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Central sleep apnea periodic breathing
#21
(07-04-2015, 12:24 PM)tedburnsIII Wrote: If one is seeing treatment-related CA's might it be easier to reduce or eliminate CA's using BPAP than APAP or CPAP?

If you search forum for words central and bilevel I think many threads would come up. Some discuss studies showing bilevel therapy tends to create treatment-induced centrals.

ASV and T and ST and ST-A are bilevel therapy modes which include a Backup (respiration) Rate and are able to treat central events.

Adding supplemental O2 sometimes will reduce centrals. But too much supplemental O2 can be dangerous.


Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
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#22
richb's AHI's totally and obviously unacceptable. This is a problem that is with little doubt remediable. Hope your doctor is board-certified in sleep medicine and can correct this aberration either through use of current machine or something else.

How have you been feeling overall, richb?
(07-04-2015, 02:57 PM)vsheline Wrote:
(07-04-2015, 12:24 PM)tedburnsIII Wrote: If one is seeing treatment-related CA's might it be easier to reduce or eliminate CA's using BPAP than APAP or CPAP?

If you search forum for words central and bilevel I think many threads would come up. Some discuss studies showing bilevel therapy tends to create treatment-induced centrals.

If it occurs in only 15% of patient population, how does it tend to create them? And are they only temporary or have they created a new medical condition? I would speculate the former.

So, what is the alternative? This is a bit confusing, as here the cart may be in front of the horse, but there MUST be a solution.

Assuming arguendo the events are treatment-induced central apneas, what indeed is the solution? I do realize the question is a medical one posed to laymen here but curious as to member's thoughts.

Hopefully we will find out more after richb's appointment with his hopefully board-certified sleep doctor.

Later: You later posted "ASV and T and ST and ST-A are therapy modes are bilevel therapies which include a Backup (respiration) Rate and are able to treat central events."

In any event, is he on a BPAP or APAP, Auto-BPAP? Not familiar with this machine, which he has listed: ResMed AirCurve 10 vauto. What does the 'v' stand for?

Later: Looked it up- it's as you say, a BPAP, and it's auto-adjusting, sorry for distraction. The meaning of 'v', please?

There must've been a REASON they placed him on that machine. I am aware with my very limited knowledge it's for patients who have difficulty tolerating CPAP pressure or their titrated pressure exceeds 15cm.

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#23
(07-04-2015, 03:01 PM)tedburnsIII Wrote: If it occurs in only 15% of patient population, how does it tend to create them?

So, what is the alternative? This is a bit confusing, as here the cart may be in front of the horse, but there MUST be a solution.

Assuming arguendo the events are treatment-induced central apneas, what indeed is the solution? I do realize the question is a medical one posed to laymen here but curious as to member's thoughts.

Yes, if memory serves, the 15% number refers to treatment-induced Complex Sleep Apnea Syndrome.

First, with present bilevel machine, lowering PS to 3 or lower (at least temporarily, while the system adapts to the therapy) may reduce number of CA dramatically.

If that does not work adequately, I would suggest a change to an ASV machine. The PRS1 BiPAP autoSV Advanced is the most general, completely adjustable (and mis-adjustable) ASV machine.

Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
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#24
Yeah, I get the lower of PS in the meantime as a good suggestion.

This is a question, though, for expert opinion, because here, the cart is in front of the horse with the assumption it was the treatment that caused CSAS, which is SHORT-HAND defined, according to this one source, as:

[Image: CSAS_zpsceiedgmr.png]
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#25
(07-04-2015, 03:01 PM)tedburnsIII Wrote: Later: You later posted "ASV and T and ST and ST-A are therapy modes are bilevel therapies which include a Backup (respiration) Rate and are able to treat central events."

In any event, is he on a BPAP or APAP, Auto-BPAP? Not familiar with this machine, which he has listed: ResMed AirCurve 10 vauto. What does the 'v' stand for?

Later: Looked it up- it's as you say, a BPAP, and it's auto-adjusting, sorry for distraction. The meaning of 'v', please?

