Breathing pattern identification, Flow limitations and posture

[SingleH]

Thanks, Ive got the machine now so applying those settings.

What should I do with TiMax. His inspiration time is normally about 1 to 1.5 seconds (although how accurate that is due to his breathing habit). Should I leave it on the default of 2 for now. I did find when it was set to 3 (from 1.5 as per Resmeds chest condition recommendation) on my previous trial it seems to help slow his respiration rate down but it could have been the other settings and also I really wasnt able to do solid testing with the other units due to the noise problems.

Perhaps I will leave it on the default for now.

[Sleeprider]

TiMax does not normally come into play in a normal individual that cycles spontaneously unless it is too short. The default setting of 2 seconds is comfortable for most people, but where an individual normally takes a longer breath, it can feel like the machine is not supporting that breath. TiMax is often used to limit inspiration time to conserve time for expiration, especially where breath stacking is a possibility due to emphysema or COPD. In other words, we want the lungs to have time to expire the last breath before triggering a new inspiration. This is much more of a consideration in ventilators where expiration is passive, and inspiration is mechanical pressure support. That's the long way of saying I think a 2-second TiMax is about right. If you find he needs more time for expiration (lungs are still partially full when inspiration begins), then it can be shorter. If he is fighting for more time of inspiration as indicated by time of inspiration graph that is flat up against the TiMax then it may need lengthened to allow a full breath.

[SingleH]

Thanks Sleeprider,

So I set him up with the machine and he had a afternoon nap for an hour. Machine was comfortable for him and quiet thankfully!

However he did wake up after an hour and looking at his stats he had a few apneas.

I see the Aircurve 10 Vauto yields a variety of new graphs, different from the Lumis 150 and different again from his F&P Sleepstyle. It makes it a little complicated to do a like for like comparison, but overall it seems the Vauto provides the most info which is the most important thing.

Observations:

• I noticed he had 4 CA's which is not something he has had before
  

• His waveform is somewhat erractic on the current settings. I notice there are multiple clusters of mini peaks in mask pressure every so often, which I suspect is when the machine is getting confused by his chest movement. Where the waveform is messed up, you can see the machine has responded with multiple smaller pressure changes.
  

• On the current settings he doesnt have the smooth peaks that was achieved on some of the previous trials.
  

Other info direct from the machine if any use:

Spont cycle 75% (I'm wondering if cycle should be set to low, as the machine might be thinking his jerky chest movement is being detected as an early end of a breath?)
RR 18
Ti 1.3s
VT 560ml
AHI 6.3
Central AI 4.3



I also imported the data into Sleep HQ

Sleep HQ report

[attachment=55939][attachment=55940][attachment=55942]

[Sleeprider]

Give the cycle sensitivity a try. I'd like to review exactly the settings used here and also caution against using a nap as a good indicator of a normal sleep session. The zoom did not include either of the CA events, so I'm at a loss as to their cause.

[SingleH]

Ok noted about the nap not being accurate, I wont use that and will only use proper nights sleep going forward.

Im going to give the cycle sensitivity a try and change it to low.

I think at the core of the problem is the machine detecting his fluctuating chest wall movement during inhalation, as either a new inhalation or an end of exhalation. Somehow need to find the right combination of settings to get the machine to initiate the IPAP phase, and for lack of a better word, "drive through" and ignore his fluctuating inhalation movement.

Current settings:

Min EPAP 9
Max IPAP 18
PS 6
Ramp 4
TiMax 2.0
TiMin 0.8
Trigger High
Cyle Med (will change to low)

Here are the screenshots of the CA's anyway.

[attachment=55945][attachment=55945][attachment=55946]

[Sleeprider]

Current charts look good and this therapy is effectively ventilating your dad without pushing pressure support breaths at him. Please be sure to ask him questions concerning comfort and include that alongside the charts.

[SingleH]

I now have screenshots from the first nights sleep. The first half of his sleep looks pretty good, then he woke up to use the toilet and in the second half of his sleep he had lots of events. He said it wasnt a good nights sleep and he was tossing and turning and had lots of dreams.

Spont Cycle was 45.0%

Max IPAP 19 (usually he gets mask leaks above 17 on his CPAP)
Min EPAP 9
PS 6
TiMax 2.0
TiMin 0.8
Trigger Very High
Cycle Low



Fullnight in total
[attachment=55959]

Fullnight with leak rate graph
[attachment=55960]

Zoomed in on apneas
[attachment=55961]

[Sleeprider]

Well, we know the Vauto works well for the half of the night his positional apnea was also controlled. I think that remains the challenge.

[SingleH]

So Im making good progress. I raised EPAP up a bit to 10.6 and limited max IPAP pressure at 17.6 apneas to reduce leaks. AHI's are down to 1.5 and he managed to sleep all the way though the night without the machine reaching max pressure.

Im tying to improve the waveform and increase the spont cycle so its 100%. I increased Timax from 2.0 to 2.5s and his daily spont cycle increased from 67 to 75%. I will increase further to see how that improves.

I also increased his Ti Min to try and override the erroneous mini breaths the machine seems to be detecting.

I used the Clinician mode Sleep report feature and noticed there is a symbol that flashes during live operation. I assume its a sensor that is detecting when the breath is either not meeting the definded Ti Min or Ti Max value, as I noted it would flash up either Ti Min or Ti Max, if I adjusted either of those values too far in one direction or another. 

Is my understanding correct as I couldnt see this in the Aircurve Manual? I ended up increasing from 0.8 to 1.0 as that seemed to go for the longest period without Ti Min flashing.

BTW, I'm really starting to see how superior this machine is in terms of its functionality and customisation as you alluded to much earlier in this thread.

       

[SingleH]

If you find he needs more time for expiration (lungs are still partially full when inspiration begins), then it can be shorter.  If he is fighting for more time of inspiration as indicated by time of inspiration graph that is flat up against the TiMax then it may need lengthened to allow a full breath.

I realised I missed this important comment about the graph flat up against TiMax. Looks like I need to Increase Timax. 

Managed to get some good results with this machine including 0.0 on one night.