[Equipment] BiPAP AVAPS vs. ST

[KuriApollo]

Yeah, thanks, sleeprider. I was just looking back at a random sampling of nights on AVAPS and, while my tidal volume didn't dip as low as on S/T, it still fluctuated a presumably unhealthy or at least non-ideal amount. I will discuss with my doctor and see if it's possible to change Rx to new machine, although I'm sure it'll be a circus to get insurer to agree to cover it outside of the normal eligibility window. Still, if it's an investment that we can afford, seems like a good time to make that change.

I am unhappy with myself that it took this long for me to learn that my therapy on AVAPS could be improved. I am SO grateful to you all for your help and, as the ethos of apneaboard maintains, we really are our best advocates. I've had to learn that in every other aspect of my healthcare but was so exhausted and anxious with the additional diagnosis of apnea that I yielded completely to my provider. I think she's good, but she's not apneaboard good. 

Will be making a donation and spreading the gospel.

Yours truly,
KA

[sawinglogz]

sawinglogz: Thank you for that interpretation and for confirming correct data import. I am attaching respiratory rate graph from same night.

I don't know what mask resist means but will look into it and if needed request that DME change it since it's locked.

sleeprider: Thank you. I feel even more tired on this therapy (I didn't think it was possible to feel more tired on top of my chronic disease baseline and first trimester pregnancy exhaustion). I generally fall asleep quickly and easily and typically stay asleep, but when I do wake up I feel like the S/T is suffocating me by not adapting to my breaths the way AVAPS does. In that event, I have re-initiated ramp (20 min probably not necessary, I should halve that) and fallen back asleep. So, no, when I am conscious, I do not feel that the S/T breath rate syncs well with my needs. And it clearly does not maintain my tidal volume very well, which maybe accounts for the breathlessness feeling if/when I awake. I assume my inability to maintain tidal volume on my own is due to the respiratory muscle weakness demonstrated in repeated spirometry studies, which have impressed pediatric and adult pulmonologists alike since first studied in my adolescence. 

Data in OSCAR says it's in S/T mode, but when I check the machine itself I do not see mode listed under provider settings at all, so I can't confirm. If it is in fact on S/T mode, I thought spontaneous breaths would be accommodated. Yet, I am not sure how S mode differs from auto-titration, which I am pretty sure S/T models do not do.

To be sure, my sample size is low for how it feels to be on the S/T therapy, I usually sleep through it the same as on AVAPS.

Someone else will probably correct me, but I *think* mask resist configures the machine to boost pressure (or maybe curve?) slightly to account for varying characteristics of whatever mask you're using. Given that it was off on your AVAPS it should probably be off on your S/T.

Also, your ramp on AVAPS started at 8 cmH2O, but your S/T is set to 4 for some reason.

Interestingly, you were on S/T - AVAPS on your AVAPS machine rather than PC -AVAPS. Here's the official difference, but I don't know why one should choose one vs. the other:

S/T: "each breath is patient-triggered and patient- cycled or machine-triggered and machine-cycled. S/T mode is similar to S mode, except that the device also will enforce a set minimum breath rate by, if necessary,"

PC: "similar to S/T mode, except that all breaths are machine-cycled. This is a pressure-limited, machine or patient-triggered, time-cycled mode. The cycle time is determined by the Inspiratory Time setting."

The difference between these modes without AVAPS vs. with is that AVAPS adjusts your IPAP within a range, presumably to match your target tidal volume. On your S/T without AVAPS, they've set it to the maximum IPAP you were using with AVAPS.

What I find striking about your data is the difference in respiratory rate, minute vent, and % patient-triggered breaths on AVAPS vs. S/T.

AVAPS: RR averages 12-13 bpm, steady MV, PTB averages 71%
S/T: RR regularly bottoms out at 10, wildly fluctuating MV, PTB averages 45%

I don't know why you'd see such a difference, but I'm not an expert on AVAPS.

[sawinglogz]

Please get the Resmed Aircurve 10 ST-A with iVAPS.  Why would you not get a therapy with smart breath rate and intelligent alveolar minute vent support?  You should have the best therapy on the market.  Just because your medical team has no clue is not an excuse.  Ask for it!

What's the difference between iVAPS and AVAPS? Or is the main benefit of the Resmed that it allows for adaptive backup breath rate?

What do you think about the AE models that also allow for auto-EPAP?

[Sleeprider]

Sawinglogz, have you ever simply compared the clinician manuals between the the Resmed and Philips machines? The details of how to setup iBR and determining the alveoplar minute vent are worth reading in the Resmed, and all Philips has in its manual is a simple settings and pressure discussion. There is no suggestion that Philips has advanced the technology patented by Respironics 20 years ago. Every machine we see with automatic algorithms performs better in Resmed, and in the case of iVAPS, the documentation shows a clearly superior technology and design process that addresses the needs of individuals that require this advanced solution. There is simply no comparison. Please request the clinical manual from Apnea Board and judge for yourself. Consider the results we frequently see across the board from Auto CPAP, BiPAP, Auto BiPAP, BiPAP SV etc. Resmed wins the efficacy challenge on every level.