There must've been a REASON they placed him on that machine. I am aware with my very limited knowledge it's for patients who have difficulty tolerating CPAP pressure or their titrated pressure exceeds 15cm.

Hi Ted,

VAuto is part of a copyrighted model name for the ResMed auto-titrating bilevel machine in the new AirCurve 10 product line. The corresponding model in the previous-generation S9 product series was the S9 VPAP Auto. I think the V in VPAP and in VAuto stands for Variable and just reflects a product naming convention of ResMed for their bilevel CPAP machines, similar to how Philips Respironics uses BiPAP in the product names for their bilevel machines.

Another major use case for bilevel machines is to optimally treat Upper Airway Resistance Syndrome (UARS) which is caused by Flow Limitation (restriction, partial obstruction) during inhalation. The APAP class machines simply raise the pressure (both IPAP and EPAP together) to overcome Flow Limitation, but it may be optimal to raise only the inhalation pressure IPAP, leaving EPAP only as high as it needs to be to prevent obstruction during exhation.

Also, in bilevel machines the pressure boost during IPAP, called Pressure Support (PS), makes it easier to breathe in and breathe out. On my ASV machine, the machine raises PS whenever it detects I am not breathing enough, and by the time PS is as high as 8 or 10 the machine is doing for me all the work of breathing. My point is that standard bilevel therapy (by standard I mean without a backup rate) makes breathing easier and (if it does not lead to central events) can contribute toward allowing sleep to be more restful.

By the way, in this thread I have been using the term Complex Sleep Apnea Syndrome (CompSAS) which I think specifically refers to PAP treatment-emergent (treatment-caused, treatment-induced, treatment-related) central sleep apnea, in contrast to the more general term Central Sleep Apnea Syndrome which I think sometimes may include both CompSAS and CSAS from various causes where the central sleep apnea syndrome is not treatment-related.
Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
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#26
vsheline-

Thank you for post #25 above. It was very informative, as I am trying to understand bilevel machines and also ASV as a distinct sub-class, if I understand correctly.

Basic query: Would it be an accurate or inaccurate characterization that ASV is a form of bi-level machine that better suits those who have Central Sleep Apnea Syndrome as 'defined' above in post #24 ?
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#27
(07-05-2015, 11:22 AM)vsheline Wrote: Hi Ted,

...
...

Also, in bilevel machines the pressure boost during IPAP, called Pressure Support (PS), makes it easier to breathe in and breathe out. On my ASV machine, the machine raises PS whenever it detects I am not breathing enough, and by the time PS is as high as 8 or 10 the machine is doing for me all the work of breathing. My point is that standard bilevel therapy (by standard I mean without a backup rate) makes breathing easier and (if it does not lead to central events) can contribute toward allowing sleep to be more restful.

hhhmmm.

Does PS raise the IPAP incoming pressure?

Does PS reduce the EPAP pressure?

If both are in the affirmative, does this apply to ASV only, or Bi-level without ASV, or applies to both?
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#28
PS applies to auto machines of the bilevel type.and it describes the amount that the IPAP is above EPAP or IPAP=EPAP + PS. To answer your question explicitly, the PS tells the machine how much to raise the pressure above EPAP for IPAP.

If you really would like to find out how the Aircurve or VPAP and ASV machines work, it would be a good start to obtain the clinicians manuals for one or both series of bilevels and for the ASV machine as well and read them.

Best Regards,

PaytonA
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#29
(07-05-2015, 12:53 PM)tedburnsIII Wrote: Basic query: Would it be an accurate or inaccurate characterization that ASV is a form of bi-level machine that better suits those who have Central Sleep Apnea Syndrome as 'defined' above in post #24 ?

Yes, ASV is a form, not the only form of machine, for treating centrals.

The simple definition in post 24 may be used by some, but to me it's focus seems to be less toward defining central sleep apnea syndrome than toward rules for arbitrarily granting or denying insurance coverage for treatment of central events (covering or not covering a bilevel machine having backup rate capability).


