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I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
Thank you for that analogy Sleeprider.  I am still digesting it, but I think I understand it basically.  Maybe I have undiagnosed UARS?  RT has constantly told me I am a shallow breather.  She said I start out the night at around 98 o2Sats.  As I start to sleep and spend more time in sleep, my o2 sats drop lower and lower and lower and co2 builds up in the bottom of my lungs.  She said that she thought the ST-A or Astral should have worked for me to get rid of the excess co2 building up in my lungs.    

I have already bought into the ASV because I can tell you and Dave have a better understanding of sleep apnea treatment and more experience with it than she does (especially with the different machines available and titrating it correctly for both performance and personal comfort). She is the expert in respiratory diseases, but you guys have far more experience with sleep apnea treatment than she has had.  I am a tough sell.  I get more skeptical with age.  But I have already bought into the Resmed ASV.  Worst case scenario I can always purchase my own and get correctly titrated here.  

I sensed the same scenario you just described with both the ST-A and Astral (IVAPs mode).  Both were very inflexible and unrelenting (unwaveringly aggressive).  I wrote the numbers down that she used on the Astral, and one of them was 15 for the rate. Me and ST-A and Astral never got in sync.   I believe the ASV will be selectively aggressive when it needs to be, and easier to tolerate for me.  The ST seems like one of the most difficult machines to tolerate on the market to me.  If I shallow breathe, the ASV will come behind my shallow breaths with some force to help me.  With no breathing it will become more aggressive.  

The other week I showed her the brochure for the Resmed ASV.  She got mad.  The 1st time I saw her mad.  She said, "Why would you want to downgrade to that from a ventilator."  I think RT's are trained to combat respiratory diseases and a ventilator is the cream of the crop that can cure anything.  Any respiratory disorder will be conquered.  Sleep apnea will be squashed by the mighty power of the ventilator.  Just what I am sensing here.  My unique problem has been trying to get a downgrade. 

She has mentioned trying a PR Trilogy Evo (APAP) on me instead of the Astral if I want to do that until my 90 day trial ends in March.  Should I even give this a try?  

I plan on seeing my PCP in March or April so asking her for the ASV.  I am not sure if RT will be on board to or not.  I would like her to be.   My PCP is very nice and I don't expect any problems getting a script for a Resmed ASV.  But we will see.  The recent cardiologist appointment and possible stent(s) should make it that much easier for her to write the script.  She is just like everyone else in this regard (everyone 100% believe I need to get the correct machine and get pap therapy going and many of my problems should be resolved.)
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RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
The Philips Respironics Trilogy Evo is their version of a NIV ventilator like your ResMed Astral. It's a lateral change not worth doing IMO. If Astral isn't right, Trilogy or newer Trilogy Evo isn't either. I know they're similar because my own RT said due to my Apnea and COPD overlap she wanted me on Trilogy or Astral.

As for ASV, it's a simple pressure setup once you get it. Start with ResMed Titration and edit a bit here and there to make it give best results and comfort.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
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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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RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
Update:  Echocardiogram:  LVEF% = 70%.  You were right Sleeprider and Dave. 
Angiogram revealed clean coronary arteries and no stents needed.  They also found mitral valve prolapse; but Doc says insignificant right now.  
I did faint after the angiogram prompting Cardiologist to order an EPS study (electric study of heart rhythm).
EPS revealed that they could trigger A-fib in me during the test.
24 hour heart monitor I wore for one week:  I pushed the button to record every time I felt "buzzing" or anything abnormal.  I pushed button about 50 times in the 7 days (100% were at night).  Cardiologist showed me print out of the 50 times heart monitor recorded me:  about 95% of the time, my heart rhythm and beats were perfectly normal.  About 2 or 3 or the 50 recordings showed tachycardia though.  No A-fib found.  So my "buzzing" has no correlation to either A-fib or tachycardia.  But 2 times during my clinical polysomnography and 2 or 3 times during the heart monitor experiment, I had tangible, recorded tachycardia.  
Doc has me on Rhythmol twice a day for any irregular heartbeats.  Also has me on a low dose beta blocker, metoprolol once a day.  He said these 2 meds should "protect" my heart.  

