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Trach + BiPap?
#1
Trach + BiPap?
okay so my sleep apnea case is pretty bad and complicated...Thank you anyone for any inputs

Long story short, for years I've tried to treat my sleep apnea but failed every machine and surgeries.

After a long thought, I decided to get a tracheostomy (may look into jaw surgery in the future) and hoped that this would be it.

Unfortunately, although my sleep did improve a bit, it was nowhere close to the normal level (i actually slept like a normal person for two nights in my adult life, so i knew what "normal" sleep felt like)

My initial thought was that the hole in my throat was too small for me to breathe comfortably during night.  Which was true but not the whole truth.  I got a Bipap machine and hooked it up to my trach to help me breathe better but I found myself losing the respiratory drive as I was falling asleep.  Then I recalled I do that sometimes even before the trach and bipap.

Maybe not in the traditional sense, but I think I have some kind of central sleep apnea, or at least the lack of involuntary respiratory drive, (I'm guessing due to my collapsed airway and poor cervical posture).

Anyhow, I was doing research and purchased a Resmed Aircurve 10 ASV after seeing how people were praising it over a ST.  I just received it today and used it but to my great shock and disappointment, it did not provide the help I needed.  I connected it to my trach (OSA is fixed) but the ASV couldn't relieve my CA.  

I simply thought an ASV does everything a Bipap ST does and more but it lacked a lot of the settings that even my regular Bipap Aircurve 11 VAuto had.  I couldn't set the IPAP nor increase the Pressure Support over 6 ( I need it to be more for me to "breathe"/ventillate better).  I also could not control the back up rate.

Bottom line is, I did not feel good using the machine and kept feeling like I wasn't getting enough air nor ventillated.

I'm basically hoping for a machine to basically "breathe" for me during my sleep.  I theorized that as my body relaxes, I lose ALL of my respiratory drive until the very last state where my body really needs that oxygen, then I start hyper ventillating to get all the oxygen back.  And the cycle continues til the morning as I constantly wake up throughout the night, knowingly and unknowingly.

I'm wondering if I'm gonna need a legit ventillator like trilogy at this point or a Bipap ST would do the job.  It would seem the Bipap ST offers a little bit more control over the ASV such as the back up rate and the IPAP( i want to set EPAP as low as possible and PS about 10~15).

I also noticed that when my respiratory drive is gone, my lungs don't exactly move as much as I spontaneously breathe, even when the ASV is pushing the air in.  I feel that there is SOME ventillation involved, but not enough.  Would the Bipap's higher IPAP and higher back up rate resolve this issue?

I'm thinking of using the "timed" mode T, and just use the machine as a ventillator without any spontaneous breathing.  Is Bipap ST strong enough for that?  Anybody know what Bipap ST-A is and if I'm better off using that?

Thank you.
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#2
RE: Trach + BiPap?
I'm not certain I'll cover it all, so my apology.

Unfortunately you're mostly correct on the ResMed ASV, it doesn't have manual or accessible timing controls. That's why ASV failed my needs. I have COPD and Central Apnea. It does have IPAP, again not user editable directly. It is via edit to EPAP and PS.

ASV will not breathe for you. The V in ASV does stand for ventilator but not in the ventilator class way that you're expecting. That ventilator class begins ironically with ResMed ST-A.

ST-A felt similar to me to ASV when I trialed on from an acquaintance. ST-A has ventilator modes like PAC and likely might be usable to you, iVAPS ResMeds version of AVAPS.

Within ResMed family, CPAP, AutoSet, ST, VAuto, ASV, ST-A are CPAP class. In its own class is Stellar 100 and 150, they probably don't get issued much because they're ventilators but for some reason don't seem to count, mystery. Real ventilator then is ResMed Astral 100 and 150. This is the big unit that might be issued to those that need the real deal ventilator. ST-A can do the same just not with all the small little things the real vent Astral can.

Due to your situation, Astral can be maybe better. The limb circuit (hose, valves, etc) I think can be configured to connect to your trach area.
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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#3
RE: Trach + BiPap?
Dave covered it great.  I have been down this road.  You basically have 2 decisions to make at this point.  1st - either the ST or ST(A) are the 2 less options to start with usually.  The ST gives a "square wave" pattern that a lot of people don't like because it feels unnatural.  The ST(A) has more options and usually feels better.  2nd - you move to the real ventilator class (hospital grade).  Like Dave has stated:  Stellar 100 and 150, then Astral 100 and 150.  I think even the Lowenstein Prisma 30ST has and ivaps equivalent also (it should be less expensive than a hospital grade ventilator also).  I have the Philips Evo ventilator, but Philips is not producing any new ones.  They still provide support though and there are some out their on the used market.  But high $ usually.  

