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[Equipment] Philips Respironics Dreamstation Auto BIPAP Oxygen Bleed In Issues
#1
Question 
Philips Respironics Dreamstation Auto BIPAP Oxygen Bleed In Issues
Hello All. New to this forum. I am the Mom and Caregiver to my daughter who has Pulmonary Hypertension and Congestive Heart Failure and an idiopathic Interstitial Lung Disease as well as Obstructive Sleep Apnea with the added challength of Bruxism (Grinding of the Jaw while Asleep) and Restless Legs Syndrome. She stopped responding to the original CPAP, also a Dreamstation back in April. We have waited since May 5th and a couple of sleep studies until yesterday. We tried the new Auto BIPAP and experienced a pretty severe desaturation while on the machine. All parts worked except her getting enough oxygen all night. Her SpO2 dropped to the mid 80s and didn't go higher than 90. I checked all connections and fit and can't figure out why this is happening even when I raised the O2 flow to 6L. Her prescribed supplemental oxygen flow is only 3L. Does anyone have any experience with this type of issue? Docs referred me back to DME and DME said they didn't know why and to contact Philips Respironics directly. My daughter suffered from migraines and other symptoms of oxygen deprivation all day. Super frustrated and worried here. I fear her PH and CHF are progressing because we aren't adequately treating her sleep apnea.
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#2
RE: Philips Respironics Dreamstation Auto BIPAP Oxygen Bleed In Issues
From memory, you need the have the bpap on manual mode for over 3 l/m and may be where it is going wrong? There should be a manual titration pressure prescription for her, that you can talk with your doctor about. 

If you are concerned and obviously you are to have a first post here. In australia I would ring an ambulance, and let the hospital sort it out, but I don't know the health care system you have and the costs involved.
she responded to the 6lt to >90% that is probably the best you can do for now. 

A dme isn't qualified and neither is your general doctor by the sound of it. She may need to be retitrated. I'd contact the titration center where she was done last and ask about the o2. also ring the treating specialist ASAP?
mask fit http://www.apneaboard.com/wiki/index.php...ask_Primer
For auto-cpap, from machine data or software. You can set the min pressure 1 or 2cm below 95%. Or clinicians commonly use the maximum or 95% pressure for fixed pressure CPAP, this can also be used for min pressure.
https://aasm.org/resources/practiceparam...rating.pdf
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#3
Thumbsup 
RE: Philips Respironics Dreamstation Auto BIPAP Oxygen Bleed In Issues
Hi There. I was able to reach a technical help desk and her Pulmonologist and the person who remote programs the BiPAP machine and was able to fix her IPAP/EPAP settings to her prescribed therapy pressures. We live in Arizona on the Navajo Reservation and our specialists are 5 hours away. The Help Desk was also able to help me adjust the oxygen bleed in as that inflow mixes with the Room Air flow from the BiPAP and gets diluted in the mask airspace. 

We will see how it goes tonight. Thanks for your input!!!
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#4
RE: Philips Respironics Dreamstation Auto BIPAP Oxygen Bleed In Issues
Lets hope you should be fine now. They would have been able to access last night's data and made the adjustment.
mask fit http://www.apneaboard.com/wiki/index.php...ask_Primer
For auto-cpap, from machine data or software. You can set the min pressure 1 or 2cm below 95%. Or clinicians commonly use the maximum or 95% pressure for fixed pressure CPAP, this can also be used for min pressure.
https://aasm.org/resources/practiceparam...rating.pdf
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#5
RE: Philips Respironics Dreamstation Auto BIPAP Oxygen Bleed In Issues
Hi mshelgamble,
WELCOME! to the forum.!
I wish your daughter luck with CPAP therapy and I wish you good luck in getting her good care. Hopefully, the tech was able to get her machine adjusted well.
trish6hundred
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#6
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RE: Philips Respironics Dreamstation Auto BIPAP Oxygen Bleed In Issues
Thank You! We will see how she responds tonight!!
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#7
RE: Philips Respironics Dreamstation Auto BIPAP Oxygen Bleed In Issues
Your daughter has many complications from health issues that honestly exceed the ability of the forum to advise on. Congestive heart failure with complex apnea can result in periodic breathing and mixed central and obstructive apnea that is very difficult to treat with CPAP or BiPAP. The use of an adaptive servo ventilator (ASV), used to be the gold standard for complex apnea and Cheyen-Stokes Respiration, but is currently contraindicated for patients with a left ventricular ejection fraction less than 45%. Further study is underway to better quantify risks and benefits of ASV for these patients, a cohort that may include your daughter.

