Neophyte Needs A Little Guidance

[monkeybusiness]

Sleeprider wrote:
I would like you to change the machine to auto mode because it will record flow-limitation and Respiratory Event Related Arousal (RERA) events in auto-mode that it will not record in CPAP mode. I think that information could be useful. You can set the minimum and maximum pressure at 17, and your machine will continue to function as a CPAP, or you can try some variable pressure like 14 min-18 max. Mostly, I'd like to see what kind of flow limitation and RERA the machine records. I suspect this will show your RDI is a much greater problem than your AHI alone suggests.
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I don't know how to change from CPAP to AUTO. Will snoop around for instructions to do so on my machine. I don't know what impact this might have on insurance coverage, though.

Sleeprider wrote:
Bilevel would help you to ventilate better. In bilevel the EPAP would be adjusted to where it stops most OA events, then IPAP will help with hypopnea, flow limits and RERA. In your case, simple bilevel may not be enough. You have enough flow limitation, combined with periodic breathing that a ASV or Spontaneous-Timed (ST) Bilevel may be needed. You're not recording CA events, and I find that interesting since your respiration is so suppressed at times, it seems equal to CA. There is air movement, just not enough to ventilate. It would be interesting to have the opinion of a professional pulmonologist regarding what he sees in this flow wave form. It's not normal, and your breathing is not efficient nor restful.
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I would be hesitant to the use of an ASV device due to a low ejection fraction. I have heard that ASV could be a factor in death.

I truly thank you, Sleeprider, for your time and the depth of information you have provided me. Depending on the results of the upcoming visit with my sleep doctor, I may ask my general practitioner for a pulmonologist referral and proceed from there.

The Apnea Board forum is a rich source of information supplied by experts who know what they are talking about. I'm very impressed.

[Sleeprider]

MB, do you have CHF? You didn't mention this in previous posts. If you do have CHF, then knowing what your LVEF is would be important to know before considering ASV. Also, this information would have been very important to disclose early on in discussing your results. You do not show classic Cheyne-Stokes Respiration, but your respiration is clearly abnormal, and is something to discuss with your cardiologist and pulmonologist.

Auto CPAP is induced from the provider menu. It is possible to select auto CPAP without changing any pressure settings. You may order a copy of your machine's provider manual, with instructions in entering the provider menu and changing options by following instructions at the CPAP Setup Manuals link at the top of this page. http://www.apneaboard.com/adjust-cpap-pr...tup-manual

To enter the provider menu, scroll to Setup, then push the control knob and ramp button at the same time. Machine will beep and go to provider menu. Select Therapy Settings by rotating the knob to that option and pushing once. In therapy settings, highlight the icon that says CPAP and press once. You can scroll through the options and select AUTO, and press once, then exit to therapy settings. You will now see Auto Max and Auto Min icons. Now make sure CPAP Min is 17.0 and CPAP Max is 17.0. This will provide a constant 17 cm H2O pressure in Auto mode, which will record flow limitations and RERA to your data. You can always return to CPAP mode, but these settings will not change your therapy. You may also request your doctor or provider to do this for you, and the only impact will be to display the additional data.

[monkeybusiness]

Sleeprider, I do have CHF with an ejection fraction <31 so ASV is probably not an option. My bad for not mentioning this at the start of this thread.

I appreciate your instructions to switch from CPAP to AUTO mode. Very simple once you know what you are doing!

I've made the machine changes and am set for tonight's sleep time.

[Sleeprider]

Thanks for the new information. Given recent research results, ASV would not likely be approved for you, however bilevel therapy may be more effective in giving you better ventilation, without adaptive servo ventilation. Given how flat your respiratory cycle is, a bilevel machine would encourage improved expiration, and the pressure support during inhale would improve, and perhaps prolong the inhale cycle. The AVAPS type of machines can be setup to provide that kind of support, even when you are in a mode where the breath is barely moving enough to avoid simply rebreathing the same air again and again.

I'm so sorry you are dealing with this. CHF took my dad, and many other loved ones. I wish you comfort and as good quality of life and sleep as possible.

Here is a link to an article that may clarify some of the PAP options. While ASV is counter indicated currently, that finding is also under further study. The sections on bilevel and AVAPS may be of interest to you. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4244615/

[Sleeprider]

Monkeybusiness I need to reset our conversation in light of your revelation. Do you feel better or worse since starting CPAP?

[monkeybusiness]

[attachment=2842] [attachment=2841]

Sleeprider, appreciate your kind words. Despite the EF number I'm pretty much asymptomatic and still enjoying life.

I effected the changes from CPAP to AUTO on my machine 2 nights ago. I didn't post results from the first night because I thought it might be some kind of fluke. This morning's SH results are almost a carbon copy of the previous night. (I've attached a SH shot from each day).

I noticed that when I switched from CPAP to AUTO, it changed the flex parameter from C-FLEX to A-FLEX. The flex value also changed but I may have inadvertently done that when initiating the change to AUTO. My previous C-FLEX setting was at '3'. The flex setting for the last two nights in A-FLEX mode is '2'. Pressure parameters were all set to my initial number of 17.

There were no RERA episodes recorded and both days FLOW LIMITATIONS were at or below 25. FLOW LIMITATIONS occurred upon retiring for the night and are probably related to mask adjusting. The number of PB's has also dropped considerably. Total AHI's were 2.6 and 2.5! I have NEVER achieved an AHI number less than 5 since starting therapy in May of this year. The 'assist' in breathing I seem to be getting from how A-FLEX works (over C-FLEX) makes all the difference in my opinion. I'm an 'active' sleeper and was amazed every time I would awake at night that my breathing was so measured and felt so natural. I can also say that I'm experiencing a level of waking up rested that I haven't had since.... well... I can't remember when.

The SH flow rates are still nothing to write home about and would appreciate your comments on the attachments.

[Sleeprider]

Man! That's great! Thanks for posting your feedback, and maybe something worth letting the doctor know. Take a look at your tidal volume...twice as much as when it first caught my attention. It's working. I don't know or really care why, but it is. Made my day. The wave-form detail is still bizarre, but much improved in volume and regularity. I guess that just goes with the territory.

[monkeybusiness]

I will be sure to discuss the FLEX issue with my doctor, Sleeprider. The link to the article discussing use of PAP in a CHF setting you provided earlier is very interesting. Thanks.

The term tidal wave doesn't mean much to me yet. I can see that I have much to learn in making sense of this crazy world called apnea. That's OK... it will keep my little mind active.

I really appreciate all the help you have provided in this thread. There is no question that you know your stuff and are the 'go to' guru.