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Dr wants another study
#1
Dr wants another study
Hi,  New to the group and all of this sleep stuff.  I have been on therapy since late March of this year, 2019. I Started with the Resmed Air Curve 10 cpap and was switched after about a month to the Vauto.  Is that a Bi pap?  Anyway, I downloaded the Oscar software thing and I am seeing that I have increasing higher CA's in the past weeks.  What causes them to be at a 40 one night and a 15 the next?? The doc wants me to do a new study and spoke of a Bipap ST . Is is customary to do this so soon??  I thought I was on a Bi Pap for this reason and I dont understand what the ST means. I didnt think to ask at the time as I was shocked he wanted a new study. I took a screen shot of the chart showing increasing purple CA's. I can't figure out how the numbers change so drastically.   Is a Bipap ST different than the machine I have and if so, will it correct the CA's.  I dont want to invest in another machine that is not correct for my situation. I also do not have the confidence or the know how to adjust things the way so many of you do.  Is the new study a good idea or just a money pit. Sorry for all of the sporadic questions, im just so confused.



   
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#2
RE: Dr wants another study
Others will respond with more knowledgeable info.

But my guess is maybe the dr is seeing your current machine isn't doing the best job, so they want to trial you with a different type of machine. That's just my guess.
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#3
RE: Dr wants another study
Hi ShariMarie. Welcome to Apnea Board.

Thank you for posting your overview graph - I think it tells an interesting story. To fill in some of the details, could I ask you to post two daily charts as well - one from May 6 or 7, and one from July 20.  These need to be formatted in according to the instructions you will find here: http://www.apneaboard.com/wiki/index.php...ganization

You may be aware that central apneas are quite different from the more usual obstructive type. Basically the brain doesn't send the "breathe now" signal to the diaphragm and you just quietly stop breathing for a while. Ordinary CPAP and Autoset machines can't treat central apnea effectively and your VAuto is likewise not suitable. Sometimes people have central apnea for no apparent reason, sometimes it's provoked by medications or illness, and sometimes it comes on as a result of PAP therapy. The additional pressure changes the balance of oxygen and CO2 in your blood, and your brain thinks everything's OK and doesn't tell you to breathe.

So a couple of questions:

1. Did you have central apnea before you started the therapy? This would show up on your initial sleep study. You need to look at the detailed numbers, not the written summary (which sometimes gets it wrong). It would help us if you could post a copy of your study - make sure you delete any private information you don't want to share with the world.

2. Have you started taking any new medications (especially pain relief, sedatives,  antidepressants or epilepsy medication)?

3. Have you had any illness or trauma recently?

4. Did the doctor explain why you're on a VAuto machine? It is (as you say) a bilevel but not normally prescribed as a first machine.

Edited to add:

The ST machine is a more sophisticated form of bilevel. Bilevel just means the inhale and exhale pressures can be set wider apart such as inhale at 6 and exhale at 12 (for example). BiPAP is a trademark of Philips Respironics, so we tend to use bilevel for preference....

...anyhow, the ST stands for "spontaneous / timed" and means that the machine can support your own breathing (spontaneous) but if you stop breathing the machine will kick in with a timed breath to get you going again. These machines tend to be very expensive. They can sometimes work for central apnea but not always. From my point of view (and I hasten to add I'm not a medical person, just somebody with central apnea) a better alternative is the adaptive servo-ventilator or ASV machine. These really are wonderful and the great majority of members who've tried them report exceptional results. Some doctors are wary of ASV due to a study done some years ago which indicated they could make things worse for patients with severe congestive heart failure. But if your ticker's OK then ASV is definitely the way to go to treat stubborn central apnea.

You probably need to go through another sleep test to demonstrate the need for the more expensive machine for insurance purposes. However talk to your doctor and ensure that the test also includes ASV titration.
DeepBreathing
Apnea Board Moderator
www.ApneaBoard.com


