[Treatment] New Member seeking help with Resp. settings

[Brett C]

I hope this post isn't too long. I just want to give you as much helpful info as I can at the outset in the hope of receiving some good help.

My father, Ray, is 74, 175 lbs, 5'11". He suffers from complications of post-polio (PPS), chronic pain, and heart disease. Incredibly, he's been fairly healthy otherwise and active until he had pneumonia this winter. He's been using BiPAP for about 9 months (except for that time with pneumonia). Results have been variable but the benefits are very evident.

I could really use some help navigating the changes I've been making to his settings. As you can see in the profile, this is a Respironics S/T. Overall compliance has been excellent but I've been having trouble getting the AHI down without complaints of too much pressure.

First of all, there is a huge difference between his side-sleeping and back-sleeping. Back sleeping invariably results in high OA. If I adjust the settings to significantly curb OA, breathing becomes short and shallow when switching to side. There are increased complaints of aerophagia as well.

Please consider the three summaries I've uploaded: 5/14, 5/28 and 5/29.

(Whoops, I guess I can't post the link after all, being a new member. So I've removed it.)


5/14 reflects the latest approved prescribed settings and the first night using Bipap since 4 mo. of pneumonia. The day prior saw signs of extreme over-tiredness. I spent the night observing and ensuring compliance and the results the next day were stunning. He was alert, and able to function without extreme fatigue.

However, with increased successive complaints of aerophagia and shallow breathing, I lowered EPAP and tried Bi-flex, which meant switching from s/t to s mode. AHI rose dramatically and sleep quality deteriorated - see 5/28.

5/29 reflects a new set of changes I made during his sleep last night, beginning with the rise of AHI while back-sleeping. I switched back to s/t mode, raised BPM, and both pressures to near-original levels. Most of 5/29 was spent side-sleeping, breaths were deeper than 5/14 for sure, and OA was much improved. To my disappointment however, H events rose, contributing to a higher AHI than I'd expected. Faint brief moans often attended expiration throughout the night.

Any suggestions will be taken as just that and will be deeply appreciated.

I.e.:How might I get these events lower without introducing other problems such as aerophagia? How might I strike a balance for side-sleeping ad back sleeping? Could I set an apnea alarm to enforce side-sleeping? How do the alarms work on these machines?

(The settings in my profile have changed some since I posted them and are likely to change again pending your response(s).)

(As another note, Sleepyhead data often cuts the sessions short, so these end times are not entirely accurate. I've since downloaded Encore Basic and found whatever's been missing. I have this Forum to thank for that!)

~Brett

[dmeRT]

Hi Brett,

It's great that you are asking questions about your fathers care and are wanting to provide the best for him. I think your father will be a complex case to fix and recommend you follow up with his doctor and dme provider.

I think you will continue to have trouble regulating your father's ahi and comfort because of his medical history. I believe you will be battling two different factors with your father. OSA and respiratory insufficiency.

Bipap s/t provides a set Ipap and set epap at a set rate. So he will get the same support no matter if his needs change during the night. i.e. sleep positions. so what might work one night might not work the next. Also, it sounds like he needs the bipap for his polio/muscle weekness and/or scoliosis which could cause some respiratory insufficiency.

I would ask his doctor about an AVAPS bipap where the support is volume based, not pressure. An AVAPS will provide the same volume with each breath with varying pressures rather than the bipap s/t which will provide the same pressures with each breath but varying volume.

sleep apnea (OSA) will still have to be managed and can be done by adjusting the epap.

Again, I would suggest managing his care through a doctor and not a web sight. You'll need to take the proper steps to get equipment approved by his insurance.

[Sleeprider]

Brett, after 4 posts you will be able to post link the images as described in my signature. Meanwhile, adding a space in the URL will let us see the images. If your dad does not need the backup rate of the S/T, he might do as well on a BiPAP Auto (VPAP auto for Resmed). I don't see any issues with CA, in spite of the very high pressure support you have set.

I think you need to rethink your approach. If AHI is rising due to obstructive events, the solution is not to increase pressure support, but to increase EPAP. This further reinforces the idea of using auto bilevel. Once pressure support is 10 cm (i.e. 15/5, 16/6) all of the respiratory effort is satisfied. Just because you can add more, does not mean you should. The answer is to get the PS back down to a reasonable level, then set EPAP high enough to prevent OA in any position, and work from there. Again, using an auto bilevel or AVAPS as suggested above, will allow EPAP to increase or decrease with sleep position automatically, while maintaining a PS that is effective and comfortable for his needs.

