[CPAP] Beyond ASV with Overlap Syndrome!

[sheepless]

I guess higher than possible combined max's allow both epap and ps maximum individual range but as you probably know, the machine won't go over 25 cmw.

[SarcasticDave94]

I do know it’s not hitting anything near 45. ASV is either capped at 25 or 30, I forgot which. No matter because I don’t hit that high.

[WillSleep]

 The problem I seem to encounter with mask on is vaguely like what it was on BPAP, the machines goals and mine aren't seeming to be on the same page in some way something like we're fighting one another at times, but without apnea events in high gear. I feel there's a tightness in breathing that reduces my breathing effort/input, at least it feels that way. This feeling happened at the same time as the month ago bronchitis episode and has not left.

Here's that 90 +/- min with OSCAR graphs in the following order:
Events, Flow Rate, Mask Pressure, Pressure, TV, MV, Resp Rate

" ... in some way something like we're fighting one another at times"

Dave,

I would be happy to leverage forward anything I can about what I have learned while trying to get the ASV to become more "synchronous" with my natural breathing patterns.    

If you want to post a few 2-2.5 min charts of example Flow Rate waveforms. 

Also. Was 10 bpm your natural Respiration Rate in the past on the ASV or other xPAPs, or do you feel the ASV  is holding your Respiration Rate artificially low?


WillSleep

[AFM1]

Up front, this is probably stretching beyond the realm of xPAP. Don't shy away from helpful comments on this title subject. I still desire input from those with knowledge in AB land. My striving to be super unique lands me in the way out there-ish territory of Overlap Syndrome. Yes I already knew I have this, but it hasn't been an issue until very recently. I don't have the numbers, but I think it's fair to say it's kinda rare population percentage wise.

I've researched a bit lately on various other machines beyond what my ASV can supply for therapy. Why should I consider a change if it's helping? As I've already mentioned, I have a rather rare status of being in the group that is called Overlap Syndrome, that is not only do I have sleep apnea but I also have COPD. Mine is even rarer due to my high CA content. I'm increasingly facing difficulty breathing while awake and asleep, hence it's likely either a COPD or oxygen level based issue IMO.

Feel free to educate me a bit. I know I have had the need for the ASV; my sleep study numbers scream that this is the right device as it treats CA. I stand by my own decision to have fought for this device. Up until very recently, my ASV was providing excellent therapy. However, after my latest bout of bronchitis, which it seems my COPD is leaning towards susceptibility to or equalling chronic bronchitis, my ASV and I don't get along as well. I can't breathe well either with or without mask, and there's no setting tweaks to help my issue of hard to breathe that I'm aware of while on the ASV. The ASV and mask seem to add to my breathing restrictions at this time.

I don't think it's just a SA situation I'm dealing with. I think COPD has gotten worse. My info fishing has a goal. I'm going to my pulmonary office today to get the medical take on this BTW. If there's a medical necessity, is there data out there on a machine like the ASV that combats CA but assists in difficulty breathing like what I'm in combat with here lately? Is it a Stellar or Astral, specifically the 150 of either, I should target? Or an ST-A? I only mentioned ResMed above, but include Respironics devices or others into the conversation. I may need the portable oxygen concentrator (POC), so that could be in the mix too. If it exists, which device is most like my ASV while providing the added support COPD may require? How should I expect these machines to feel and act different than my ASV? Maybe these questions are redundant, but there they are anyway.

I'll be questioning the nurse practitioner I see today to find out which tests we can do such as for oxygen levels to consider a POC or if I need to change from the ASV to an actual ventilator. Things are far from boring in the land of SarcasticDave94.

I also have CORD, and ended up in the hospital emergence at the beginning of this year, they calmed down my CORD so that I could breath, but my repertory surgeon, who is also a sleep doctor, wanted to do further tests as I was having another problem which made it hard to breath.
I had very bad reflux and coughing up phlegm all the time, even with all the reflux tablets and other things I was taking to stop it raising up my esophagus, and into the my windpipe which was burning the upper parts of my windpipe and into my lungs, and causing a terrible cough and constant phlegm making it impossible to breath, with my CORD.
I had a Nissan Fundoplication operation (keyhole surgery) which strengthens the existing non return valve at the top of the stomach that stops the reflux entering the upper esophagus.
Now this may not be your problem, but I would certainly be asking your doctor to have some tests down, on how much acid your body is producing in your stomach, and is it rising up your esophagus, as there is nothing worse when you cannot get that full amount of breath

[SarcasticDave94]

