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Bi-Level, S, ST, ASV??
#81
RE: Bi-Level, S, ST, ASV??
Follow the suggestions Sleeprider has presented on setting edits. I'd take that emergency call aspect as something to consider strongly. When dealing with 37 CA events, this is seriously wrong. And yes this could affect one's heart condition that's weakened already in light of that LVEF number. This doc needs to correct this ASAP. Hope you get action immediately.
Dave

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#82
RE: Bi-Level, S, ST, ASV??
I really appreciate everyone's feedback here.

I have a call in to Dr... not holding my breath (no pun intended) for a response before Monday.  I asked my dad not to use it tonight.

I went back to review the documents I have...

Script says: Bilevel ST @ EPAP 7, IPAP 16, BR Off, AirSense AirCurve 10 ST. EPR: On, 2, Humidifier:3
[This already has many issues.. using the name AirSense for Bilevel... setting EPR on for Bilevel.]

Dr report on titration study:
Recommendation: Successfully titrated to BiPAP 16/7.  Central events improved on this setting.
[This is VERY misleading... and leaves out what I discovered below in the small print.]

Now... I went and dug into the actual study... specifically the tech comments... which show:
16/7 Cm, Timed Insp 1.8, Backup rate of 14 was proving to be curative in side position REM and NREM. Patient in supine position did not appear to have the capacity to maintain respiratory effort.  Supine sleep was not witnessed with an optimal PAP setting however, and effective BiPAP pressure of 16.7 was achieved with the help of positional therapy.

So... it was NEVER mentioned in meeting with Dr that he should avoid supine, and that the best results were achieved on side.  Also specifically stated by Dr and on script that he did not need backup rate... but tech info shows that it WAS used during titration.

So, the question is... did the Dr screw up here AGAIN, or is there some reason they prescribed differently than the titration study used.  I know what my bet is...
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#83
RE: Bi-Level, S, ST, ASV??
(11-16-2019, 05:55 PM)jtech1 Wrote: I really appreciate everyone's feedback here.

I have a call in to Dr... not holding my breath (no pun intended) for a response before Monday.  I asked my dad not to use it tonight.

I went back to review the documents I have...

Script says: Bilevel ST @ EPAP 7, IPAP 16, BR Off, AirSense AirCurve 10 ST. EPR: On, 2, Humidifier:3
[This already has many issues.. using the name AirSense for Bilevel... setting EPR on for Bilevel.]

Dr report on titration study:
Recommendation: Successfully titrated to BiPAP 16/7.  Central events improved on this setting.
[This is VERY misleading... and leaves out what I discovered below in the small print.]

Now... I went and dug into the actual study... specifically the tech comments... which show:
16/7 Cm, Timed Insp 1.8, Backup rate of 14 was proving to be curative in side position REM and NREM. Patient in supine position did not appear to have the capacity to maintain respiratory effort.  Supine sleep was not witnessed with an optimal PAP setting however, and effective BiPAP pressure of 16.7 was achieved with the help of positional therapy.

So... it was NEVER mentioned in meeting with Dr that he should avoid supine, and that the best results were achieved on side.  Also specifically stated by Dr and on script that he did not need backup rate... but tech info shows that it WAS used during titration.

So, the question is... did the Dr screw up here AGAIN, or is there some reason they prescribed differently than the titration study used.  I know what my bet is...

YOU HAVE IT!  Please set the machine to ST mode with a rate of 14 BPM and Ti Min 1.8!  Your doctor made a bad bad error!  Bolster pillows are a common item to help patients avoid falls and to avoid supine sleep when needed.  You can correct his error and everyone can avoid the lawyers.  It is obvious that the technician used the backup function during the test and the doctor skimmed the recommendations rather than understanding them and properly prescribing.
Sleeprider
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#84
RE: Bi-Level, S, ST, ASV??
I just read an nih article that states:

"some reports suggest that a brisk response (or shorter rise time) may have some inherent oscillatory behavior that may set the stage for “emergent” central apneas."

The ST unit defaults to "min" for rise time... which I assume is as fast as possible (but would be nice if they documented ms for min.. next lowest setting is 150 ms).  Do you know of any threads on here where people have discussed rise time?  Search did not turn up any.