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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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#4
RE: Dr wants another study
Thank you so much for your reply. It gives me a bit more hope that this will be worked out. You are very knowledgeable, wow.  I don't know if I have a copy of my first study but I will definitely get one in the beginning of next week after I do the new study. I think I had both Central and obstructive apnea's when first diagnosed but will read up on how to post the info you asked for. Also, thank you for the heads up on what machine(s) the study needs to be testing me on next week. No new meds, nothing really different but my numbers just seem to be all over the map. With that said,  next week on the first, I am having major surgery so I will be on pain meds etc for a bit following that.  Is is a big deal to have surgery with central apneas happing so much?  Do my numbers appear to be considered mild, moderate or severe??I will be sure to tell the anesthesiologist for sure. Kinda freaked now just a little about anesthesia. I have an appointment, but will try to post those charts later today. Thank you again!
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#5
RE: Dr wants another study
Shari, the problem is the ST is the wrong machine for you. The correct device for treating complex apnea (mixed obstructive and central events) is the ASV (adaptive servo ventilator). Here's why. The ST is intended to treat people with respiratory insufficiency arising from disease, neuro muscular conditions or obesity related hypoventilation. The ST provides the same pressure support (PS is inhale pressure IPAP minus exhale pressure EPAP), for every breath. When you don't breathe spontaneously, it switches to IPAP on a timed basis to maintain your breathing rate.

The ASV is "adaptive". It provides a range of pressure support that is designed to maintain your respiratory rate and volume using the amount of pressure support you need when you need it. It is specifically designed for central and complex apnea, and is far more comfortable than ST. You should ask your doctor why he is considering ST rather than ASV. The ST and ASV are both bilevel machines with breathing rate backup, but are intended for different types of patients and conditions. Unless I'm missing something, you should be evaluated for ASV, not ST.

What we can tell from your summary chart is that your AHI increased as you moved from fixed CPAP to BiPAP, and then got worse as pressure support was increased (that is the height of the red bar above the green bar). It appears you are currently using 15.0 IPAP/8.0 EPAP (PS 7.0). This is actually making your central apnea worse. The study your doctor is proposing is a titration evaluation, and may look at CPAP, bilevel and bilevel with a backup rate (ASV or ST). From what I see in your summary chart, you may actually tolerate CPAP. I'm a bit perplexed why your doctor has moved in this direction, however, you appear to have treatment onset central apnea that is aggravated by pressure support. The solution is to go back to CPAP at a pressure that does not induce centrals, or to move to ASV. The suggestion to use ST is not consistent with the manufacturer's intention for the use of these machines.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

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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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#6
RE: Dr wants another study
Welcome and congrats.

Congrats because you have a sleep doctor that seems to understand.  
3 months is the point that doctors rule out treatment emergent Central Apnea because it typically dissipates by then.  You are also at a point that normally takes a year plus of difficult effort to get to.
The road to ASV
1. Fail CPAP (done)
2. Fail BiLevel without backup (VAuto) (done)
3. Fail BiLevel with backup (ST) the titration study
4. Success with ASV

This it is fairly important that you get both ST and ASV included in your study.

Especially with Central Apnea, but with any Sleep Apnea keep a folder with all your Full Sleep Studies and Prescriptions.  This frequently is needed if you move, change doctors for any reason, or even choose to go outside the medical system in the future.

The fact that your diagnostic study shows Central apnea pretreatment will always be important.

Central Apnea usually presents with a consistent property and that is that it is all over the place.  We call it Consistently inconsistent.

Do you have any non-apnea breathing issues? This could impact the choice of machine for you.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

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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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#7
RE: Dr wants another study
I just talked to the nurse at the study center. I am scheduled to have the new study on Monday night starting with the ST Machine with orders to progress to ASV if central are not resolved so I guess that's good. I lthink its possible Insurance requires that the ST is tried and failed before approving ASV? Does that sound like a reasonable explanation as to why the ST is even involved at this point? ? All I know is that my Centrals are very up and down and what if I do well on ST the night of the study, (a good night) but continue have problems two nights later? That's what I'm worried about now. I
I am at my doctors office now getting allergy testing so I'll get a copy of the sleep reports from May and March I think it is. Thanks so much you guys, I'll be posting them later today. You have already been such a great help in helping me understand a bit better.
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#8
RE: Dr wants another study
CPAP choice to treat OSA, CA, obstructive or pulmonary restriction[edit]
The Auto CPAP such as the AirSense 10 AutoSet is typically the initial machine of choice for treatment of obstructive apnea and hypopnea
Just to clarify The VAUTO, ASV, S, and the ST are all BiLevel machines for treating three different conditions, they are NOT interchangeable. They are not a choice between them to treat a single condition.
They should be chosen to treat the specific condition that the user has, Here are the various CPAP machines and what they are designed/intended to treat
This info is from the ResMed Sleep Lab Titration Guide

