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Future BiPAP user.. Which machine to ask for?
#51
(03-24-2017, 03:16 PM)Sleeprider Wrote: First of all, you omitted the most effective machine of all of them for your central/complex apnea, the Resmed Aircurve 10 ASV.  The results we have seen among forum members don't lie.  That machine beats the Philips Respironics BiPAP SV Advanced nearly every time.  As far as S/T and AVAPS, the are not suited to your condition as described.

totally agree
they gave me a regular machine

from what i am finding out i need the ASV type
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#52
PROGRESS REPORT

Well, I had my appointment with a different pulmonologist, and have made some progress toward a ASV prescription.

As I expected, he requires another sleep study with ASV titration.
Unfortunately, the appointment on July 6th is the earliest they have.

Meantime, the doc is putting me on oxygen therapy to help my low SpO2 (drops to the 70s).

Maybe it's me, but I don't see how oxygen will help if I'm not breathing.
My recording pulse oximeter readings have been in the high 90s until I have an event.

While the new doc is a better listener, I'm left with the impression he doesn't have a complete grasp of machine functions.

While discussing the BiPAP ST prescription from the previous doctor, I asked a question about how the machine operates.

I wanted to know if once the machine (ResMed S9 VPAP S/T) triggers into the timed function, does it check for normal breathing and revert back, or does it keep timing my breath for the rest of the night.

He just said "it determines when I need timed".

I couldn't help thinking he didn't really know, because that still doesn't tell me if it knows when I DON'T need timed.

Anyway, just thought I'd let everyone know what's going on.
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#53
Ohmy 
Coffee Good news on your progress report. Hang in there Herb. Glad new doc is better-ish. BTW I got my copy of my sleep study yesterday. Trying to get time to post it for decipher. Best to ya on new studies.  Coffee Cool
Sarcasm is a hobby of mine. I am not sarcastic on serious issues, implied or otherwise.
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#54
If your doctor would just write the prescription with ASV default settings, I could help you get dialed in within a week.
Min EPAP 4 cm H2O
Max EPAP 15 cm H2O
Min PS 3 cm H2O
Max PS 15 cm H2O
See page 41 https://www.resmed.com/us/dam/documents/...lo_eng.pdf

Oxygen is a bridge that keeps your blood saturation levels higher until you are on effective therapy. It's better than nothing, but not as good as just getting treated. Unless you absolutely need a titration study for insurance, the default settings combined with the AutoASV algorithm and data will let us dial in the machine precisely and quickly. Seems to me it's better (and less expensive) than waiting until July. The auto algorithms are smarter than a PSG titration study because they constantly deal with variables. Most doctors and sleep clinics don't want to hear this.
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#55
I sure tried steering him into a prescription right off, but he was having none of it.

I even had my polysomnography chart from the titration running on my laptop when he entered the room.

Never got that far.

Don't know if it was his decision, his accountant's or his lawyer's, but so be it.



If it wasn't for the fact I'll need hoses, masks, tanks, filters, etc. I'd just buy one.

I'm curious to see the readings on my recording oximeter when I'm on oxygen.

Maybe my blood will be so saturated, it won't matter if I skip breathing for 20 seconds LOL


As far as doctors and sleep clinics not wanting to hear it, I suppose everyone hates being replaced by automation.

But these evening sleep study soirees are costing insurance companies a mint.

Quite the profit center.

Two beds supporting two daytime jobs, three night time, and a doctor I recon.
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#56
SleepRider-

Well, the battle still rages but victory is near (I hope).

I have escalated my complaints through the sleep center manager to one of the owners.

Both the manager and owner appear sympathetic to my cause, but since they have no medical credentials they can't green light an ASV, but they offered to take my case to their other Pulminologist for a second opinion. 

If I can convince him, they said I can get a ASV machine prescription with settings based on the previous titration, or another PSG on ASV to confirm.

So...... Having laboriously gathered my data, I am presently writing what is beginning to look like a dissertation in order to convince the other Doc to prescribe an ASV. 

Not bragging, but it's looks pretty damn convincing if I do say so myself.
(I pinched some of your post comments for ideas) 
Pretty much a no-brainer in favor of ASV, but we'll see.


While in the process of wresting bits of info piecemeal from the center, I received the "CPAP/Bilevel/Oxygen Titration Table" for the night of my PSG:

CPAP 5/0/0, duration 1:24:21 = Hypop -  5, CA -13, OA - 1,  AHI 24.2
CPAP 6/0/0, duration 2:36:34 = Hypop - 12, CA -15, OA - 2,  AHI 11.6
BIPAP 11/6/0, duration 0:16:26 = Hypop - 0, CA - 2, OA - 0,  AHI  7.3
BIPAP 11/7/0, duration 0:19:26 = Hypop - 0, CA - 3, OA - 0,  AHI 12.9
BIPAP 11/6/0, duration 2:00:59 = Hypop - 0, CA -31, OA - 1,  AHI 21.8

No mixed apneas or RERA recorded at all.

I don't know much about this, but NO record of BIPAP timed ???!!

Anyway, SleepRider, what do you think?

