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Bilevel machine - advice needed
#61
RE: [split] Bilevel machine - advice needed
Titration is the addition of pressure, starting from a "best-guess" of a pressure that will be less than your requirements. I would start EPAP at 8.0 and look for obstructive apnea and raise EPAP until that was no longer present. My "guess" of 8.0 may be a bit low, but remember that we are talking about Auto ASV, so it doesn't take long to reach the current EPAP of 12, while giving fair evaluation of 9, 10, 11 cm to see if they work. Your PS min of 6.0 is based on getting enough ventilation, so we would not change that at all, but PS max can be allowed to range up to 15 cm to ensure any central apnea are treated. Chances are, you will respond with somewhere between 8 and 12, but again, the machine can do the pressure change on the run.

In reality, the modern ASV auto machine is faster and better at meeting your needs, than a technician trying to manually titrate you. The best titration test would be to set a reasonable range of parameters and let the algorithm do its work. For many clinics, that is the disconnect between modern ASV machines and the attempt to "titrate" to old fashioned fixed ASV. Many just have not caught up with the technology.
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#62
RE: [split] Bilevel machine - advice needed
I have been reading threads in this forum and reading some of RobySue's extensive SleepyHead information. A few more things are starting to make sense.  Oh-jeez

I like your suggestion of starting EPAP at 8. My current pressure settings are still really high for me. I'm still trying but I'm often short of breath all through the day after using my current machine. My AHI was 33.28 two nights ago. Only one Hypopnea and all the rest were 252 centrals.

Thanks for the explanation of Titration. That helped as well. I'm also relieved to know that even in Auto mode that we can keep the pressure support at a minimum of 6. I'm also thinking that telling the lab tech about my experience of changing the pressure support to 17/12 and how I couldn't get enough air the next day would be good so that they know to keep the PS at a minimum of 6.

Would you want to make a suggestion of the all starting the settings going into the sleep study? You posted this in your other reply so is this all I need to tell the lab tech?

SLEEPRIDER:
"I already suggested your ASV settings could be EPAP min 8.0, EPAP max 12.0, PS min 6.0, PS max 12.0.  As you can see, his recommendation is at the top of the range I have previously suggested.  We need at least 8.0 EPAP for OA, and we need the 6.0 PS min to preserve your comfort and tidal volume. PS max can range from 12 to 15 to ensure hypopnea and centrals are treated. It is very important that your doctor pay attention to not just your EPAP, but the fact you need that minimum pressure support, or you will not get the titration you need."

It's not until October 15 but I'm going to call tomorrow and see if they have a wait list for any cancellations so that I might get in sooner. I'm exhausted all day but try to keep moving and getting things done then by evening having such a hard time concentrating and staying awake. 

Am I allowed to contact the DME and tell them that I'll be needing to switch to an ASV and why so that they might be willing to order the new machine as soon as the sleep study is done to help eliminate that 5 week time wait that I had from the June sleep study to finally getting my current machine August 8? I know that the insurance will still need to approve but I'm just hoping to somehow speed up this process a little.

I hope that it's okay that I'm relying on you and the this forum to help with any final changes in settings after I get the new machine.
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#63
RE: [split] Bilevel machine - advice needed
(09-27-2018, 08:23 PM)Sleeprider Wrote: That is a great outcome!  Now we need to work on him a little more...

Here is the Resmed recommended titration protocol for AutoASV. It starts at EPAP min 5.0, EPAP max 15.0, PS min 3.0 and PS max 15.0.  I already suggested your ASV settings could be EPAP min 8.0, EPAP max 12.0, PS min 6.0, PS max 12.0.  As you can see, his recommendation is at the top of the range I have previously suggested.  We need at least 8.0 EPAP for OA, and we need the 6.0 PS min to preserve your comfort and tidal volume. PS max can range from 12 to 15 to ensure hypopnea and centrals are treated. It is very important that your doctor pay attention to not just your EPAP, but the fact you need that minimum pressure support, or you will not get the titration you need.  In fact centrals may not show up, or you may not sleep if you are given only the 3.0 PS min in the Resmed protocol.

