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New User Problem with BiPAP AVAPS - Part 1
#21
I agree with robysue's conclusions and strategy. I share her lack of comprehensive understanding of AVAPS and any health issues that have you using that machine and the settings you posted. I intuitively see complex apnea, and am well aware of people having success with the Auto SV or Resmed's ASV. I hope you will be able to put together a presentation for your doctor to consider. I'm very impressed with the post above.

Some of your settings seem odd to me. You are setup for 15 breaths per minute with Ti at 1.5. That seems like a pretty high respiratory rate and sort inhalation time for a big guy with a large tidal volume. Again, I don't know the rationale for that. I would have expected something like 10-12 BPM at Ti of 2.0.

In your first post you reported "My new prescription was for AVAPS, PC mode, tidal volume 800, back-up rate 12, IPAP max 25, IPAP min 7, EPAP 10". I would suggest implementing these pressure and BPM rate, with any modifications you have discussed with your doctor. I still think you would benefit from adaptive servo ventilation to address comples apnea, and hope things move that direction for you soon. Keep in touch on the forum, but I don't feel qualified to suggest changes to your prescription with your current equipment, and I don't think it will be long before your doctor acknowledges you're inadequately treated and moves to a new plan...we can only hope.
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#22
Robysue, thank you very much for your excellent, informative, and understandable analysis and the time and expertise spent in your careful review of my case. I am in a rural pretty isolated area so there are not always so many choices in specialty care. My sleep doc is (like so many) of Pulmonologist background who I suspect is sleeping much better at night himself since he switched to full-time sleep medicine and no longer serves ICU patients!

Perhaps he has been influenced by my history, when on BIPAP AUTO I was averaging AHI's mostly in the teens or low twenties, with about equal OA's and CA's for several years, but felt fairly good symptom-wise; far better than I did before RX started. It's been the last 4-6 month or so that my totals seemed to be increasing and my symptoms also which prompted the new study and changes. I have printed out the pdf's of EncoreBasic for him and I guess his last review showing some "progress" - at least decrease in AHI's from the 40-50's to the 20's - prompted him to recommend waiting to make changes "for awhile." (I did think his initial RX settings were just copied from the suggested initial settings flier from Phillips rather than based on my history of high pressures.)

But I certainly want to feel better than I do now so shall do my best to tactfully "suggest" the actions you discussed. He is in no way a prima donna, but still I don't want to alienate him. In my untutored opinion I think part of the problem is Phillip's. In all of their glossy booklets, real, clinically helpful information is sparse. They give line after line about the wonders of heated hoses, but very little about the confusing variables that can be input. Their titration protocol section on the AVAPS clearly lists "Complex Sleep Apnea" as an indication for AVAPS RX. The clinical data your link led to does seem to have much more information for the ASV than AVAPS. I assume the AVAPS is newer technology? Or is it because no one uses it?!?

BTW, I don't have a separate PS setting; can only influence it through setting min EPAP and min IPAP.
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#23
(10-23-2016, 03:52 PM)jmayer180 Wrote: In my untutored opinion I think part of the problem is Phillip's. In all of their glossy booklets, real, clinically helpful information is sparse. They give line after line about the wonders of heated hoses, but very little about the confusing variables that can be input.
I agree 100% here. Way too much promotional literature on the bells and whistles of patient comfort and way too little technical info for the professionals about the innards of how the machines' algorithms actually work. Most of that is because the standard problem with dealing with CPAP patients is compliance, and the bells and whistles are designed to make it easier for a standard OSA patient to get used to CPAP and recover quickly.

You, of course, are not a standard OSA patient. You are a difficult case: Complex sleep apnea is much rarer than either OSA or CSA. It's not fully understood. And you haven't responded in the "standard" way to "standard" treatment. (BiPAP and BiPAP Auto are the first things tried for complex sleep apnea since the CAs often do disappear when a person with complex sleep apnea is switched from CPAP/APAP to BiPAP/BiPAP Auto.)

My guess is that if your doc took the time to call Philips with some specific questions about the machines' algorithms, they'd be happy to provide some detailed answers. The fact is cases like yours are the exception, and it is challenging to find a doctor who is dedicated enough to actually going the extra mile for an exceptionally difficult case. It's a myth that doctors *like* hard cases where it takes a whole lot of effort to figure out the way to fix the patient's problems. They much prefer simple, well understood situations where the patient responds exactly as the standard literature says they should.


Quote:Their titration protocol section on the AVAPS clearly lists "Complex Sleep Apnea" as an indication for AVAPS RX. The clinical data your link led to does seem to have much more information for the ASV than AVAPS. I assume the AVAPS is newer technology? Or is it because no one uses it?!?
I'm skating on thin ground here. I think it's the ASV technology that is newer and less known. If sleeprider or others know better, I'm sure they'll correct me.

