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[Treatment] Switched from CPAP to Bilevel but results no better
#1
Switched from CPAP to Bilevel but results no better
I started on CPAP 7 months ago. My AHI's were consistently in the 20's range on CPAP. I had a mix of OA's and CA's.  My CPAP pressure was set at 14 which wasn't breaking through the OA's. I wasn't able to tolerate higher pressure because it hurt my ears and causes me to swallow air and doc was concerned about CA's. I had an in-lab sleep study for titration in June and doc switched me to a Bilevel machine, the ResMed Aircurve ST.
I've been using it for nine days and each night has been a struggle. The machine pushes air into my mouth at a rate much quicker than feels comfortable. I feel as though I should relax and let the machine take over my breathing but that is disconcerting and causes me anxiety and the feeling of hyperventilating. Falling asleep is really a challenge. Doc turned down the pressure settings to EPAP 11 and IPAP 14 and switched the back up breathing rate from 9 to 7. Since then,  I have had large leaks on two nights and my mask is blowing out so much air that I am ripping it off in my sleep. I awake and find it in the bed. Falling asleep with the pulsing air is still challenging. Now doc is suggesting another titration lab for an ASV machine. I kinda feel like we're going all over the place. He's also suggested an oral appliance to use along with the Bilevel.

Anyway, if I can get this machine to work for me, I would be grateful. I realize it takes some fine tuning but I don't know where to start.

A little background info: My BMI is 25, I sleep in an adjustable bed with the head inclined due to vertigo issues. I can lower it if it would help. I started taking CBD oil a month ago for help with sleeping. I know it is counter intuitive for apnea but the lack of good sleep was beginning to cause much anxiety and melancholy. Notably, my AHI's have not increased while using it and I had a few nights with 11 and 12  AHI's on my previous CPAP machine, so I wonder if it actually helped?

One frustrating note: This new machine does not break out OA's from CA's. Everything is lumped together in the report. How do I know what's what?

I have attached the OCSAR report from my first night on the Bilevel with doc's original settings. Any help is much appreciated.
Thank you for this forum!


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#2
RE: Switched from CPAP to Bilevel but results no better
Welcome to the forum.  The ST, I believe, is the wrong machine for you.

Quote:This info is from the ResMed Sleep Lab Titration Guide
  • CPAP (continuous positive airway pressure) Fixed pressure delivered with optional expiratory pressure relief (EPR). It Treats OSA
  • AutoSet/APAP (automatic positive airway pressure) Automatically adjusts pressure in response to flow limitation, snore and obstructive apneas. It treats OSA
  • AutoSet for Her/APAP Automatically adjusts pressure in response to flow limitation, snore and obstructive apneas along with an increased sensitivity to each flow-limited breath, providing a more comfortable therapy for women. Increases sensitivity to each flow-limited breath, providing a more comfortable therapy for women (OK for men too). It Treats OSA
  • VAuto Automatically adjusts pressure in response to flow limitation, snore and obstructive apneas; Pressure Support (PS) is fixed throughout the night and can be set by the clinician. It Treats OSA, non-compliant OSA
  • S (Spontaneous) Senses when the patient is inhaling and exhaling, and supplies appropriate pressures accordingly. Both treatment pressures are preset: inspiration (IPAP) and expiration (EPAP). It treats Non-compliant OSA and COPD
  • ST (Spontaneous/Timed) Augments any breaths initiated by the patient, but also supplies additional breaths if the breath rate falls below the clinician’s set “backup” respiratory rate. It Treats COPD, Neuromuscular disease (NMD), Obesity Hypoventilation Syndrome (OHS) and other respiratory conditions
  • T (Timed) Supplies a clinician-set respiratory rate and inspiratory/expiratory time, regardless of patient effort. It Treats COPD, Neuromuscular disease (NMD), Obesity Hypoventilation Syndrome (OHS) and other respiratory conditions
  • iVAPS (intelligent Volume-Assured Pressure Support) Maintains a preset target alveolar minute ventilation by monitoring delivered ventilation, adjusting the pressure support and automatically providing an intelligent backup breath. It Treats COPD, Neuromuscular disease (NMD), Obesity Hypoventilation Syndrome (OHS) and other respiratory conditions
  • ASV (adaptive servo-ventilation) Targets the patient’s minute ventilation, continually learning the patient’s breathing pattern and instantly responding to any changes. It treats Central or mixed apneas, complex sleep apnea, Periodic Breathing (PB)
  • ASVAuto Provides an ASV algorithm plus expiratory positive airway pressure (EPAP) that automatically responds on the patient’s next breath to flow limitation, snore and obstructive sleep apneas. It Treats Central or mixed apneas, complex sleep apnea, Periodic Breathing (PB)
  • PAC (Pressure Assist Control, also known as Pressure Control) The inspiration time is preset in the PAC mode; there is no spontaneous/flow cycling. Inspiration can be triggered by the patient when respiratory rate is above a preset value, or delivered at a set time at the backup rate. It Treats Neuromuscular disease (NMD), pediatric patients
ST (Spontaneous/Timed) Augments any breaths initiated by the patient, but also supplies additional breaths if the breath rate falls below the clinician’s set “backup” respiratory rate. It Treats COPD, Neuromuscular disease (NMD), Obesity Hypoventilation Syndrome (OHS) and other respiratory conditions  Which do you have?  Thought so.


This is what you need 
ASVAuto Provides an ASV algorithm plus expiratory positive airway pressure (EPAP) that automatically responds on the patient’s next breath to flow limitation, snore and obstructive sleep apneas. It Treats Central or mixed apneas, complex sleep apnea, Periodic Breathing (PB)

You have a lot of Hypopneas, they are NOT being treated with a PS of 3.  Central Apnea requires a MUCH higher pressure support to initiate or force a breath.  I suspect that you also have significant Flow Limitations.