  • CPAP (continuous positive airway pressure) Fixed pressure delivered with optional expiratory pressure relief (EPR). It Treats OSA

  • AutoSet/APAP (automatic positive airway pressure) Automatically adjusts pressure in response to flow limitation, snore and obstructive apneas. It treats OSA

  • AutoSet for Her/APAP Automatically adjusts pressure in response to flow limitation, snore and obstructive apneas along with an increased sensitivity to each flow-limited breath, providing a more comfortable therapy for women. Increases sensitivity to each flow-limited breath, providing a more comfortable therapy for women (OK for men too). It Treats OSA

  • VAuto Automatically adjusts pressure in response to flow limitation, snore and obstructive apneas; Pressure Support (PS) is fixed throughout the night and can be set by the clinician. It Treats OSA, non-compliant OSA

  • S (Spontaneous) Senses when the patient is inhaling and exhaling, and supplies appropriate pressures accordingly. Both treatment pressures are preset: inspiration (IPAP) and expiration (EPAP). It treats Non-compliant OSA and COPD

  • ST (Spontaneous/Timed) Augments any breaths initiated by the patient, but also supplies additional breaths if the breath rate falls below the clinician’s set “backup” respiratory rate. It Treats COPD, Neuromuscular disease (NMD), Obesity Hypoventilation Syndrome (OHS) and other respiratory conditions

  • T (Timed) Supplies a clinician-set respiratory rate and inspiratory/expiratory time, regardless of patient effort. It Treats COPD, Neuromuscular disease (NMD), Obesity Hypoventilation Syndrome (OHS) and other respiratory conditions

  • iVAPS (intelligent Volume-Assured Pressure Support) Maintains a preset target alveolar minute ventilation by monitoring delivered ventilation, adjusting the pressure support and automatically providing an intelligent backup breath. It Treats COPD, Neuromuscular disease (NMD), Obesity Hypoventilation Syndrome (OHS) and other respiratory conditions

  • ASV (adaptive servo-ventilation) Targets the patient’s minute ventilation, continually learning the patient’s breathing pattern and instantly responding to any changes. It treats Central or mixed apneas, complex sleep apnea, Periodic Breathing (PB)

  • ASVAuto Provides an ASV algorithm plus expiratory positive airway pressure (EPAP) that automatically responds on the patient’s next breath to flow limitation, snore and obstructive sleep apneas. It Treats Central or mixed apneas, complex sleep apnea, Periodic Breathing (PB)

  • PAC (Pressure Assist Control, also known as Pressure Control) The inspiration time is preset in the PAC mode; there is no spontaneous/flow cycling. Inspiration can be triggered by the patient when respiratory rate is above a preset value, or delivered at a set time at the backup rate. It Treats Neuromuscular disease (NMD), pediatric patients

These represent Modes 

I would ask to get results from both on your Titration night.
As Sleeprider pointed out, an ST always provides higher pressure than an ASV will, therefore you have a less flexible machine, and a machine that has a higher likelihood of having user issues (higher pressure increases aerophagia and mask leaks, and patient discomfort.)

An ST is certainly capable of treating Central Apnea, and before ASV was the ONLY option, but above you see that the ST is NOT intended, per the manufacturer, to treat Centrals.

And I saw that CPAP working with apparent success and also wondered why VAuto.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Soft Cervical Collar
Mask Primer
Dealing with a DME
Organize Charts
Attaching Charts

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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#9
RE: Dr wants another study
        Here are the two charts you asked to see Deep Breathing. One from May 7th and from June 20th.  I will try to get my study report photographed and posted but I'm not sure if you want every page??? Thank you ShariMarie

Wow Thank you. That is a lot of information. My head is spinning. I am not sure but I think I had half osa and half centrals in my first study, again, I dont know how to read it exactly. I will try to get the report and post. Thank you again, a very informative post.
ShariMarie
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#10
RE: Dr wants another study
I’m on my phone but want to discuss the inconsistent nature of your CA events and the difficulty getting a representative sleep test. As you can see, on any particular night you might have very few events, or many. It is the nature of central Apnea to be consistently inconsistent. The success of a test is not solely dependent on the right pressures or technology, but also whether you are having events or not. It is very unpredictable.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files

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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