You may end up needing an EPAP of 12, but  a titration should not start at what we assume to be the target.  A good way to guide the technician would be to start below your current EPAP pressure and use normal titration techniques to determine the need for higher pressure, because you are going to get more comfortable therapy at a lower pressure provided it works.  So ask the doctor to "titrate" the pressure starting at a lower pressure than your current machine, increasing EPAP if needed to address OA, maintain your needed PS min of 6.0, and use the pressure support maximum to treat the hypopnea and centrals. This approach is consistent with the recommended titration protocol and may yield effective treatment at a lower EPAP pressure. There is certainly no harm in trying to make lower pressure work, especially since you want to be issued a modern auto-ASV. The objective should be to find an effective range that uses the advantages of auto ASV rather than try to determine a fixed pressure. 

You're almost there, now read this protocol and ask any questions:

[Image: attachment.php?aid=4210]

Thanks for posting this picture. I've been looking it over since you posted it and also reading on this forum. I'm thinking that it makes sense to me. I'm not sure what questions to ask. But am wide open to any further explanation on any of it that you think would benefit me. I'm just try to absorb all that I can and am willing to read whatever you think would help.

You also said "In fact centrals may not show up, or you may not sleep if you are given only the 3.0 PS min in the Resmed protocol."

Am I right that the centrals may not show up because of the low pressure and they are showing up at such a high amount now because of the 18/12 pressure I currently have?

Also you said that "I may not sleep."  This happened during my June sleep study. I went in so tired, thinking that I would fall asleep right away but I didn't except for occasional very light sleep and didn't understand why. Now I know that somewhere around the time that I was switched from CPAP to Bilevel I finally fell asleep. The lab tech mentioned in in the morning that I didn't sleep much and then the doctor mentioned it. But I didn't know why and they seemed like they didn't either. 

So my question is would I possibly not fall asleep at a 3.0 PS min because I'm not getting enough ventilation? So that can keep me awake?

Thanks for all your help,

Lynn
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#64
RE: [split] Bilevel machine - advice needed
Lynn, let me start by pointing you to a new thread posted by Mark Sadler on the forum.  The point to take away is how he was issued ASV after being on CPAP and BPAP, then how his ASV pressure settings were too high.  This is the path I think you may also be on if your doctor does not try the lower pressures and titrate upward.

Quote:You also said "In fact centrals may not show up, or you may not sleep if you are given only the 3.0 PS min in the Resmed protocol."
Am I right that the centrals may not show up because of the low pressure and they are showing up at such a high amount now because of the 18/12 pressure I currently have?

Yes.  Your need for a higher minimum PS is driven by what we discussed in Post #28, where your doctor has targeted flushing CO2 from your blood stream. In addition, you have problems feeling adequately ventilated, and sleep poorly with lower PS than 6.0.  Therefore, you should be sure to review and discuss these two points from previous therapy decisions with your doctor, and ensure that they are incorporated into the ASV trial as the minimum PS.  The ASV test must have the PS min of 6.0, or you will likely feel uncomfortable and not sleep well, and at the lower default PS of 3.0, you may not even experience CA events.  

Since the need for your current PS of 6.0 came from your doctor, and lead to the 18/12 pressure you currently use, this should be a part of the study. However, the minimum EPAP of 12.0 may, or may not be needed.  EPAP prtessure is used to maintain the airway and prevent obstructive apnea. Your charts suggest that obstructive apnea is not present at 12, therefore, there may be a rationale to try lower EPAP pressure when titrating your requirements on ASV.  The technician can start at a lower EPAP pressure and observe for OA events, and raise EPAP pressure if and when your airway is obstructed.  This is part of the titration protocol we posted earlier.  You may indeed require a minimum EPAP of 12.0, but remember, modern ASV is capable of auto-adjusting the EPAP pressure to meet your needs, so we don't want to end up with unnecessarily high starting EPAP pressure. This goes back to the post I linked earlier by Mark.
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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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#65
RE: [split] Bilevel machine - advice needed
While at my last appointment I ask the doctor how he knew that I would need a PS of 6 and he shrugged his shoulders and said he had nothing to do with that number. He just didn't want them to put me on a back up rate. He said the tech found out that's what I needed during the study. But then looking at my sleepyhead data to concluded that the based on what he saw that the EPAP Minimum needed to stay at 12 and the PS at no lower than 6.