Your doctor is clearly aware of standard ventilator technology with his pulmonology background. And much of that knowledge would transfer to the AVAPS in CP mode. My understanding is that mode is probably the closest mode to a invasive vent's way of working. It's possible that your doctor may just not be aware that AutoSV has been more or less developed to specifically deal with the issues of central sleep apnea. And because he's not fully aware of AutoSV, he's reluctant to prescribe it.

Quote:BTW, I don't have a separate PS setting; can only influence it through setting min EPAP and min IPAP.
That is a difference between AVAPS and ASV then. Do you have a min IPAP setting as well as a max IPAP setting? If so, you could try setting the min IPAP 1 or 2cm above the min EPAP setting.


Questions about SleepyHead?
See my Guide to SleepyHead
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#24
Not sure if trying to change title will work or if it is helpful, but thought I'd try it for those patient and helpful folks who have been following my tails of woe last month.

UPDATE: Sleep doc agreed with trial of ASV and I've been using the PR System One BiPAP autoSV Advanced since 15 Nov 2016. Subjectively I feel much better. I no longer have those frequent awakenings during the night with sudden, huge pressure bursts blowing my mask seal (no matter how well secured).

I have wrestled with software issues, as EncoreBasic and Sleepyhead will not work with this machine, no matter that many others say it does work for them. (See thread on Software Forum if interested.) Anyhow, I'm trying to learn EncorePro which I finally got installed and which does process the data.

Last go-round there was some discussion about seeing the actual wave-form data which I guess could not be done with the AVAPS. I can now get this with EncorePro and will try posting a typical night's graphs. My total AHI's have been pretty consistent in high teens or twenties, but with OA's usually under 1, and CA's under 5. Hypopneas make up the bulk of the events, in the teens or twenties. In spite of this, I feel so much better I have to wonder if the H's ARE as significant as the other events??

Oops. I find the file is 16MB so cannot be posted as attachment. Any suggestions?
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#25
Encore reports are probably PDF. If you own Acrobat or some other programs, pages can be converted to a graphic format like jpg or png.

Feeling better is pretty much what it's all about, and hypopnea are nowhere near as bad as a full apnea. It is a period of either shallow breathing or low respiration rate resulting in a 30% to 50% reduction in volume. You should be able to see which in the waveform. Given your weight issues, this may hypoventilation, and is relative to your normal respiratory volume. The thing is, your tidal volume through the night is exceptionally high, so a reduction may merely mean you are breathing at a rate or volume closer to normal for most people. The only way to know if it's significant is whether is is disrupting sleep, or causing SpO2 to desaturate.
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#26
(11-26-2016, 12:27 PM)Sleeprider Wrote: Encore reports are probably PDF. If you own Acrobat or some other programs, pages can be converted to a graphic format like jpg or png.

The only way to know if it's significant is whether is is disrupting sleep, or causing SpO2 to desaturate.

Yes .pdf is the only option with my EncorePro. I just have Acrobat Reader. Is there any chance for some sort of work-around without the full Acrobat program?

On my first sleep study I just marginally crossed the threshold of desat which at that time (7 years ago) justified O2 at 2 l/min. I had 2 follow-up overnight pulse oximetry studies over the years while on BIPAP in an effort to get off the O2, but seemed to stay just barely over the min threshold. In my recent sleep re-study, I was slightly above the threshold, and with the new more stringent insurance criteria, O2 was no longer recommended. I've toyed with the idea of getting my own oximeter, but in a cursory search it seemed most models were for spot checks only. Is a self-owned recording monitor feasible for those of us who are OCD enough to want to have more data?
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#27
Do a search online for Free PDF to JPG converter.
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#28
I had no idea that was possible. Thanks for the teaching.

Okay, I have the pdf converted to individual jpg pages. The entire file is still over 11MB zipped. Each of the 17 pages is about 700kb and seems to have about 30 minutes of data. That's still above the attachment limit of 600kb.

Messing about, I tried a "Snipping Tool" of one of the pages. It saved as about 290kb in .png. Will that post okay? It would take quite a few posts to send all 16 pages with data? Would a couple randomly chosen help?
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#29
Use the link in my signature about using Imgur to link images. Imgur will host the jpg images, and will even bulk-upload the whole batch. You can choose which ones to post, or just link the album where they are hosted. Be sure to make them public. It should take about 5-minutes to do the whole thing if you choose.
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#30
Didn't know you could use any image with Imgur. Here goes:

[Image: tWyBrW5l.jpg]

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[Image: ltH3Brgl.jpg]

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[Image: VpJe3ujl.jpg]

[Image: K5nIOJfl.jpg]

Sorry about the order. The Imgur uploads seem to self-shuffle into no particular order and the image text size is so small can't make out the times without opening them. which seems to further shuffle the order. Anywho, thought these five or so 1/2 hour clips might be enough?
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