Before you make a get a machine from your insurance, or even purchase one on your own, check back here with me and Dave and others to help you make the best possible decision based on the choices you are given in your specific situation.
Download OSCAR
OSCAR Chart Organization
Attaching Files

Advisory Members serve as an "Advisory Committee" to help shape Apnea Board's rules & policies. 

Membership in the Advisory Members group does not imply medical expertise or qualification for advising Sleep Apnea patients concerning their treatment.  
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#4
RE: Trach + BiPap?
FWIW I had a new sleep study because I'm hopeful the Johns Hopkins doctor will help get me a machine and be willing to listen. I still have CA and OA.

Split study, they tried ST and it woke me. Terrible. Square wave bad stuff.
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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#5
RE: Trach + BiPap?
(06-18-2024, 10:58 AM)Jay51 Wrote: Dave covered it great.  I have been down this road.  You basically have 2 decisions to make at this point.  1st - either the ST or ST(A) are the 2 less options to start with usually.  The ST gives a "square wave" pattern that a lot of people don't like because it feels unnatural.  The ST(A) has more options and usually feels better.  2nd - you move to the real ventilator class (hospital grade).  Like Dave has stated:  Stellar 100 and 150, then Astral 100 and 150.  I think even the Lowenstein Prisma 30ST has and ivaps equivalent also (it should be less expensive than a hospital grade ventilator also).  I have the Philips Evo ventilator, but Philips is not producing any new ones.  They still provide support though and there are some out their on the used market.  But high $ usually.  

Before you make a get a machine from your insurance, or even purchase one on your own, check back here with me and Dave and others to help you make the best possible decision based on the choices you are given in your specific situation.

Thank you for the response!

Out of desperation, I bought a used Resmed Aircurve 10 ST a few days ago and I used the "timed" mode to somewhat breathe for me during the sleep.

As you said, that "square wave" made it near impossible for me to fall asleep and stay asleep.  My initial thought was maybe I'll just get used to it but thinking more and more about it, it's probably best if I find a machine that "smoothes" it out.

After doing some research, I suppose that "smoothness" comes from "Fall Time", the opposite of "Rise time".  ST unfortunately doesn't let you adjust it but I did find out that Stellar 150 has that setting.  I'm wondering maybe...just maybe this machine is finally the answer lol.  A "timed" mode with some smooth fall time, I feel like would do the trick.

Is there a really need for a higher machine like Astral? I'm not even sure if my insurance will cover the Stellar lol

Also, is it just me but breathing thru a machine feels very stuffed and low oxygen-ish.  It always feels very suffocating and unnatural.  I suppose that is to be expected but is this something that ill get used to?

Can I finally get the sleep I need...

(06-18-2024, 11:04 AM)SarcasticDave94 Wrote: FWIW I had a new sleep study because I'm hopeful the Johns Hopkins doctor will help get me a machine and be willing to listen. I still have CA and OA.

Split study, they tried ST and it woke me. Terrible. Square wave bad stuff.

Thank you for the response!

So I actually bought a ST a few days ago, hoping that would be the answer.

But I just couldn't fall and stay asleep with it.

After doing some research and the responses on this post, I'm thinking the main issue is the unnatural breathing by the ST, at least the exhalation part.

Apparently, the Stellar 150 allows us to adjust the "fall time" to smooth out the exhalation which would make the breathing a lot more natural and comfortable, hence the better sleep.  Is there a need for a higher machine like Astral?

Is it just me or breathing thru the machine always feels stuffy and suffocating.  Is this something I'll get used to?
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#6
RE: Trach + BiPap?
The air quality feel maybe is tied to humidity, but it may also be if there's not enough air moving that can feel that way.

Well it's happened, you've mentioned a control with Stellar I have not heard.

I know from my experience, Stellar wasn't even mentioned. I had the ASV then, and the RT said due to my timing needs and COPD/Asthma I should be on Trilogy or Astral. Saying this to tentatively conclude the Stellar isn't suggested it seems by medicals.

If it's Central Apnea that's your main treatment need, the ASV is right. If it's a ventilator, Trilogy or Astral, although an ST-A would be the mini version more or less.

Are you using anything to post OSCAR data? The ResMed AirCurve 10 ASV has single EPAP and as a range depending on mode. Again it will not breathe for you. Yes the ST can but... otherwise poor.
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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#7
RE: Trach + BiPap?
I've just tried to read up on the Stellar 150.  It says it has, "Personalized ventilation

ResMed Stellar™ offers reliable, intelligent ventilation in one easy, accessible device. It’s versatile with two customizable programs that can be preset for extra flexibility and offers a comprehensive range of alarms. Stellar also includes Vsync and ResMed TiControl™, proven technologies that work together for improved ventilation, comfort and sleep."

I, personally have never used the Stellar series.  I have used this Trilogy Evo ventilator, the ST (A), and the Astral 150 ventilator.  Each a little bit different, but for the most part, identical therapy.  