(07-05-2015, 01:22 PM)tedburnsIII Wrote: Does PS raise the IPAP incoming pressure?
Does PS reduce the EPAP pressure?

If both are in the affirmative, does this apply to ASV only, or Bi-level without ASV, or applies to both?

All bilevel therapy modes have a setting for the exhale pressure EPAP, and some (such as basic S mode) also have a setting for the inhale pressure IPAP, but self-adjusting modes (VAuto, BiPAP Auto, ASV, ST-A, etc) have a setting for Pressure Support (PS) instead of an explicit setting for IPAP.

PS is always defined as the pressure boost during inhalation:
IPAP = EPAP + PS

Expiration (Exhalation) Pressure Relief (EPR) refers to a reduction in pressure during exhalation.

For the non-bilevel ResMed models, EPR is a fairly straightforward reduction in pressure by 1, 2 or 3 cmH2O during exhalation.
EPAP = IPAP - EPR

Turning on or increasing EPR will increase the likelihood of obstructive events unless the Pressure (IPAP) is also increased equally in order to maintain unchanged the pressure at the end of exhalation (unless using an auto-adjusting mode, in which case the machine will automatically increase the pressure as needed). The end of exhalation / beginning of inhalation is the most vulnerable time for airway collapse to occur. During bilevel titrations done in overnight sleep labs, effectively it is the exhalation pressure EPAP which is increased until apneas and hypopneas are prevented, after which the inhalation pressure IPAP is further increased to eliminate Flow Limitation.

ResMed EPR is not offered in ResMed bilevel modes because it would be redundant, because EPAP and IPAP are already independently controllable in bilevel modes.

For the PRS1 models:

C-Flex is used in fixed-pressure CPAP mode and offers Flow-based pressure relief while actively exhaling. "Flow" refers to the rate of air entering or exiting the lungs. As the speed of exhalation slows down toward the end of exhalation, the Flow is reducing and the amount of pressure relief is reducing along with it, so there is little to no pressure relief as we are trying to finish exhaling. During the natural pause between actively exhaling and actively inhaling there is no Flow and therefore no pressure relief, and the pressure has returned to the set pressure (IPAP). There is method in this madness - this premature or preemptive return to full IPAP pressure is intended to avoid airway collapse from starting and setting in. A setting of 3 produces the most reduction in pressure.

C-Flex Plus is also used in fixed-pressure mode and includes both C-Flex (Flow-based pressure relief) plus an additional 2 cmH2O pressure relief starting when actively exhaling and ending at start of actively inhaling.

A-Flex is used in APAP mode and is similar to C-Flex Plus. In addition to pressure relief during exhalation, settings of 1, 2 or 3 also affect how soon the pressure starts decreasing toward the end of inhalation, as the Flow is slowing down. A setting of 3 causes the reduction in pressure to start too early, as soon as the rate of inhaling slows down a little, well before we are finished inhaling.

Bi-Flex is used in bilevel modes and is similar to A-Flex except the 2 cmH2O of additional pressure relief is not added because EPAP and IPAP are already independently controllable in bilevel modes.

For all versions of Flex, settings of 1 or 2 or 3 affect only the Flow-based portion of pressure relief.

Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
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#30
Thank you, PaytonA. I am just trying to understand what pressure support really means. Bilevel or ASV or similar machines are not applicable to my condition, though may be to someone I know who says she was told she had CSAS, but she was given straight CPAP under Medicaid.

In any event, I understand EPR, called Reslex (applicable to my APAP machine).

And I understand that EPAP + PS= IPAP, correct?

But does pressure support affect exhale pressure or also inhale pressure? One sets an IPAP and an EPAP, correct? The difference is the PS, am I right?

But does the PS increase the inhale pressure because I had another exchange with vsheline or someone else about it and did not quite understand. I want to understand it first with non-variable pressure support in contrast to Auto bilevel for the time being.
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