New to Actually Posting - 2nd sleep study results (Need an ASV)

[metsfan302]

It would be helpful to zoom in on the flow rate waveform during some of these events to really see where in the respiratory cycle the event is initiated.

This is a very important idea. We could get a much better idea of what to suggest by looking at the waveforms in question.

RichB

Printing this as I type so I can highlight exactly whats needed, thanks again I was in Vaughn's prior post that explained what to post. will figure it out in a bit to post that.

[metsfan302]

Srry for my noobness, hope this is what you were asking for / needing......

I took a few incase in hopes one of them is right lol. if not i guess re-explain

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[metsfan302]

This is from last night, Machine says AHI - 22.1 but its slightly diff on sleepyhead. guess i might have a setting diff for naps or maybe its cause it runs from 12-12?

I did change the settings to

Epap - 8
Min Ps - 4
Max ps - 13

Think its the wrong direction for sure....... Not sure were it should be

Here are screens from past 2 nights



...

[richb]

Wow! Those events marked UA are most likely Central Apneas. It seems to me that your initial pressure is set too high. The result of high initial pressure is that periodic breathing is converted to Central Apnea. In other words what would be a rising and falling pattern with no machine or low pressure is converted to pauses where there is no breathing. My machine is set with a EPAP (exhalation pressure) of 6 and an IPAP (inhalation pressure) of 8. For me these pressures are low enough to not trigger many of the events marked UA in your graph. It seems that it is too late to treat the Centrals that may be caused by your machine in the first place, Your body may be convinced that you have no need to breathe and the very high pressures put out by the machine can't convince it otherwise. So, try going back to a starting point of much lower starting pressures and let your machine try to treat hypopneas instead of Centrals.

Rich

[justMongo]

metsfan302: read your posts. Don't sweat the opiate addiction. That's the past; and the question is: What are you going to do today?

To me, your graphs are a mess; and I confess to having only limited knowledge of ASVs. We have some brilliant people on the board. No disrespect to them, I am concerned for you. In your selected screenshots, the machine is doing what it's supposed to do, providing pressure pulses; but the flow is not there. Seems puzzling to me.

Are you working closely with a doctor on this?

[richb]

Hi again Metsfan302,

Your post about opiates sort of confirms the Central Apnea theory. Opiates and their derivatives are commonly implicated in suppressed breathing resulting in Hypopneas and Centrals. ASV machines are commonly used to treat suppressed breathing related to opiate therapy. Do a Google search on the following: Sleep-disordered breathing in stable methadone programme patients: a pilot study.
As you can see from above you will have a lot of support from this Board.

Rich

[Sleeprider]

Metsfan, I apologize because I'm going to talk around you with Rich and Vaughn for a minute. The data posted is presented very well, but it's confusing to me, so feel free to ignore the conversation here, because I need to speculate on what's happening.

Rich, I disagree the events indicated as UA are central. They look obstructive. The machine goes all the way to 25 cm and there is no flow response until the recovery breath. As usual, it is very unique and I have not seen this same flow pattern before. Let's use the graph below and describe what is happening (I hope you and Vaughn are in a collaborative mood because I'm not all that certain of my interpretation).

At 14:30 exhale transitions into an inhale which terminates in a flat line (0-flow) and no exhale until the UA is flagged at 14:45, followed by strong inhale and then a weak 2-part exhale. The next inhale is followed by a partial quick exhale and zero flow from 14:56 to 14:47 at the UA flag slight exhale followed by strong inhale. This is repeated, with most apena appearing to be breath holding after inhale. The machine increases pressure to 25 and cannot make a dent in the flow. This is pretty much a hallmark of obstruction, as there is plenty of pressure in the mask to induce inhale in an open airway.

The mask pressure shows the machine attempts to maintain breathing rhythm and volume, but the user does not respond in spite of an apparent PS of about +15.



Since significant parts of the night do not exhibit any apnea or hypopnea, I speculate that the periods of apnea are strongly related to sleeping position. These are obstructive apnea following inhale, and do not respond to any pressure stimulus.

Could a lower EPAP pressure encourage exhalation, and prevent the breath holding? Is higher pressure needed to prevent OA? I dunno! What we can say is the the apena are all 10 to 15 seconds in length, and may not actually result in significant SpO2 desaturations. I'm interested in Vaughn's insights as well.

[justMongo]

This article is in peer reviewed literature on a non-commercial site. They may be directly link to.

http://www.ncbi.nlm.nih.gov/pubmed/11255580

"Sleep-disordered breathing in stable methadone programme patients: a pilot study.
Teichtahl H1, Prodromidis A, Miller B, Cherry G, Kronborg I.

Abstract
AIMS:

To explore the possibility that stable MMP patients have sleep-disordered breathing (SDB) and abnormal sleep architecture defined by nocturnal sleep stages and sleep efficiency.
DESIGN:

Observational.
SETTING:

Regional Methadone Service and sleep disorders laboratory in a university affiliated hospital. Participants and measurements. Ten stable MMP patients and nine normal subjects were assessed clinically and with overnight polysomnography.
FINDINGS:

There were no differences in age, sex and body mass index between the groups. The methadone dose ranged between 50 and 120 mg/day. Six patients had central apnoea index (CAI) greater than 5, four had a CAI greater than 10 and three of these exhibited periodic breathing. No normal subject had central sleep apnoea. The patients had lower sleep efficiency (p < 0.05), less slow wave sleep (p < 0.01), less rapid eye movement sleep (p < 0.05) and more Stage 2 sleep (p < 0.05) than controls.
CONCLUSIONS:

Stable MMP patients have more sleep architecture abnormalities than controls and a higher prevalence of central sleep apnoea. Further studies are needed to confirm these findings, to delineate the mechanisms for the abnormalities and to assess whether the SDB is related to sudden death in stable MMP patients. We recommend that MMP patients have awake and sleep respiration assessed to identify those potentially at risk."

[richb]

In reply to Sleeprider: It is possible that the pattern you refer to is Obstructive, but there are lots of pointers to Central Apnea as well. My suggestion is that metsfan302 try the lower pressure settings to see what happens. Metsfan is already at high pressure settings with negative results. The connection to methadone is in particular a strong pointer to Central Apnea. My hope is that metsfan would see a reduction in the UAs reported at lower settings. My machine still reports occasional UAs at lower settings. ASV machines don't check for Centrals when trying to provide therapeutic pressures. When on bi-pap at higher settings I had nearly all Centrals. For metsfan starting at lower pressures would be similar to a new titration.

Rich

[Sleeprider]

Rich, going back to his sleep study, it was ALL central. The waveform is just unusual to my experience where apnea appears to onset with the end of inhale. I agree, a lower EPAP pressure, might encourage that exhale to occur faster, and it appears Metsfan does not hesitate to inhale once that occurs.

So going back to my previous post, how does EPAP of 8.0 sound, leaving everything else the same (PS Min 4.0, PS Max 15, IPAP max 25)?

Metsfan, the Aircurve 10 ASV is pretty similar with the exception it is able to increase EPAP min to manage obstructive apnea, and should properly identify CA vs OA. It's certainly an improvement on your current machine, so the sooner the better. Similarly the Philips Auto S/V models automatically adjusts both EPAP and IPAP within the pressure support range, and have some other settings that would be an improvement. So move forward with your ASV titration, and be sure to keep us posted on the results. We can try to optimize the S9, but it will be interesting to see what the pros come up with in titration.