I would like to see detailed views of your chart, 2-minute view to see flow limits and breath form clearly, a 10-minute view to see the overall pattern of your breathing.  These around 01:30 where you are having UAs. 

Also post a redacted copy of your sleep study. That will help us to help you.

Ramp, Most of us here do not use a ramp, especially a long 45-minute ramp.  Your machine does not look for events during the ramp so that is a period that you are not being treated

If you want we can optimize this ST but seriously, you belong on an ASV.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#3
RE: Switched from CPAP to Bilevel but results no better
Agreed. If they state you have mixed apnea, the ST will not ever really help. Tell them you want a ResMed AirCurve 10 ASV Auto. No substitutions. The doc that sent you home with an ST needs to look at the calendar, we're in 2020. Most of these doctors and Respiratory Therapists ignore the best machine there is for Central Apnea and mixed apnea. Tell somebody there to recognize the central apnea aspect and treat it with something that is not antiquated and very outdated.
Dave

OSCAR
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#4
RE: Switched from CPAP to Bilevel but results no better
THANK YOU SO MUCH, bonjour and SarcasticDave94. You have empowered me to be done with this ST machine and ask for the ASV Auto.

I have attached the results of the sleep study they sent to me online. There are no charts or anything like that. Just a long list of apneas/hour, etc.

I also tried to hone in on the detail of my OSCAR print out that you asked for, bonjour. (I had to read the tutorial for OSCAR on how to do this so I hope it came out right. My F12 key doesn't work so I had to use snipping tool.)

I had extensive testing including MRI, CT scan, EKG, and all sorts of blood work last fall/winter for my vertigo. I am healthy with the exception of this sleep apnea and some inner ear balance problems. I take no prescriptions. It's the apnea that knocks me down on many days.


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#5
RE: Switched from CPAP to Bilevel but results no better
Looking forward to seeing the results from the ASV hopefully that will be a RESMED machine as well good luck
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#6
RE: Switched from CPAP to Bilevel but results no better
Because of your combination of events I feel you will do much be[we on ResMed ASV and feel you need the more aggressive algorithm of the ResMed for the obstructive portion of your apnea.

Your UA a}ears to be mostly Central apnea that was not treated (couldn't be at your settings)

It is not uncommon for your doctor to require a titration study using an ASV prior prescribing an ASV. Also currently a cardiac function test is required, soon to not be required, to measure your ejection factor. That is more of a formality.
Fred Bonjour - Project Manager and Lead Tester for OSCAR - Open Source CPAP Analysis Reporter 
OSCAR

Download OSCAR
New to Apnea? Helpful tips to ensure success
Soft Cervical Collar
Mask Primer
Dealing with a DME
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#7
RE: Switched from CPAP to Bilevel but results no better
You're welcome, glad to help out.

FWIW on the ejection fraction or full name is Left Ventricular Ejection Fraction (LVEF). This ASV path probably will require an echocardiogram, an ultrasound exam that records audio/visual of the heart. There is no prep needed, and is typically done at a hospital or other medical facility most likely in the Imaging dept. It's about a 30 minute test to get the efficiency rating to get a percentage grade of 45% or higher/better. You have to lie on an exam table while the technician pushes the wand around your chest over the heart area. Be warned, the gel used on the wand is very cold.

Mine graded at a 55% LVEF in 2017 in prep for the ASV.

After the exam itself, a cardiologist reviews the test and does a write-up. It's a few days to get this part done typically, and then their office sends the results back to the ordering physician.

Given enough time, this test should be done away with. But for now, this is still on the table.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#8
RE: Switched from CPAP to Bilevel but results no better
OK! You are all a wealth of helpful information. My doc said he would request me to be scheduled for the ASV titration study. My last study in June was delayed due to Covid so hopefully this won't take too long to get on schedule.
Just curious, what is the reason for the cardiac function test?
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#9
RE: Switched from CPAP to Bilevel but results no better
There was a flawed study and report involving ASV causing health problems among patients that were on the ASV with lower LVEF. The study goes by SERVE-HF and ResMed was linked to it somehow as I recall. This study has since proven to be inaccurate and is expected to be pulled from the shelf so to speak with a new and supposedly more accurate study.

The very basic fact about this is they inaccurately linked to heart failure and patients with ASV being a contraindication. In other words if one has heart failure you shouldn't use ASV. If heart failure applies to you, you would already know it along with your cardiologist. Personally, I know I have heart conditions, and not one negative thing is because of ASV. Don't let it worry you too much. I'm just prepping you that this will be an ASV hurdle.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#10
RE: Switched from CPAP to Bilevel but results no better
To prepare for your discussion with your doctor regarding ASV, I want you to read parts of the Resmed Sleep Lab Titration Guide. It's easy reading and clearly explains the intended use for every machine Resmed makes. Look closely at the intended use for ST vs ASV. https://www.resmed.com/us/dam/documents/...er_eng.pdf

Please review and ask any questions you may have. Note especially that the ST is intended for individuals with COPD, NMD, OHS and other respiratory conditions. The ASV is for patients with Central or mixed apneas, complex sleep apnea, Periodic Breathing (PB) like you. I will assure you we have many members using these machines, and once you have one, your therapy will be transformed to a much more satisfying and comfortable one you can look forward to each night. The Resmed Aircurve 10 ASV in ASVauto mode does not require a sleep lab titration. Just set the default settings for EPAP min, EPAP max, PS min and PS max and the magic will happen.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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