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[CPAP] UARS, data interpretation OSCAR, what to do?
#51
RE: UARS, data interpretation OSCAR, what to do?
While the ASV can treat most Apnea events, its scope of treatment focus is Central Apnea. So what Ratchick says is correct. Different PAP machines target different ailments. When my own ASV treatment was working on Apnea, it did very well. Add in my COPD/Asthma and it's not as good.

The goal for you is to be certain you have the right tool to act on your symptoms and events. ASV isn't the best choice. A BPAP without backup rate is better, such as the VAuto or an APAP like the AutoSet.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
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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#52
RE: UARS, data interpretation OSCAR, what to do?
OK, I've had a quick look and from what I can see so far, the answer is "because he believes his own research".

So it seems like much of the info talks about his paper on treating people struggling with insomnia with OSA and that ASV was better at treating things compared to CPAP. As far as I can see, he hasn't researched BiPAP (but I've only spent a few minutes looking). The issue is that for some people, treating OSA with CPAP/APAP can cause iatrogenic Central Sleep Apnea to occur - i.e. because of the very treatment that is needed to control OSA can cause Central Apneas. While it's pretty normal to see a few of these at the start of therapy, for many it would no doubt mean they struggled to get good relief if the CSA persists, plus, of course, a lot of people are palmed off with not very effective CPAPs and no real decent titration (especially after initial titration studies).  So yes - using an ASV may well manage OSA with treatment-emergent CAs that persist better than CPAP, and these titrations were done under carefully managed conditions - not in real-world usage. 

The problem is that UARS isn't OSA/CSA. And AFAIK has relatively little research done on it. Plus, one person's paper is never enough to upend ALL previous research. To change the consensus, you have to present a well-designed paper, with a rigorous protocol, and then that research needs to be repeated by others, the results replicated etc. Even in the paper itself, it says that it needs further research to see if using ASV rather than CPAP overall is the most effective way to treat people. 

Honestly, I've not read through all of his research so feel free to take my post with a pinch of salt, but in just a couple of minutes my conclusion is that these machines are designed to work in very different ways, UARS is not well understood as a whole, and the research is pretty new. He believes in it and for many people, it's probably way overkill. But for some, it will definitely help a LOT. However, if you, personally, are trialling ASV and despite that, and low AHIs, it's not controlling your symptoms, then I would give the BiPAP a trial.


See my comparison of Viatom/Wellue and CMS50F oximeters here.

Not a doctor, definitely not your doctor, all advice is given as-is and represents simply my own understanding as a fellow patient and OSCAR user.
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#53
RE: UARS, data interpretation OSCAR, what to do?
KKBB, I know you are tired, but you keep making assertions without supporting them in any way. You have posted relatively little that substantiates a significant UARS or RERA problem. The only history we have is the chart back at page 2 with EPAP 4.0, PS 6.0-11.0 in ASV mode. We can't really interpret arousal or flow limitation with the charts provided so far. Your therapy is effective, but lacks the insight of progression from more conventional therapy approaches with BPAP that are effective for most people. ASV may be fine, but without being able to try the more customary BPAP, it is very difficult to coach you. You are currently using a minimum PS of 6.0. What were your results with 4.0? I don't know, and you haven't offered that insight. My point is, you seem to think we should know what is going to work best to solve your problems with sleep, and we know nearly nothing about your response to any solution but the one you have presented, and you seem not to like when we ask you to post additional charts or details. That is the source of my frustration in coaching you on ASV, along with the fact you had spread your therapy across 3 different threads with incomplete information.

Dr. Krakow's ideas have had a very strong influence on my opinions pertaining to flow limitations, and it was his article in our wiki that first caused me to be a strong advocate of bilevel therapy to treat it, and to learn how to use pressure support to minimize RERA http://www.apneaboard.com/wiki/index.php..._and_BiPAP His use of ASV came later and is not widely adopted by sleep clinicians. That's not saying much, as I think ASV should be considered as a therapy alternative in individuals unable to obtain relief with CPAP or BPAP. I think if you had experience with CPAP or conventional BPAP, that would be helpful in better defining your condition. What you have posted so far, shows 0.00 flow limitation as the 95th percentile statistic, and the few closeup charts in this thread show no flow limitation but a lot of variable respiration typical of being awake. http://www.apneaboard.com/forums/attachm...nail=32250

Here is an interview in Sleep Review with Dr Krakow that I thin fairly show his views, and that his normal progression includes full diagnostics and evaluation, CPAP, BPAP before ever trying ASV:
Quote:SR: With regard to treatment, you’ve had success using ASV (adapt-servo ventilation) versus standard PAP devices with insomnia patients. Why do you prescribe more advanced devices?