On GERD: I have it rather severe at times day or night, treated with meds including 2 meds and bottle of as needed Max strength Mylanta like generic antacid, the esophagus to stomach valve does not close tight/normal but bariatric surgeon that performed my weight loss stomach surgery called a Bariatric Sleeve says no action was needed 3 months or so ago after he did an EGD diagnostic, there was a hiatal hernia involved that did get addressed same time as bariatric sleeve, noted it has herniated again but somewhat less as noted after same EGD and prior of same EGD by other facility about a year ago due to severe chronic GERD, it's on list to address and I'll suggest action to address next year as enough other medical self advocacy on other things to address current poor medical status is on the plate, I'll ask about the surgery mentioned, currently I must sleep on or tilt left, flat on back low tolerance due to severe spinal issues, right side mostly a no-go

I'll post a few zoomed Flow Rate charts that I've got in separate post to follow, respiratory rate normally is on low side 9-12 with I think higher TV numbers or so as noted on ASV, can't say I feel ASV holding it artificially low, my current Big issue is based on real or perceived restricted difficulty breathing on or off mask but worse at night and a bit more yet mask on, ASV and I don't seem to be on same page as was before episode of bronchitis which may trace to my COPD and/or overlap syndrome

Thanks for replies.

Can I get a reminder on how we calculate proper (meaning normal-ish regardless of if COPD affected) Tidal Volume number? Is it based on height such as my 70 inches? Ditto inquiry on RR? TIA.

[Sleeprider]

Dave, your tidal volume looks fine at about 600, the problem is your minute vent being only 6.25 due to a fairly slow respiration rate. The slow respiration rate appears to be due to inspiration time of 3-seconds. So your sense of difficulty in breathing is not in your imagination. You probably observed the inverse I:E ratio. We might want to look at some zoomed flow rates and mask pressure to verify what is going on.

The ASV you use has no controls for time of inspiration, trigger and cycle sensitivity, and we can't set the backup rate. All of these features are in the iVAPS wheelhouse. The ASV uses the baseline minute vent and respiration rate you provide and maintains that, and it appears to be steady through the session you posted. I don't agree with your doctor's suggestion that higher IPAP is the answer, and see nothing here to support that the problem is obstructive that would be helped by that change. You are the best judge of the effectiveness of your EPAP min at 8.0, but the Auto ASV is only changing EPAP by less than 0.5, so higher is not the first direction I would go. I do thin a higher PS Min might be helpful to kick-start inspiration with the ideal of preserving more time for expiration. I could see PS min at 4 to 5 cm to help overcome inspiratory resistance, most likely related to either the current infection or COPD. Your current median pressure support is over 5-cm. Anyway, that is where I would start. You might look back over your historic Tv, Mv, RR, and Ti just to see if there have been any notable changes there.

[SarcasticDave94]

Thanks for the look, the ammo provided, and suggestions Sleeprider. I'll post zoomed Flow Rate with mask pressure below.

Care to retouch on I:E Ratio some (basics is fine)? I feel need of a refresher.

I'll bump PS Min to 4 and see what happens over weekend. I did try it fairly recent, but other pulmonary issues may have negated any possible positive effects, and I returned to PS Min 3.

Note within past 3 weeks dropped EPAP Min from 9 to 8, attempting to address breathing difficulty mask on. No noted event increases so I left it there, despite it not attaining goal of reducing difficulty.

[SarcasticDave94]

Three shots about a 2-3 min zoom:

[attachment=17371]

[attachment=17372]

[attachment=17374]

Last of 3 shots, I expanded mask pressure Y Axis to show from 7 pressure, had forgotten to edit when I dropped EPAP Min to 8

[Sleeprider]

Based on the screen shots above, your respiration rate is reporting accurately, but the inspiration time is much shorter than expiration. There is no apparent flow limitation and volumes look textbook normal. Timing on inspiratory pressure support looks good, so I don't know why the the time of inspiration and expiration seems off. We often see this and actually expect it on the Philips machines, where part of the null flow in expiration is counted as inspiration, so we can disregard that statistic.

We have a pretty good description of I:E ratio in the SH Beginner's Guide wiki. http://www.apneaboard.com/wiki/index.php...ailed_look With COPD, we want to ensure that there is plenty of time for exhale to complete. Your flow charts are much better than the statistics, which is why we look in the first place.

[SarcasticDave94]

Copy and thanks Sleeprider. I'll read wiki in a bit. I'll schedule a doc visit to explore machine change because I know my ASV doesn't have timing, backup, trigger, and cycle settings that some or all need adjusted, which are available in iVAPS. It is an issue needing addressed because the machine person interaction has broken. As is, it is now a disruption to sleep and not helpful as it once was. Your input is helping define why that interaction is broken.