It seems I have an acute sensitivity to pressure, leading to treatment induced centrals, and that the persistence of CA while OSA is controlled confirm my symptoms include CompSA. (They didn't mention CompSA in their report)


Also, based on these numbers, what about ASV settings?

Thanks!
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#57
(04-06-2017, 06:10 PM)Sleeprider Wrote: If your doctor would just write the prescription with ASV default settings, I could help you get dialed in within a week.
Min EPAP 4 cm H2O
Max EPAP 15 cm H2O
Min PS 3 cm H2O
Max PS 15 cm H2O
See page 41 https://www.resmed.com/us/dam/documents/...lo_eng.pdf

Oxygen is a bridge that keeps your blood saturation levels higher until you are on effective therapy.  It's better than nothing, but not as good as just getting treated.  Unless you absolutely need a titration study for insurance, the default settings combined with the AutoASV algorithm and data will let us dial in the machine precisely and quickly.  Seems to me it's better (and less expensive) than waiting until July.  The auto algorithms are smarter than a PSG titration study because they constantly deal with variables. Most doctors and sleep clinics don't want to hear this.

I suggested settings in this post.  For most people that works pretty good, but I have found Min PS 2 work better for a number of people I have worked with to allow spontaneous breaths to occur without as much pressure support.  You almost can't go wrong with these settings and observing the data to fine-tune.
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#58
I did note the settings in the previous post, Thanks.

It's just that looking over my titration table, it appears I don't handle PAP well.

Don't know if my AHI climbs more than normal since I have no reference.

I'm hoping the AirCurve 10 ASV does a good job of minimizing EPAP on automatic.
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#59
Herb, in your titration table, you did pretty good with regard to OA at EPAP of 6-7 cm, and OA events were low at all pressures, including CPAP. With the ASV set for EPAP 4 on auto mode, any obstructive events will result in a gradual increase in EPAP pressure that should reduce those events. Your CA and H events were high at all pressures, particularly in CPAP mode, and even the initial successful titration at 11/6 was not repeatable. The ASV will treat CA and H events with variable pressure support a needed to cause a breath to occur. While we don't know exactly what pressure will cause your lungs to inflate when you don't spontaneously breath, or you fail to take a breath with normal volume, we do know that it will probably be less than a PS of 15. The machine will only apply what is needed. So the default settings with EPAP 4 and variable EPAP pressure to address OA has a high probability of eliminating the few events of that type noted in titration. All remaining events are CA and H, and we know that PS-5 does not do anything, nor would we expect it to. This is where the ASV is brilliant and the ST is not. The machine will rapidly ramp up PS and will probably find a response near 8.0 cm, and will increase pressure beyond that until a normal breath occurs, then drop back to EPAP pressure.

Many of the people I have worked with here, find a lower minimum PS of 0 actually promotes more spontaneous breathing. As PS is increased in spontaneous breathing, more CO2 is blown off which can affect normal respiratory drive (hypercapnic drive) http://respiratorytherapycave.blogspot.c...heory.html . The use of low pressure support, a feature not supported by ST, is critical in promoting spontaneous breathing in complex apnea patients. ONLY when a central apnea or hypopnea (including periodic breathing) occurs, is pressure support applied by auto-ASV. This combined with the minimum PS maintains the normal hypercapnic drive by preserving normal arterial CO2.

To technical? The bottom line is, ASVauto in the default settings, appear to be ideally suited to prevent most of your events. It many be necessary to slightly increase min EPAP, or decrease min PS for optimum results. We can also decrease max PS to accomodate aerophagia and other complications, such as was the case with user "mymontreal". His is a case study you can look up on the forum and note he self-financed his ASV, and immediately experienced AHI less than 0.5, which was fine-tuned mainly for air ingestion complications. I am personally yet to find the individual that cannot be remarkably improved with a complex apnea condition and using Resmed ASVauto mode.

One more point. Additional titration studies will yield very little useful information for this auto-logic machine. Your past titration studies offer pretty much everything we need to make the above conclusions. The actual titration will be performed by the machine on a breath to breath basis, and any "guidance" we need to give the machine's program will be minor changes. You just need to get on the therapy so you stop experiencing the punishing AHI and desaturations you have without treatment. Why is the medical community so willing to let you continue to be untreated, or use the wrong treatment; yet insist upon more titration studies that will yield no further benefit?

Quote:CPAP 5/0/0, duration 1:24:21 = Hypop - 5, CA -13, OA - 1, AHI 24.2
CPAP 6/0/0, duration 2:36:34 = Hypop - 12, CA -15, OA - 2, AHI 11.6
BIPAP 11/6/0, duration 0:16:26 = Hypop - 0, CA - 2, OA - 0, AHI 7.3
BIPAP 11/7/0, duration 0:19:26 = Hypop - 0, CA - 3, OA - 0, AHI 12.9
BIPAP 11/6/0, duration 2:00:59 = Hypop - 0, CA -31, OA - 1, AHI 21.8
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#60
No it's not too technical.


This is JUST what I need, valid points specific to my condition.

I was struggling with this aspect of my request.

You are really helping me to clearly state my case to go on ASV.

THANK YOU for your generous help with such a detailed explanation!!
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