Krakow: Yes, I’ve had great success, personally, using ASV for nearly 4 years. It eliminates 95% of awakenings at night, which are noticeably fewer disruptions than what I experienced with other PAP devices. In general, insomnia patients do better with advanced devices. The driving influence is the anxiety factor so common to insomnia patients. During expiration, the discomfort from standard pressurized airflow seems to trigger an anxiety response that the insomnia patient cannot overcome; whereas with the use of auto-bilevel devices, including ASV, the patient’s comfort level is noticeably higher.

In these cases, the subjective and objective finding is expiratory pressure intolerance (EPI). Conventional wisdom alleges EPI dissipates with time. We dispute this point. We have seen nearly a thousand, second-opinion patients who were using CPAP or APAP for several years. But, when we looked at the expiratory limb of their airflow signal during the initial titration protocol at our sleep center, we found they were still fighting with the machine. You can also spot this problem during the desensitization period before the sleep study formally begins.

SR: How do you get insurance to pay for ASV?

Krakow: You can’t start with ASV for the majority of patients. In our setting, the patient can objectively and subjectively fail CPAP or BPAP at either the desensitization period or the early phases of the titration. Also, we can quickly spot that the device is not eliminating RERAs; instead the device is producing expiratory pressure intolerance. Other objective markers of an inadequate titration that show up include: failure to generate REM sleep, excess sleep stage transitions, and other signs of sleep fragmentation. After these adverse findings are observed, the sleep tech switches the patient to the advanced technology for the rest of the night. The sleep tech then must constantly override the auto mode, because only through a manual titration combined with the device set for auto mode do we gain the best chance to treat RERAs. With this method, there’s a potential for normalizing the air flow curve, rounding both the inspiratory and expiratory limbs.

About half to three-quarters of patients do well on standard auto-bilevel devices initially, but some patients have residual central apneas. When outcomes are not improving, patients typically are covered by insurance to return for another titration, which we think of as a “treatment procedure.” During this procedure, we see the residual central apneas, after which the patient can be titrated on ASV, assuming they qualify by insurance standards for this switch. Moreover, it is essential to recognize that when a patient uses one device and experiences no benefit, it is within the physician’s prerogative to talk to the insurance company about trying another device for that individual patient.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


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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#54
RE: UARS, data interpretation OSCAR, what to do?
(05-19-2021, 11:28 AM)Sleeprider Wrote: KKBB, I know you are tired, but you keep making assertions without supporting them in any way. You have posted relatively little that substantiates a significant UARS or RERA problem. The only history we have is the chart back at page 2 with EPAP  4.0, PS 6.0-11.0 in ASV mode. We can't really interpret arousal or flow limitation with the charts provided so far.  Your therapy is effective, but lacks the insight of progression from more conventional therapy approaches with BPAP that are effective for most people. ASV may be fine, but without being able to try the more customary BPAP, it is very difficult to coach you.  You are currently using a minimum PS of 6.0. What were your results with 4.0?  I don't know, and you haven't offered that insight. My point is, you seem to think we should know what is going to work best to solve your problems with sleep, and we know nearly nothing about your response to any solution but the one you have presented, and  you seem not to like when we ask you to post additional charts or details.  That is the source of my frustration in coaching you on ASV, along with the fact you had spread your therapy across 3 different threads with incomplete information.

