription after I got the copy from the DME showing the back up as marked "off".

So either have the current branch of the DME reset the current machine so that the back up rate is set to AUTO or get the clinical manual for you machine from here and set the back up rate to AUTO yourself.

I was not happy with the old doctor because he was simply signing off on the patient/ physician assistant system he had going. The physicians assistant while helpful absolutely refused to prescribe any setting changes on the machine. The 24 pressure setting brought me to my knees. I am a strong man. They had me whupped.

Sounds like the old doctor deserved to be fired. It's really ridiculous that the previous doctor prescribed a BiPAP ASV and then had the DME set the back up rate to OFF. It's even worse that the doc's PA would not bring up this issue with the doc and authorize the change in the back up rate setting.

How long did you have to put up with this runaround???

I had nothing but trouble with the Bipap Auto SV Advanced from Respironics. I do understand completely that the DME sets the machine to the prescription, okay? The first machine I had was brand new with warrantee. When it began being a problem heating up and I was still experiencing times waking up not breathing.

My main question is: Have you had a chance to use the BiPAP ASV with the back up rate correctly set to AUTO instead of OFF?

All I'm saying is: The best price I saw on-line for a Resmed S9 VPAP Adapt is $3800 for just the blower unit. So, yeah, you can put a lot of money into buying the Resmed VPAP Adapt and make sure it's set up with the new script. But you may or may not find it any easier to sleep with than the current machine if the back up rate on the current machine is correctly set to AUTO and the pressure settings are set to what the new script specifies.

In other words, it's worth resetting the current machine to the new script's settings, including setting the back up rate to AUTO now while you're still considering what you really want to do as far as replacing the machine is concerned.

If the new settings make a big difference in your ability to get to sleep and stay asleep, you might just decide you don't need to spend $3800 on a Resmed VPAP.

If the new settings only make a bit of difference in your ability to get to sleep and stay asleep, that will at least let you do some real thinking about what you want to do concerning buying a new machine. And it will let you do some serious shopping around to see just how much you're going to need to pay for the new Resmed machine.

And if the new script's settings don't make it any easier to use your current BiPAP ASV, you might want to let the new sleep doc know that the new settings aren't any easier to sleep with than the old ones were. That may indicate the new settings need to be tweaked some more or it could be evidence that you might do better with the Resmed's ASV algorithm.

[me50]

Hi RobySue, I have a new prescription from the new sleep doctor with the backup clearly marked "auto" on the BPM Rate line.
I showed him the old prescription after I got the copy from the DME showing the back up as marked "off".

I had began going to a different branch of the DME and they were more helpful and I appreciated that. That is where I found out a new sleep doctor was in town with excellent credentials and was a neurologist rather than a pulmonologist. My insurance when I still had it had my old sleep doctor as a preferred provider. They dropped that but for a while there was no other doctor.
I was not happy with the old doctor because he was simply signing off on the patient/ physician assistant system he had going. The physicians assistant while helpful absolutely refused to prescribe any setting changes on the machine. The 24 pressure setting brought me to my knees. I am a strong man. They had me whupped.

I had nothing but trouble with the Bipap Auto SV Advanced from Respironics. I do understand completely that the DME sets the machine to the prescription, okay? The first machine I had was brand new with warrantee. When it began being a problem heating up and I was still experiencing times waking up not breathing.

I finally took a day off and drove the 300 miles to the DME office to try and resolve the problem. I was at a very low point in my life working full time totally exhausted from lack of sleep my treatment was not helping me in fact I felt like I had been consigned to Hell.

In all of that was the need for compliance to keep being treated. I was compliant by a slim margin. I was determined to get help. The Boss at the main branch DME helped me by giving me what I thought was a new machine. It was not until later I learned there was another branch of the DME in a town closer to where I actually live. I went to them - they were the ones who when I told them my new machine was not working right again; checked their files and found the Boss had given me a re-certified machine. We called my insurance, and they(the branch DME) also called their main office and learned that my warrantee was voided. They tested the machine and said it was fine.
It got worse. I was down to 3 hours of sleep a night. Some where in there I was no longer able to have enough cognitive function to safely do my occupation. As my insurance expired I found out about the new doctor in town and paid out of pocket. Even at that point I did not sort out the back up rate situation until later. The machine by the way besides heating up became completely dysfunctional, pulsing the mask on my face searching the algorithm all night which finished me. They tested it again and it was fine.
As I said before I am looking forward. Back was a system failure. I will at no time recommend either that DME, the original sleep doctor or the Respironics Bipap Advanced ASV that cost my insurance company $5,500 dollars.
The Sleep Study people were awesome and I have no complaints other than I cannot afford another $4,000 dollar study until I get central sleep apnea treatment and am able to work and get my insurance back.
I have cashed in an IRA and and paid the penalty so I can get a new machine. Believe me I want that new machine and I want a two year warrantee. When I am back on the job and insured the warrantee will carry me to the 5 year mark that my insurance requires to buy a new machine.
I need a new beginning RobySue I have floundered through the old situation for three years. I did the best I could. I went from being an exhausted hardworking guy with a darn good job to a stay at home on an internet forum on no form of social service or insurance or income. Another words, teachable. Sometimes life just makes us hit a wall and then we lurch forward again. That is me lurching forward.

I don't know where you live but have you thought of filing for SSI even if you can go back to work at some point?

[Peter_C]

I so feel for you, and I see and agree with robysue's logic. I am also wondering if you do plan to take control, I would wonder perhaps about setting your machine into full AUTO mode for a few nights while watching the data - simply to see if in fact you (the machine decides that you) really need such a high pressure - from one that's been there, it can be very hard to get good sleep at such a setting. But, I know nothing about CSA events, so please take my words strictly as comments.

[goodonya]

Greetings Peter C, My very last set of encounters with the Respironics Bipap AutoSV Advanced was after the DME made the last determination that nothing was wrong with the machine. The new sleep doctor had given me the new prescription:

Epap min. 6, Epap max 12, Ps min, Ps max 10, max pressure 20,

BPM auto

The DME reset the Respironics to the new settings with the Auto on
The machine which was fine according to the DME did exactly what it did before taking it in to get checked out. It pulsated air against my face on the inhale and on the exhale. I was so exhausted I went to sleep with it doing it and woke up three hours later with it still doing it.
I tried it one more time after that and then I was done. No more Respironics Bipap AutoSV advanced, DME, old sleep doctor. Three years was enough.
I have permission from the new sleep doc to use the same prescription to purchase a new machine.

[goodonya]

Hi Robysue, I missed your post some how and answered by way of peter c's post. I reviewed everything again after replying to Me50 and found your post. It is a terrible thing to me to have my brain scrambled like this.
The whole mess went on for three years. I was going downhill all that time. The new sleep doctor is a good guy. It is hard for me to wrap my mind around what happened. The new prescription did not work on the old machine because the old machine(the Respironics Bipap autoSV advanced) does not work right and the DME wont fix it and the warrantee was voided by their way of doing things. Plus at this point and experience of two malfunctioning machines of the same make and model, I am convinced that that machine is a piece of garbage.
I apologize for being so unclear. I could be a case study for what happens to a good brain after a complete CSA treatment snafu. Thank you for your interest, advice and support.