Do a search for BiPAP Titration Protocol to learn more about how pressure adjustments are done for different problems. Your approach to use PS ahead of all other adjustments is not going to work and the problems your dad is having is a result of poor titration decisions. I would go back to his prescription until we can talk further using the data, or have a discussion with his doctor.

[trish6hundred]

Hi Brett C,
WELCOME! to the forum.!
I wish you good luck as you help your father with his CPAP therapy and I wish your father good luck with getting used to it.
Hang in there for more responses to your post, and you have come to the right place for help.

[Brett C]

Thank you both for responding to my post. Having just got home from work, I will not have time to reply as much as I'd like but I will at least re-attempt to post the link to those PDF files I obtained for you to look at. 

 <<http://fc.hermon.net/~clemons/uploadedfiles/>>

---

And thanks for the note Trish!

[Sleeprider]

Thanks for posting the images. It is far preferable to post the daily details with summary data as shown in the first link in my signature, rather than use the report function in Sleepyhead.   There are three very different scenarios provided.  From the posted images, here is the machine being used, and the results summary for three scenarios.  The machine is a Philips Respironics System One (60 Series) BiPAP AVAPS, and the settings and results posted are summarized as follows:

Mode: Auto Bi-Level (Fixed PS) EPAP 10.0 IPAP 17.0 (cmH2O): OAI=1.08 HI=3.79 CAI=16.05 REI=0.00 VSI=0.00 FLI=0.00 PB/CSR=0.00% (PS 7.0)

Mode: AVAPS  EPAP 5.0 IPAP 15.0 (cmH2O): OAI=29.20 HI=1.95 CAI=12.57 REI=0.00 VSI=0.00 FLI=0.00 PB/CSR=0.00% (PS 10.0)

Mode: AVAPS EPAP 8.0 IPAP 17.0 (cmH2O): OAI=4.29 HI=7.15 CAI=7.75 REI=0.00 VSI=0.00 FLI=0.00 PB/CSR=0.00% (PS 9.0)

Clearly none of the results are satisfactory.  The best OA results were on BiPAP mode fixed PS with PS at 7, however this was also the worst CAI.  The AVAPS at 17/8.0 had moderate levels of OA, H and CA and was the best overall results at about AHI 19.3.

I would like to suggest a path to helping your dad, but I think he is on the wrong machine.  If he is not suffering congestive hearth failure, and has a good left ventricular ejection factor, an Adaptive Servo Ventilator (ASV) would be much more effective in resolving the complex apnea situation with many OA, CA and H events. The only person that can help his to get that device is his doctor.  The ASV uses variable EPAP to provide enough pressure to resolve obstructive events.  It uses pressure support that can vary on a breath by breath basis to provide comfortable ventilation for his COPD, and more pressure support only as needed for the CA and hypopnea.   What this means is that your dad could perhaps resolve his OAI using an EPAP range of 8-11 which could be set in the machine as a range.  Then he could use a minimum pressure support to provide relief for COPD, with higher pressure support available for central apnea and hypopnea.

Since your dad has mixed or complex apnea, the machines he is currently using actually aggravate and cause the centrals.  Lower pressure support will reduce the incidence of centrals, but when they occur, the PS can be raised automatically by ASV to trigger a breath based on the backup rate.  While AVAPS is appropriate for COPD, it is the presence of complex apnea that appears with the pressure support that makes its use a problem. I would waste no time in discussing your options with the doctor, including looking into using the backup rate function of AVAPS to perhaps deal with the centrals, as an alternative to ASV.  Assuming he is medically fit for ASV, that appears to me to be the better option.

[Brett C]

I am deeply grateful for your help, Sleeprider and appreciate your prompt reply to the reportd I sent. As I'm sure you can tell, I am woefully new to all of this and still getting my bearings as far as the knowledge involved. It's also difficult, as you can imagine, to be in the "middle" position - the one navigating this realm on behalf of someone else.