Dr. Krakow's ideas have had a very strong influence on my opinions pertaining to flow limitations, and it was his article in our wiki that first caused me to be a strong advocate of bilevel therapy to treat it, and to learn how to use pressure support to minimize RERA http://www.apneaboard.com/wiki/index.php..._and_BiPAP   His use of ASV came later and is not widely adopted by sleep clinicians. That's not saying much, as I think ASV should be considered as a therapy alternative in individuals unable to obtain relief with CPAP or BPAP.  I think if you had experience with CPAP or conventional BPAP, that would be helpful in better defining your condition. What you have posted so far, shows 0.00 flow limitation as the 95th percentile statistic, and the few closeup charts in this thread show no flow limitation but a lot of variable respiration typical of being awake. http://www.apneaboard.com/forums/attachm...nail=32250

Here is an interview in Sleep Review with Dr Krakow that I thin fairly show his views, and that his normal progression includes full diagnostics and evaluation, CPAP, BPAP before ever trying ASV:
Quote:SR: With regard to treatment, you’ve had success using ASV (adapt-servo ventilation) versus standard PAP devices with insomnia patients. Why do you prescribe more advanced devices?

Krakow: Yes, I’ve had great success, personally, using ASV for nearly 4 years. It eliminates 95% of awakenings at night, which are noticeably fewer disruptions than what I experienced with other PAP devices. In general, insomnia patients do better with advanced devices. The driving influence is the anxiety factor so common to insomnia patients. During expiration, the discomfort from standard pressurized airflow seems to trigger an anxiety response that the insomnia patient cannot overcome; whereas with the use of auto-bilevel devices, including ASV, the patient’s comfort level is noticeably higher.

In these cases, the subjective and objective finding is expiratory pressure intolerance (EPI). Conventional wisdom alleges EPI dissipates with time. We dispute this point. We have seen nearly a thousand, second-opinion patients who were using CPAP or APAP for several years. But, when we looked at the expiratory limb of their airflow signal during the initial titration protocol at our sleep center, we found they were still fighting with the machine. You can also spot this problem during the desensitization period before the sleep study formally begins.

SR: How do you get insurance to pay for ASV?

Krakow: You can’t start with ASV for the majority of patients. In our setting, the patient can objectively and subjectively fail CPAP or BPAP at either the desensitization period or the early phases of the titration. Also, we can quickly spot that the device is not eliminating RERAs; instead the device is producing expiratory pressure intolerance. Other objective markers of an inadequate titration that show up include: failure to generate REM sleep, excess sleep stage transitions, and other signs of sleep fragmentation. After these adverse findings are observed, the sleep tech switches the patient to the advanced technology for the rest of the night. The sleep tech then must constantly override the auto mode, because only through a manual titration combined with the device set for auto mode do we gain the best chance to treat RERAs. With this method, there’s a potential for normalizing the air flow curve, rounding both the inspiratory and expiratory limbs.

About half to three-quarters of patients do well on standard auto-bilevel devices initially, but some patients have residual central apneas. When outcomes are not improving, patients typically are covered by insurance to return for another titration, which we think of as a “treatment procedure.” During this procedure, we see the residual central apneas, after which the patient can be titrated on ASV, assuming they qualify by insurance standards for this switch. Moreover, it is essential to recognize that when a patient uses one device and experiences no benefit, it is within the physician’s prerogative to talk to the insurance company about trying another device for that individual patient.

Sorry it's just tedious to upload all the data, and I'm confused what data I need to upload. its easier in a discord if this site has one. 

idk if im getting RERAs using the machine, all i know is i wake up feeling like trash (i feel like tbh worse than without it). the thing is such a hassle to use too like i ripped off my mouth tape and the machine last night and actually felt GOOD in bed for once, i feel like a prisoner with tape + pap + earplugs lmao. cant get the mouth+nose mask to fit properly, i suspect cause of my beard, which i need to hide the very fact im a mouth breather in the first place lmao.....

anyway to anwer your Qs yes I tried CPAP. I hated it. i thought i was suffocating when i first put it on, i was like wtf is this. i haven't tried PS 4.0, i started at 6.0 I believe. the lady put the settings at random i think. shes not familiar with anything other than cpap.

i guess i just want some sort of protocol or understanding of how to approach it. i hate using this machine, it's a nightmare. I will definitely get MSE and DJS and whatever other myriad of surgeries to solve this problem, plus whatever surgeries come to fruition in the next decades too. i will eviscerate my uars
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#55
RE: UARS, data interpretation OSCAR, what to do?
The thing about surgeries that's repeated many times here that we've seen, one goes for surgical procedure then still end up on PAP later.

