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[Treatment] New Member seeking help with Resp. settings
#11
P.S. (re: Sleeprider) I have since talked to my father. We still aren't sure of the name of the device originally suggested by the pulmonologist for the sleep study, but he did confirm that the change was made to BiPAP because of heart condition. Reading over your reply again, I see your specific caveats about CHF, ejection factor, etc when considering AVS, so that could well be why he ended up with the machine that he has instead.

AVAPS looks promising though. I would like to try dmeRT's suggestion if there is a way to do so with my machine. And if I can't, I would be happy to consult the Dr. about getting one that can.
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#12
bipap AVAPS = 1160 (would say bipap AVAPS on the top or bottom)

bipap s/t = 1060
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#13
Ok, yes, it's a 1060. Do DME providers offer upgrades/trade-ins on old devices if doctor prescribes new device? Looking at the calendar, I see that my father has his annual with pulmon. in two weeks.
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#14
no trade ins.  if the bipap is still in the rental phase then it would be returned when new equipment received.  You'll have to work with your doctor/DME company/insurance to get the more advanced machine approved.  especially the AVAPS.  I believe he might qualify under the "restrictive thoracic disorder" guideline due to his polio and scoliosis.  I'll post those guidlines at the bottom of this reply.  

Another thought...  you could try getting the ASV machine due to the many central events.  You would have to work with your current DME company to this.  Contact them and see what they can do.  ASV and bipap s/t fall under the same billing code so insurance wouldn't care.  Although DME companies don't like you messing around with your own settings.  Dr. may not want the ASV though.  

Hope I didn't confuse you further.  Good luck.

as far as bipap s/t settings.  try ipap 14 / epap 10 / rate 10.  get a good 2 weeks on those settings and show summary report to the dr.  

------------------------------------------------------------------------------------------------------------------------------


to get AVAPS--

Restrictive Thoracic Disorder
Medical records document:

-Progressive neuromuscular disease (i.e. amyotrophic lateral sclerosis) or a severe thoracic cage
abnormality (i.e. post-thoracoplasty for TB); and

-Arterial blood gas PaC02, done while awake and breathing the usual FI02, is ≥ 45 mm Hg; or

-Sleep oximetry demonstrates oxygen saturation ≤ 88% for ≥ 5 minutes of nocturnal recording time
(minimum recording time of 2 hours), done while breathing the beneficiary’s prescribed recommended
FIO2; or

-For a neuromuscular disease only, maximal inspiratory pressure is < 60 cm H2O or forced vital capacity
is < 50% predicted; and

-Chronic Obstructive Pulmonary Disease (COPD) does not contribute significantly to the beneficiary’s
pulmonary limitation.
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#15
dmeRT, glad to see you on the forum, and hope you will continue to be involved here. Your suggestions have been very impressive, and it's great to have someone conversant in AVAPS S/T here. It's very difficult to get good results out of the PRS1 1060, especially in the presence of mixed apnea. Your suggestions would bring the backup rate (10) into play, and that is certainly going to be needed with higher EPAP in this case.

Brett, the risk with ASV is a "statistically significant" increase in sudden cardiac MI in patients with LVEF < 40% in one study. Those results are being further reviewed, but in the meantime, ASV has basically been contraindicated for anyone with CHF and LVEF impairment. It's unfortunate since it is the only technology that treats Cheye-Stokes respiration, central apnea and complex apnea. The original study found the risk http://www.resmed.com/us/en/news-and-inf...comes.html

A follow up shows that ASV continues to have a positve outcome provided LVEF is preserved http://www.resmed.com/us/en/news-and-inf...comes.html

The bottom line is, you need to know through echocardiogram whether your dad actually falls into the higher risk group, or if he might benefit from the technology. The knee jerk reaction of most doctors was to withhold ASV for all CHF patients, but as you can see, the situation is fluid, and worth following.
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#16
(05-31-2017, 09:00 PM)Sleeprider Wrote: dmeRT, glad to see you on the forum, and hope you will continue to be involved here.  Your suggestions have been very impressive, and it's great to have someone conversant in AVAPS S/T here.  It's very difficult to get good results out of the PRS1 1060, especially in the presence of mixed apnea.   Your suggestions would bring the backup rate (10) into play, and that is certainly going to be needed with higher EPAP in this case.

Yes, thank you for your kind help dmeRT. As usual my dme provider hasn't gotten back to me regarding the model of my device, but you have given me the help and info I needed. I appreciate it.