The sobering fact of the matter is, that if this all came down to negotiations between the patient (my father) and the pulmonologist, there would be a BiPAP machine in his closet collecting dust following his first week of being unable to adjust to it. The original prescription was based on a sleep study that was done when my father was suffering badly from seasonal allergies and in which he slept exclusively on his back and primarily through his mouth. Needless to say, the first script was very steep with IPAP around 25, as I recall. Compliance was not going to happen and neither the Dr or the dme provider followed up even enough to notice that the machine wasn't being used.

That's when I stepped in and made an appt with dme lady seeking some way to ease my father into the regimen. It only seemed reasonable to me (tell me if I was wrong) that sub-optimal compliance would be better than no compliance. Wasn't there a way to start off gently to at least get my father acclimated to the device, I asked?

DME lady worked with me to get the script changed to lower settings and the results (not only in terms of compliance but in terms of improved health) were remarkable. Yet as you have observed, we are dealing with a host of complex factors as far as my father's health is concerned. The onset of pneumonia last winter seems to have really set things back. (Although, for what it's worth, and though you do not know my father, and barely know me for that matter, it's quite wonderful to be hearing the sound of him laughing and joking with my mother down the hall even as I'm writing this note). I haven't pulled up the report yet today, but he seems to have at least gotten enough sleep to be up and around, and enjoying his morning so far.

Going back to the original script and sleep study and visit with pulmonologist:

There was, I believe, some discussion at that time about ASV. I was not there and, as I said, I am still learning all the lingo. But as I recall, the Dr. originally was going to conduct the sleep study using ASV instead of BiPAP. Whatever it was, it was some device that was more powerful or at least potentially more effective than BiPAP. The suggestion was met by much concern about ejection fraction, CHF, and my father's heart conditon generally. There were apparently some reports of people in his condition having serious, and even fatal responses to such therapy. PCP got involved and possibly cardiologist too. This may explain why he was given a BiPAP instead of ASV, despite ASV being perhaps better suited to his sleep behaviors. Like you, the pulmonoligist apparently saw that as the better route. To me, it still sounds like it could be too, so I am very open to discussing this further.

I am also by no means averse to taking this matter up with the doctors et al involved. I can certainly understand your encouragement to do so. It is, however, no easy feat. I am new to the forum but I doubt I would be alone in saying that good help among medical profs these days is getting increasingly hard to find. I do not doubt the expertise of my father's pulm. But I have had the unpleasant experience of trying to get appts with him. He (and pulm generally in this area) are spread way too thin. Not to mention, he is in India 6 mo of the year. DME prov. has proven much more helpful, but she is overworked also.

In talking with you and getting some direction here, I intend to be better prepared to take the necessary next steps. I do not care about insurance coverage having discovered that buying outright is at least as cost effective as using Medicare.

I will also sit down with my father today and discuss what I've been learning so far. I will also ask him to recall what happened at that sleep study and if it was, in fact, an ASV that was originally scheduled for use.

Again, I appreciate you launching out to help me, especially while knowing so few details overall. Caution has its place and I can understand anyone in your position using it in situations like this. But getting ready help sure is nice too, even in the form of suggestions and the discussion of options.

I'll be in touch.

[dmeRT]

If you truely have an AVAPS bipap, here is what I would try.

First you'll have to "turn on" the AVAPS.

Set tidal volume to 400 ml
Set max ipap to 20
set min ipap to 12
set epap to 10.
set the rate to 10 (you'll have to be in s/t mode for rate)
everything else just leave alone.

try that for a few nights and see what happens.

[Brett C]

If you truely have an AVAPS bipap, here is what I would try.

Thank you for that. There is evidently some confusion about whether this device actually IS AVAPS or not. And I am not sure myself. I just put in a call to DME provider but will not hear back until tomorrow morning. Receptionist was only able to affirm that it is an S/T. EncoreBasic and Sleepyhead both list it as: BiPAP S/T 30 (System One 60 Series) (1060P) (C144552352BC1 3.05).

Back when I changed from S/T mode to S mode, Sleepyhead rendered the results as AVAPS, as opposed to "Bi-level fixed". But the only differences I noticed in making this change were that the Backup Rate (BPM) setting was unavailable while Bi-Flex became available. I don't see a way (or place) to enter the information you've suggested. So does that mean I don't truly have an AVAPS machine or that I just haven't found the right menu?

[Crimson Nape]

Brett,
Most CPAP's will list their model on a label normally located on the bottom of the machine.  Make sure your humidifier is empty or disconnected before flipping it over.