Have you shown a recent OSCAR chart for us to assist in setting edits? As is I've still got the impression you're not on the correct PAP machine. You should be just fine on VAuto. I've not yet seen any indicator of need for ASV. As has been mentioned, ASV targets different parameters to operate than regular CPAP and BPAP.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
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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#56
RE: UARS, data interpretation OSCAR, what to do?
(05-20-2021, 11:30 AM)SarcasticDave94 Wrote: The thing about surgeries that's repeated many times here that we've seen, one goes for surgical procedure then still end up on PAP later.

Have you shown a recent OSCAR chart for us to assist in setting edits? As is I've still got the impression you're not on the correct PAP machine. You should be just fine on VAuto. I've not yet seen any indicator of need for ASV. As has been mentioned, ASV targets different parameters to operate than regular CPAP and BPAP.

Yeah i get u. i just dont want to go through the hassle of getting another machine. id like some indication that ASV is doing SOMETHING. if barry krakow thinks it works why cant it work for me.


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#57
RE: UARS, data interpretation OSCAR, what to do?
If you don't find it worth helping yourself so be it. ASV isn't correct for you despite your belief that since Barry Krakow says it's needed. It operates different than other PAP machines by targeting other parameters.

PS the OSCAR is missing the left panel. There's little context without it.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
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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#58
RE: UARS, data interpretation OSCAR, what to do?
With ASV the EPAP holds the airway patent against obstructive apnea during exhale. You have not had OA events at 4.0, but I’m going to start you at 5.0. PS min is the setting to treat flow limits and RERA. A good starting point is 4.0 for most people. We will increase if needed, but we need this starting point for reference in comfort and efficacy. PS max is the adaptive part of ASV. You don’t seem to need more than 5.0 above PS min, so we will make that 9.0. My recommendation to attempt titration is starting at EPAP min 5.0, PS 4.0-9.0 and use this as a reference point. Keep notes on how you feel and what bothers you at this pressure. We make adjustments from this starting point.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


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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#59
RE: UARS, data interpretation OSCAR, what to do?
(05-19-2021, 10:45 AM)Ratchick Wrote: OK, I've had a quick look and from what I can see so far, the answer is "because he believes his own research".

So it seems like much of the info talks about his paper on treating people struggling with insomnia with OSA and that ASV was better at treating things compared to CPAP. As far as I can see, he hasn't researched BiPAP (but I've only spent a few minutes looking). The issue is that for some people, treating OSA with CPAP/APAP can cause iatrogenic Central Sleep Apnea to occur - i.e. because of the very treatment that is needed to control OSA can cause Central Apneas. While it's pretty normal to see a few of these at the start of therapy, for many it would no doubt mean they struggled to get good relief if the CSA persists, plus, of course, a lot of people are palmed off with not very effective CPAPs and no real decent titration (especially after initial titration studies).  So yes - using an ASV may well manage OSA with treatment-emergent CAs that persist better than CPAP, and these titrations were done under carefully managed conditions - not in real-world usage. 

The problem is that UARS isn't OSA/CSA. And AFAIK has relatively little research done on it. Plus, one person's paper is never enough to upend ALL previous research. To change the consensus, you have to present a well-designed paper, with a rigorous protocol, and then that research needs to be repeated by others, the results replicated etc. Even in the paper itself, it says that it needs further research to see if using ASV rather than CPAP overall is the most effective way to treat people. 

Honestly, I've not read through all of his research so feel free to take my post with a pinch of salt, but in just a couple of minutes my conclusion is that these machines are designed to work in very different ways, UARS is not well understood as a whole, and the research is pretty new. He believes in it and for many people, it's probably way overkill. But for some, it will definitely help a LOT. However, if you, personally, are trialling ASV and despite that, and low AHIs, it's not controlling your symptoms, then I would give the BiPAP a trial.

thanks this was a nice summary! and yes i might give it a trial.
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#60
RE: UARS, data interpretation OSCAR, what to do?
Can anyone comment on how to assess if PAP therapy is working for me beyond just how I feel in the morning.
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