Also, above you translated my words "timed insp" to "Ti min"... how do you know that?  Could it be Ti max?  Ti min is currently 0.3s, and going to 1.8 is a big jump... I assumed it meant Ti max should be 1.8.
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#85
RE: Bi-Level, S, ST, ASV??
The clinical manual has a good writeup on timing including suggested values,
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter

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#86
RE: Bi-Level, S, ST, ASV??
I'm honestly not familiar with setting inspiration time on the ST for treating this condition, and it is your doctor's responsibility to consult with the therapist that conducted the test. After further consideration, I think the sleep clinic technician used the Timed mode rather that ST mode. I will discuss both:

This machine can also be used in T (timed) mode, and in that mode the Ti (time of inspiration) can be set. So in T mode you can set 14 BPM and a Ti of 1.8 and met the conditions of the prescription with EPAP of 7.0 and IPAP of 16.0. I believe this most closely conforms to the recommendations.

In ST mode, both Ti Min and Ti Max can be set. Ti Min may be any time from 0.1 up to the Ti Max. Ti Max has a default of 1.8, so settig Ti Mn and Ti Max equal at 1.8 meets the conditions of the recommendations, and differs from T-mode in that it allows for spontaneous breathing, while T-mode is strictly on a timed rate.

The idea behind Ti Min (or Ti) is to ensure the inspiration pressure is held at least that long, and I was interpreting the report as setting Ti Min equal to Ti Max which would give a fixed inspiration time of 1.8 seconds. This prevents premature cycling back to EPAP before inspiration is complete, and this setting is specifically used for patients whose inspiratory effort is extremely weak. If we assume a rate of 14 BPM, each breath cycle will last 4.28 seconds, so a Ti Min of 1.8 means expiration may last 2.48 seconds. This would be a normal I:E ratio of 1 to 1.38.

Based on my understanding of this machine and the discussion in the titration report, it appears the technician intends to set the machine in T-mode at IPAP 16, EPAP 7.0 at 14 BPM and Ti at 1.8. My original interpretation of the recommended settings, for Ti Min at 1.8 remains unchanged unless you use T-mode and set Ti which has the same result. This is my best shot, and every post I make has a disclaimer...read it. I think this is the safest way to go until you can talk with the doctor that screwed this up.
Sleeprider
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#87
RE: Bi-Level, S, ST, ASV??
Jtech, since you are going to be talking to the doctor anyway, be sure to ask about the ST-A in iVPAS mode. iVAPS means intelligent volume assured pressure support, and it is designed to specifically maintain a set minute vent at the lung aveoli. It is a more modern approach to ensuring patients with extremely weak respiration or compromised thoracic function are delivered a prescribed volume of air on each breath. If you doctor is aware of this technology, he may see it as similar to ASV, but it does not have the same warning for individuals with low LVEF. I think it is at least worth discussing. Also, don't let the doctor off too easy. He screwed up.
Sleeprider
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#88
RE: Bi-Level, S, ST, ASV??
Thanks, I will bring that up.

I have been looking at tidal volumes also... mine are always around 500, with minor variances during the night... my dad's, during time periods with no apneas, are around 850... but during the periods when centrals are happening, it varies from near 0 to over 1700. I assume that is from the large pressure support value. If I understand correctly, it is the high tidal volume that does not allow the CO2 levels to get above the threshold that triggers breathing, thereby causing a central... then tidal volume goes to 0, then CO2 rises, then brain triggers breath. Sound close to accurate?

I am trying to understand if there is a difference between CPAP induced centrals that resolve over time, and high tidal volume centrals. Makes me wonder if a titration study that sees some centrals in a few minutes of CPAP therapy is really accurate... and whether there is merit to a week or more on regular CPAP (or Bilevel with PS 4) to see if that is a better fit. I will discuss that with Dr also, if real world numbers do not improve with the correct settings on Bilevel.
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#89
RE: Bi-Level, S, ST, ASV??
Based on the numbers of centrals even when on CPAP only pressures I do not believe that these centrals will self resolve. That’s just my opinion. We have patients come here very worried by 6 or 8 centrals a night. Your dad had 34 centrals a minute all night long
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#90
RE: Bi-Level, S, ST, ASV??
On the tidal volume question, it is clear that he is over-ventilated from time to time, and the root cause is certainly the fixed PS. With a fixed Ti, this problem may become more acute. The iVAPS provides a much more consistent tidal volume, using adaptive PS. Here is a thread by an individual caring for his terminally ill father using iVAPS. It gives you an idea of how that machine works in comparison to the stone-age technology of the ST. http://www.apneaboard.com/forums/Thread-...-on-report
Sleeprider
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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