It seems like going by cost, the lowest cost would be the ST (A).  It has the same IVAPS program as the Stellar and the Astral.  It has the least timing controls, the Stellar has the 2nd most, and the Astral has the most settings.  

One problem that I incurred with the Astral was a super-sophisticated and super-sensitive alarm system.  I set off between 5 and 7 different alarms with my particular breathing pattern at night.  And the alarm system has a volume control of 1 to 5.  The alarms could not be completely silenced.  I am not sure about the Stellar (or even ST (A)'s alarms for that matter.  When I used the ST (A), I never set off any alarms, but I never was able to fall asleep with it either.  

If you plan on using your insurance, I encourage you to read up on all of these machines.  I found out here on this forum that the Lowenstein Prisma 30st has an algorithm similar to IVAPS (assures a constant tidal volume all night during sleep), but I don't know anything else about it or even how to acquire one here in the states.  

My RT at my DME was helpful when it came to ventilators.  If you use your insurance, talk to them.  If you go self pay, read up thoroughly before your purchase (and you can always come back here and post with any other questions).  
Download OSCAR
OSCAR Chart Organization
Attaching Files

Advisory Members serve as an "Advisory Committee" to help shape Apnea Board's rules & policies. 

Membership in the Advisory Members group does not imply medical expertise or qualification for advising Sleep Apnea patients concerning their treatment.  
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#8
RE: Trach + BiPap?
As for ST-A and alarms, my rogue trial sessions didn't set alarms, but I specifically didn't turn them on.
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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#9
RE: Trach + BiPap?
Based on your own experiences with the major ventilators like Trilogy and Astral, how were your comfort levels?

Were the breathings "natural" and comfortable enough for you to fall and stay asleep?

I couldn't really find anything about "fall time" in their guides, maybe they have different terms for it or already have it preset..
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#10
RE: Trach + BiPap?
My RT 1st gave me the Astral 150 to try.  The constant alarms that went off at night prevented me from ever falling asleep with it.  I pretty much never set off any alarms with the Trilogy Evo (the Trilogy ventilators are no longer being manufactured by Philips though.  They still provide support on them for awhile I think though.  There are some on the used market I think.  Some Astrals also.  And probably some Stellars.  Used ST(A)'s also.  

It took some time to get all of the numerous settings just right to make breathing at night feel comfortable.  Lots of tweaking.  But now it is great.  I usually maybe wake up once during the night.  

What is Rise Time?
The speed at which inspiratory pressure increases to the set target pressure is known as the rise time on most BiPAPs. Adjustments in rise time can improve patient comfort/tolerability with BiPAP. Rise times generally go from 100ms to 600ms, with settings of 1 through 5. A setting of 1 is the fastest while a setting of 5 is the slowest. Adjustments in the rise time change the waveform delivery of the pressure, furthermore, affecting your I:E ratio.
Why is this important?
Adjusting the length of time needed to cycle from EPAP to IPAP can be very useful. BiPAP waveforms can be altered with the rise time by changing the angle of the pressure delivery. A faster rise time, setting 1, can result in a square waveform, where a slower rise time, setting 5, will be more sinusoidal.
This slope change allows the patient to get more or less inspiratory flow to reach the target pressure. Setting this will vary with different patient populations. COPD patients tend to need a faster inhalation and prolonged exhalation. A shorter rise time will aid in this style of breathing for this patient population. A restrictive or neuromuscular patient may need a longer rise time to allow for adequate gas exchange. Patients in acute respiratory failure may be flow starved, therefore, needing a shorter rise time to meet their inspiratory demands.

So how do you determine the correct rise time?

Examining the waveforms and minute ventilation will help ensure proper setting of the rise time.  The goal with proper rise time is to reduce the work of breathing and increase patient comfort. Understanding the slope, along with clinical examination of the patient, will allow you to achieve this.
Asking your patients simple yes or no questions will also help achieve optimal rise time. These may seem like obvious questions, but simple terms are always best for your patient. Does your breathing feel easier? Do you feel like you can take a full breath? Is this tolerable? (I don’t use comfortable because for some BiPAP is never comfortable but they can tolerate it).

Ti - Sets the duration of inspiration in timed breath.  
Ti Max - Sets the maximum limit on time that the device spends in IPAP.
Ti Min - Sets the minimum limit on the time that the device spends in IPAP.  
Cycle - Sets the level of inspiratory flow below which the device changes from IPAP to EPAP. 
Download OSCAR
OSCAR Chart Organization
Attaching Files

Advisory Members serve as an "Advisory Committee" to help shape Apnea Board's rules & policies. 

Membership in the Advisory Members group does not imply medical expertise or qualification for advising Sleep Apnea patients concerning their treatment.  
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