[KuriApollo]

Hi all. I've been back on AVAPS past 2 nights. Looks like the settings match my previous AVAPS and updated Rx. The first night I felt so much better compared to the past week on the rental S/T, and AHI was <4. But LAST NIGHT WAS HORRIBLE. AHI 10.58 with more periodic breathing and clear airway events (what is the difference between PB and CA? They don't always match up) than I'm used to seeing, and a night full of hypopnea. 

I am pregnant and know that pregnancy brings changes in especially increased obstructive events, but that doesn't appear to be my main problem given last night's data, and with the clustering I'm assuming they may have been positional. 

Any impressions and thoughts before I discuss with my doc appreciated. I'm not on any new meds that are particularly sedating/CNS suppressing. 

Many thanks,
KA

[Sleeprider]

My first and foremost thought is try to get a trial on a Resmed Aircurve 10 ST-A with iVAPS. I think it is just a much more sophisticated and responsive machine. The clusters of apnea at 4:20 and 8:05 are positional. I assume you have read the Positional wiki http://www.apneaboard.com/wiki/index.php...onal_Apnea and Soft Cervical Collar wiki http://www.apneaboard.com/wiki/index.php...cal_Collar As far as settings go, your EPAP min at 9.0 is fixed pressure and is letting through considerable hypopnea. You might discuss with the doctor if an increase in EPAP should be considered, along with a change in PS min to 6. Tidal volume looks good and your resp rate is 13 which is above the set minimum rate.

It might be interesting to get some zoomed shots of the flow rate and mask pressure charts to see what that looks like and the machine response.

[sawinglogz]

Hi all. I've been back on AVAPS past 2 nights. Looks like the settings match my previous AVAPS and updated Rx. The first night I felt so much better compared to the past week on the rental S/T, and AHI was <4. But LAST NIGHT WAS HORRIBLE. AHI 10.58 with more periodic breathing and clear airway events (what is the difference between PB and CA? They don't always match up) than I'm used to seeing, and a night full of hypopnea. 

I am pregnant and know that pregnancy brings changes in especially increased obstructive events, but that doesn't appear to be my main problem given last night's data, and with the clustering I'm assuming they may have been positional. 

Any impressions and thoughts before I discuss with my doc appreciated. I'm not on any new meds that are particularly sedating/CNS suppressing. 

Many thanks,
KA

Glad you're back on your original therapy!

PB and CA are unrelated. "Periodic Breathing" (sometimes caused by Cheynne-Stokes Respiration, sometimes not) is when your breathing oscillates between shallow and deep over and over. The machines are cautious, and thus prone to false positives. The occasional brief PB is almost always just an artifact of the machine's best guesswork. But if you saw lots of PB (a large portion of the night), it would probably be worth looking into. Evidently large increases in PB over several days can also indicate something going on.

"Clear Airway" events are the machine's best guess as to why it didn't notice a breath. They don't call them "central apneas" because they'd need an EEG to confirm that, but in practice that's what they indicate. Again, the occasional CA isn't a cause for concern: we naturally pause breathing when we transition between sleep stages. But if they're especially frequent or especially long, that could be significant.

Given that your machine has a backup breathing rate of 10 bpm, I'm wondering how it decides you've experienced a CA. Normally with ventilators you have essentially none, because it's breathing for you when you don't breathe on your own.

I'll defer to Sleeprider on specific recommendations. The high number of hypopneas is really what stands out to me. Did you use a different mask or have a stuffy nose? What does a better night look like?

[Gideon]

SR edited to say PS Min to 6

I believe that is a rare slip of the fingers.
Should be PS Max to 15.  This gives your machine more "room" to deliver your therapy.

[sawinglogz]

I believe that is a rare slip of the fingers.
Should be PS Max to 15.  This gives your machine more "room" to deliver your therapy.

Is the hope that that would help even out the tidal volume? It looks pretty bumpy to me still, but I notice most of the dips are when IPAP is maxing out.

KuriApollo, you may want to turn on Preferences... > Appearance > Square Wave Plots in OSCAR. For Respironics machines, that more accurately reflects what your machine is reporting.

[Gideon]

Remember that this is a neuro-muscular disorder that is causing the breathing issues.  In theory, the PS provides the impetus to assist in inhalation.  A higher PS, which on this machine is variable, allow more pressure for inhale resulting in fewer incomplete breaths, thus smoothing out the Tidal Volume.