The RT at my DME took back the Astral and gave me a PR Trilogy Evo (AVAPS-AE mode - self titrating) to try for a couple of weeks.  Not expecting much, I was pleasantly surprised.  I was able to use it for 8 straight hours at night for 3 straight nights (I stopped because the next day was the Angiogram, and then later EPS heart study, and then heart monitor for a week).  
Smooth (maybe because it is slower responding?) and fairly tolerable was my experience with the Trilogy Evo.  No alarms went off (at least I did not hear any).
As I get ready to sleep I lay down in my recliner with my soft cervical collar, and I start the Trilogy Evo, It has a PS gauge on the screen that is active all night.  Just as I am falling asleep I see the gauge oscillating back and forth between 2-7, 3-8 etc.  - in this range as I fall asleep.  I wake up a couple of times during the night and the gauge is oscillating back and forth between 15-20.  *I have a question.   I would like to better understand why the Evo is using 15-20 at this time of the night.  Is it because of my 1.  OSA?  Is it a major positional obstruction?  2.  My CSA?  3. My shallow breathing - RT says I am close to having chronic hypoventilation diagnosis because of my shallow breathing, but I don't qualify for OHS because of my BMI.  Also, there is a congenital hypoventilation syndrome, but I obviously don't qualify because of my age now.  4.  Or is it a combination of these 3 factors?  RT says I have these 3 major problems most likely occurring simultaneously at night.  

I can tell when the AVAPS-AE is self titrating.  It sends a very fast inward pressure then outward pressure back and forth for about 15 to 30 seconds.  It seems to self titrate every 5 minutes or so.  It does not bother me at all when it is doing this.  
I want to give the Astral IVAPS a thumbs up.  I think I could have done 21 straight nights for 8 hours with it when the setting were just right for me (RT adjusted setting about 10 x's.)  The alarms were the only reason the Astral IVAPS didn't work for me I think.  ST(A) was lightening quick and powerful.  I never could overcome my sympathetic nervous system's response (Flight or fright) to the very quick consecutive high pressures.  I would always become more alert.  Astral IVAPS (with the correct settings) was kind of like right in the middle between the ST(A) and the Evo.  Evo is the most comfortable and tolerable to me personally.  
I read a post by a member here that said she absolutely hated the Trilogy Evo.  I had a different experience.  Same pattern all the time with AVAPS-AE.  One breath every 4 seconds.  Then 3 seconds to exhale.  A problem I had with both the ST(A) and Astral at times was that I felt like I was suffocating because I didn't have enough time to fully exhale at times.   No such problem with 3 seconds the AVAPS-AE always gives me to fully exhale.  

My only concern is:  is the Evo treating me sufficiently?  Evo has USB drive.  I copied data onto a USB stick.  The data is encrypted though.  I contacted a GeekSquad to see if they could decifer it somehow (I wanted to upload the flow charts, etc. here for everyone to look at). I sincerely apologize it is not OSCAR - I have the latest OSCAR on my desktop ready to go though.  
 I ordered a nighttime SPO2 and Heart rate monitor and plan on experimenting (one night with no PAP; then one night using Evo to see the difference)  

ASV:  I read your thread Dave on overlap (when you were using the ASV). I also read a thread by a member who said that she successfully used the Resmed ASV for awhile, but then because of hypoventilation found she was dropping below 90 SPO2 at night and waking up using the ASV.  If I understand the algorithm, it calculates based on the previous minute or 3 minutes.  So theoretically, a very shallow breather could fool it into delivering a lower and lower and lower volume of air as the night progressed.  Is this going to be a problem for me with the ASV?  Will I be able to tolerate the ASV?  AVAPS assures "x" amount of volume every minute no matter how erratic my breathing becomes.  