There are technical complications using BiPAP with oxygen bleed that are poorly understood, even by professionals. First, the flow rate of CPAP and BiPAP causes significant dilution of the oxygen bleed. More than 3-times the respiratory tidal volume is delivered to the mask to prevent rebreathing, so the prescription of 3 L/m O2 is diluted at least 3-times and greatly reduces the O2 delivered to the patient. Very few doctors or suppliers know how to quantify or counter this dilution. In addition, using pressure support in the BiPAP (difference between IPAP/EPAP inhale/exhale pressure) can increase the instance of central apnea.

The Philips Respironics BiPAP Auto is a fully data capable machine. Since you are your daughter's best advocate, you should be looking at this data and ask question that can be addressed by the doctor. You can use the free #Sleepyhead software on a PC or Mac computer to see the nightly results, including the number and type of apnea, patterns of periodic breathing or Cheyne-Stokes, and other events. The software lets you see, breath-by-breath details of what is going on. We can help you to understand it, but may not be able to advise you on how to "fix" it, but it will facilitate discussions with your doctor.

I'm going to get into some details here of the dilution of oxygen that may be part of the problem in your daughter's case. Without any oxygen addition to air, we all breath about 21% oxygen (inspired oxygen FiO2 = 0.21). Your daughter needs a higher concentration of O2 in her inspired air. Without CPAP, a 3-liter/minute oxygen bleed will result in FiO2 of .32 (32%). There is a quick lookup chart to estimate delivered oxygen:

[Image: oxygen-therapy-26-638.jpg]

Your daughter's BiPAP may be delivering between 40 to 70 L/min in addition to her respiratory volume. The data in Sleepyhead shows the total leak rate and respiratory minute vent on a chart so you can actually estimate this very accurately. If the total amount leaked is 50L/m and your daughter's minute vent is 10 L/min, the total air volume is 60 L/min. To this your are adding a tiny 3 L/min of oxygen. Mathematically we can calculate her delivered oxygen concentration:

(oxygen flow rate at 100% + air volume at 21% O2) / Total air volume = oxygen concentration
(3L x 100) + (60L x 21) = 1360 / 60 L/min = 22.66% oxygen.

So in this example, the 3-L/min oxygen bleed only raises oxygen 1.7%. The effect of CPAP or BiPAP dilution flow must be understood by the professional attempting to deliver an oxygen prescription. The above is intended only as an example, however the tidal volume and leak flow rate for the BiPAP is available in the machine data. I would suggest to you that this calculation has not been done to account for the effect of the ventilation dilution caused by PAP pressure. In the above example, the oxygen bleed would need to be 7.25 L/min to deliver a 33% FiO2.
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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#8
RE: Philips Respironics Dreamstation Auto BIPAP Oxygen Bleed In Issues
Thank You for the extremely detailed answer. Her Pulmonary Hypertension Specialist, in fact, wanted her to use an ASV. She's recently had two sleep studies done, one at altitude of 6900+ feet as we live at 5700 ft elevation and one at 1070 ft which is the elevation of Phoenix and where my daughter's SpO2 on nasal cannula can be as low as 2-3L and reach 96-98%. That's where the prescribed 3L oxygen bleed in came from. The one done at altitude did NOT include a titration. 

I had reached out to the DME company we work with and according to them, they remotely fixed her IPAP to 15 and EPAP to 9 but more than 4 hours into the session, her IPAP was only 11.3. I don't know how long it takes to ramp that pressure up to 15. All I see now is a steady 9 cmH2O whether she's breathing in or out so she's nowhere near the therapeutic Inspiratory pressures she needs. I am at a loss. Her Pulmonologist who is her Sleep Apnea specialist is gone for the week and a doctor who doesn't know her at all is directing her therapy. 

How do I get the information you shared with me to the right person? That's my quandary.
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#9
RE: Philips Respironics Dreamstation Auto BIPAP Oxygen Bleed In Issues
I am not the expert here and some are responding here, but if I may, I suggest that you post the daily charts that you do have access to.  Please pay attention to the organization of the charts.  Not all are of equal importance.  
The data will help to understand what is happening.  

Fred
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#10
RE: Philips Respironics Dreamstation Auto BIPAP Oxygen Bleed In Issues
Rather than take someone elses word for what the settings are, press the control knob and home button at the same time for 4 seconds, then go to settings. Record what you see and post back.
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


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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