He has told me a couple times in the past that he is a very busy man and it takes months to get an appointment to see him. He is right, If I didn't need to meet the 90 requirement, I wouldn't have gotten back in for 5-6 months. So since I've met that 90 day requirement I can't get an appointment with him before the sleep study. And then not until I need that 90 day requirement again. He also doesn't like the many MyChart messages he gets and has told me mine are too long anyway. So I feel stuck with figuring this out with enough surety to convey to the sleep tech the need to try to go lower even though the doc is asking to start minimum EPAP of 12. He was also writing the script to the tech to minimize the ability of the back up rate to work for me. Make it more like a standard setting. That's why I have a feeling that we are going to have some work to fine tune my settings after I after I get it. Maybe when all is done, I'll find a new doctor. Or maybe after we fine tune the settings I'll keep him because he doesn't get involved and I can just get this to work without the extra Doctor appointments. 

I decided for the first time in 3 months to not use the machine at all last night, just to see how I felt without all the centrals. I woke up often but slept well. I actually felt like I had some energy to start my day, my legs and muscles were more responsive, no headache, I feel like I can concentrate, my stomach isn't bloated from the air, and I'm able to urinate more. In the past three months while using the machine I was holding a lot more water that usual. Overall the difference of just sleeping on my own was wonderful. It's easy to see why people give up and why I also did two years ago. 

Right now I'm trying to talk myself into using the machine again at all or just wait and let them all get mad at me until I get a machine that will actually work for me. I truly don't function well after using my current machine with the way it is now. I think that's just frustration talking though because I have been trying to focus on reading the success stories for those who have switched to an ASV. I'm holding onto hope that given the right machine and settings that I will also wake up feeling better that without a machine at all. 

If I switched it to auto, can I maintain the PS of 6 and let my current machine help me a bit more or is that not a good idea? I don't want to mess up my insurance approving a new ASV if they think that I can get by on the Bilevel Auto settings from the AirCurve 10 VAuto.

I think I have read Mark Sadler's threat but don't recall all the details so I will read through it again this evening if I don't get the time to this afternoon. Thanks for the input and suggestions. All are welcome.
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#66
RE: [split] Bilevel machine - advice needed
Using Vauto mode, you can try EPAP min 8.0, EPAP max 12.0 and PS 6.0 and your current machine will titrate your EPAP without any problem. You don't need to wait for the ASV titration to do this. This will not resolve central apnea, but will give you a good idea if you need the higher EPAP. I think we have discussed using a lower PS as well, but you indicated that less than 6 PS would not work for you from a comfort standpoint.
Sleeprider
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____________________________________________
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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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#67
RE: [split] Bilevel machine - advice needed
(10-03-2018, 12:22 PM)Sleeprider Wrote: Using Vauto mode, you can try EPAP min 8.0, EPAP max 12.0 and PS 6.0 and your current machine will titrate your EPAP without any problem. You don't need to wait for the ASV titration to do this.  This will not resolve central apnea, but will give you a good idea if you need the higher EPAP.  I think we have discussed using a lower PS as well, but you indicated that less than 6 PS would not work for you from a comfort standpoint.

 I went ahead and changed part of my machine settings. I first changed to Auto then EPAP min 8.0 and PS to 6.0 but I don't see EPAP max. I do see Max IPAP. it's set at 25.0.

So right now my I have the following:

Mode:   VAuto
Max IPAP:  25.0
Min EPAP:    8.0
PS:              6.0
Ti Max.         2.0s
TI Min.         0.3s
Trigger:       Med
Cycle:         Med

Is all this correct?

I do want to try the support on 8.0 before the sleep study and see if it controls the other apneas like my current settings do. Thanks.
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#68
RE: [split] Bilevel machine - advice needed
Everything is correct, but for IPAP max of 12, the maximum pressure needs to be 18-cm (12 EPAP + 6.0 PS =18) With primarily CA events at your current settings, we don't want the machine going to higher than 18/12. The settings you posted could result in pressure as high as 25/19.
Sleeprider
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____________________________________________
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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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#69
RE: [split] Bilevel machine - advice needed
I'm very happy with the results from last night! Although I am still very tired, and I had a hard time falling asleep but my AHI was only 3.99! I can actually breathe well, my chest wall isn't hurting and I can even think more clear today as opposed to my other days with the AHI so high!
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#70
RE: [split] Bilevel machine - advice needed
[attachment=8679]
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