Current Evo AVAPS-AE settings: 
Passive Circuit prescriptiong1
Mode:  AVAPS-AE
Tidal volume:  400ml
PC Breath:  off
Max Pressure:  30
Insp. time:  1.0s
Flow cycle sens.  Auto
EPAP min/max:  4/10
Breath rate:  15
Rise time:  3
PS min/max:  4/26
Trigger type:  Auto-Trak
AVAPS speed:  5 cm/h2o/min
using default calibration

Is the Resmed ASV or PR Trilogy Evo best for me?  Thank you in advance.
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RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
You are in ventilator territory I am completely unfamiliar with. You are the first member I know of to get this spectrum of evaluation and therapy. Your symptoms and conditions seem pretty minor, so I guess you're the guinea pig. As long as you feel comfortable and are able to sleep with the therapy, that is a remarkable improvement. I'm sure Dave is going to have major ventilator envy, but I'm completely out of my wheelhouse.
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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RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
Going by your comfort on a Trilogy Evo then that alone can make it the right machine for you. I suspect it's more than breath timing, in that Respironics are slower response timing and then it seems to suit you better. Exhale and inhale timing should be adjustable on any of these ST-A, Astral, Trilogy Evo, but response time is probably unique to the brands.

My RT had told me that some people will do better on ResMed and some on Respironics. Even when it comes to a NIV like the Astral and Trilogy/Trilogy Evo. So really if it works, if it's comfortable, then your body has made the choice for you.
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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RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
Thank you very much Sleeprider and Dave.  Without both of your help I never would have made it this far.  My RT has taught me some things about sleep apnea, but I have learned much more here at apneaboard.com   

I will try to post again when the SPO2 and heart rate nightly monitor arrive.
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RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
You're welcome. Keep your medicals on their toes.
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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RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
Last night I woke up a couple of times hearing noises from my full face mask from leaks and air shooting into my left eye.  During the night my jaw falls wide open and I think I become a 100% mouth breather.  I tighten the straps as tight as I can, but eventually I wiggle loose when my jaw drops wide open.  The obvious solution seems to be the biggest full face mask that they make.  I asked my RT if she would get me the largest one she carries.  Does anyone know the largest that is made?  XL?  XXL?  Brand makes no difference.  

In the middle of the night I switched to my nasal pillow mask.  I decided to tape my mouth shut also.  I watched as the Trilogy Evo maxed out it's pressure to about 30 cmH20 on the gauge.  At 30 cmH20, no air was getting through my nose to my throat or lungs.  It could not force me to inhale.  With this set up, my body wanted to breathe through the tiny corners of my mouth instead of through my nose.  When I tried to consciously breathe through my nose, I could get some air in, but not much.  

During my home sleep study, I remember lying in bed not being able to breathe out of my nose.  I put a knuckle over one nostril to block it, and I could not inhale through the open nostril.  I put my knuckle over the opposite nostril and I could not breathe out of the open nostril either.  

During the day I just about 100% breathe out of my nose with no problems at all.  Only when I physically exert myself, do I breathe out of my mouth also for extra air.  

With the full face mask and my mouth wide open, 20cmH20 pressure forces me to breathe and fills up my lungs just about completely.  What is most likely causing the obstruction in my nasal passages?  Some type of blockage?  Inflammation?  Mucous?  Sinus?    The only thing I could think of was ordering some Flonase.  I will try that.  That may not be the problem though.  I would like to use my nose and nasal passages to breathe during the night.  

I did see the ENT (Ear, Nose, Throat) Dr. in November.  He put the small camera down one nostril and down my throat and ask me to make snoring noises.  His conclusion was that anatomically everything looked normal and no surgery that he could do would benefit me.  I was sitting upright and it was the middle of the day when he tested me though.  

All help figuring both of these out is appreciated.   Thank you very much.
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RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
I really think the solution is either a chinstrap that pulls upward like the Kinghtsbridge dual strap or a soft cervical collar. Wearing the mask too tight is uncomfortable and rarely gives a good fit.
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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RE: I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?
Thank you for that Sleeprider.  I currently wear a soft cervical collar every night (I have a smaller one and larger one and have been using the smaller one, but will try the larger one), but I will purchase the the Kinghtsbridge dual strap also.  I guess I could have had the mask straps too tight.  
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