And thank you again, Sleeprider for your guidance and support. I am uploading last night's results to the same location for your consideration, and I welcome your thoughts. For what mine are worth, I'm actually quite thrilled with what I'm seeing. It's obviously not ideal and I'm probably missing some key points (which I hope you, and/or others here, will flag), but in all the months my father has used this device, it's been very rare to acheive an AHI below 20, think nothing of single digits.

http://fc.hermon.net/~clemons/uploadedfiles/05_31.png

I realize too that AHI isn't everything, which is why I solicit your help in pointing out other factors of concern. By the way, this is the second night of readings like this. Increasing the backup rate seems to have helped a lot, as has lowering PS. He's also been sleeping on his side fairly consistently.

I do have a specific question on that point: I direct your attention to the 3:00 am point on the graphs. That's when I went into my father's room and found him sleeping on his back. At about 3:10, after listening to his breathing for a while, I woke him and suggested a shift to side. His back breathing actually sounded surprisingly good (better than it has anyway). There were a mix of shallow and deep breaths but no noticeable gaps (obstructions). I figure the backup rate was helping him. I'm not sure, but is what I'm seeing reflected on the "patient triggered breaths" graph (which I included this time for the sake of this question)?

My underlying question is: should I continue to encourage my father to sleep on his side as much as possible? He's indicated that he would love to sleep on his back sometimes due to occasional hip pain, but he has been very agreeable to my suggestions nevertheless.

Ultimately, I am excited to learn more about the other options being mentioned here, namely AVAPS. I'm nearly positive that ASV is not going to pass muster in my father's case, given that he has practically all the contraindications you've listed. (I've since learned the the ventricular caveart you mentioned yesterday applies to his also.) Nevertheless, and as I mentioned to dmeRT, he has an appointment with pulm. in two weeks. Getting educated in advance, I would love to inquire further about ASV with him.

So in light of the complexities you've both noted about my father's condition and getting S/T to work, how would you say my new report looks?

Given its comparative and marked improvement over all previous adjustments I've made, I'm reluctant to try yet more changes at the moment. But if you both see need for more immediate action, I will be happy to try your further suggestions, dmeRT. I look forward to your reply.
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#17
AHI 9.82  --  looks like your headed in the right direction.  "Patience is the key to successful titration" as once was told to me.   Wink

OA - looks good not concerned
CA - 3.0  -- I'll consider this acceptable considering where you started out
Hypopneas - 6.16 --  I'd make a minor adjustment to the EPAP, up it to 9 cmH2O.  

That's it, don't change anything else.  give your dad a few days on these settings.
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#18
Interesting results in this graphic.  I'm really happy to see OA reduced.  The CA corresponds with patient triggered breaths, and this is where the backup rate becomes important, (and where ASV excels).  These are vastly improved results.  I agree with increasing EPAP as suggested by dmeRT, but might maintain IPAP (PS 8.0), since that will maintain volume during hypopnea.  I'd be interested in dmeRT's opinion in that regard since I am mainly shooting from the hip here, and I think we have the assistance of someone with relevant experience.

[Image: 05_31.png]
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#19
First, I agree with sleeprider that an ASV would be ideal with the ability to have varying pressure support.   I'm just trying to work with what we've got. 

I've always fixed hypopneas with epap as I consider the airway partially obstructed.  That's why I suggested the epap of 9.  1 cmH2O of less pressure support, I don't think makes much of a difference, so I left that alone.  The other reason I didn't increase the ipap is because that would also increase the mean airway pressure which I feel could contribute to more CA's.  I saw one of the earlier reports where the setting was 17/10 and the CA was very high.  that makes me want to stay away from the higher pressures.  one of the reasons why I recommended 14/10 earlier.  I haven't done many bipap titrations with the ipap/epap difference more than 4. 

I'm not saying that keeping the PS at 8 is wrong, I don't think it's necessary.  I could be wrong.

Whatever Brett decides to do, I'd like to see the settings stay the same for a while before making any more changes.  The report could change from day to day, I don't want to make any knee jerk reactions.
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#20
I sure feel fortunate to be getting such good help with good results too. Thank you both 
Tonight I am staying up while my father sleeps. When I got home from work he was in quite rough shape. It was like he was over tired. Worse he was afraid to go to bed because he insisted something must be wrong. Why was he so exhausted, he wondered, when his sleep has improved so much? 
After a grueling hour of watching him struggle to stay awake, he finally consented to Sleep when I assured him I'd be right here. 
Even then though he fought sleep until finally conking out. He's barely budged in the three hours since. 
Any idea what that might be about? Could he still be over tired after some good nights? 
RR is about 28 right now. I upped epap to 9. Curious to see how it goes. 
Writing this on my phone btw.
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