Help for father

[Gideon]

This was a BiLevel titration of PS= 6,7,8,9,10. They are apparently trying to help your father breathe. This is what PS can do.
The PS was previously 5. So a big change. See how he does with it.
Post both standard and advanced charts. Advanced charts concentrate on breathing stats.

[SonofBiPAPuser]

Thank you.

I plotted 2 standard (SpO2 shown on 2nd) and one advanced.  The results don't seem good to me...  

Should I zoom in somewhere?

[Sleeprider]

This is an individual that needs a backup rate to trigger IPAP when apnea occur. Don't let the sleep study tell you you can't see what you see on the OSCAR results from the VPAP. With PS 9.0 central apnea are a near certainty, and without the backup rate, the apnea is not mitigated. Your dad's lung impairments, use of supplemental oxygen and many other factors tell us, he should qualify for bilevel ST therapy. This is exactly the kind of situation it was designed for. Read pages 37 to 39 of this document and the indications should be clear. The prescription needs to be changed to ST with a backup rate of 14 BPM (normal respiration rate minus 3 BPM). For some reason the apnea rate of the titration was very low. We don't know if there was a backup rate being used, but it sure looks like it.

If you need more attachment space, consider opening an IMGUR account and posting from there. You can have unlimited images and copy the BB code or linked BB Code to embed as many images as you want.

[Gideon]

You asked about zoom, a 3 and a 10 minute view of the first and last UA cluster to see if we classify them obstructive or central.

With your father's reduced lung capacity I don't know about shifting him to an ASV to manage the centrals. Ask why no timed backup breathing, for the centrals. Note: the VAuto is not capable of this.

Ask his pulmonologist about ASV maintaining his Minute Vent to his average(90 second moving average) or to an ST or better an Ivaps with timed backup to manage his reduced lung capacity.

His oxygen sats dipped 4 times to extended durations below 88% get the duration info from the oximeter data for your talk with the pulmonologist.

Basically, these settings failed!!!
Steps, give your med team a chance to react to this. He should have either new settings not latter than tomorrow night.

He NEEDS supplemental oxygen NOW, if he has it he needs it Inreased. Call now.
.

[Sleeprider]

i think the medical history and pulmonary impairment contraindicate ASV, however the best therapy is likely ST-A with iVAPS rather than ST. The ST-A is a much more modern device with intelligent breath rate and variable pressure support that targets alveolar vent rate. This is far more sophisticated than ASV which is not appropriate in this case. Although there are centrals, the pulmonary disorders would not allow it. The Clinical Titration Protocol document I linked earlier describes this limitation right on the titration protocol decision tree:

ASV’s algorithm is not cleared or appropriate for the following patients:
- Chronic and profound hypoventilation
- Moderate to severe COPD
- Restrictive thoracic or neuromuscular disease

[SonofBiPAPuser]

SleepRider: thank you.  What document were you referring to?  (I have the ResMed Sleep Lab Titration Guide - is that the one?)

I am trying IMGUR now.  

I understand your point about timed backup rate.  I have composed a mail for my father's doctor.  I will send it after reading any responses to this post.

Gideon: thank you also.  He has 4 L/min supplemental O2.  I understand your points, I think.  No change will happen today though, the system is not that responsive.

The longest time under SpO2 was < 88% was ~ 5:454 around 5 am.  The average during this time was ~ 80%.

Attached are a 3 & 10 minute zoom of the first and last UA clusters.

[Sleeprider]

The ResMed Sleep Lab Titration Guide I linked is teh https://document.resmed.com/en-us/docume...er_eng.pdf has all of this information an more. It is a very good source for "wording" your letter on what machine are approved and appropriate for you father. The Vauto is a great machine, but is normally used for individuals that are non compliant for CPAP and need the comfort of the bilevel to improve therapy, especially for flow limitations. When central apnea events are evident with the bilevel, the Titration Guide recommends looking at ASV. In your father's case, he is using extraordinarily high pressure support up to 9-cm difference between IPAP and EPAP. This has the desirable effect of improving ventilation, but also flushes CO2 from the respiratory system and has a significant adverse effect on respiratory drive. This is an example of a simple bilevel without a backup rate being used to treat someone with pulmonary impairments, which is the role of the ST. An improvement to ST therapy is the ST-A which has the intelligent iVAPS mode, but also has ST, PAC, T, S modes. Read the information starting on Page 34. Note what this machine treats and is intended to be used for. There is far more information there than I can write in this post, and a number of illustrations to help you understand how and why it works. Your doctor should be concerned that your dad has such high event rates just as you are. The best solution is ST-A. If he can at least get ST, that will help. Both are under the same HCPCS insurance code E-0471, so there is no reason not to get the ST-A because it can do ST and upgrade to iVAPS. I think it is a fair question to ask your doctor if he is aware of these devices and why he has not recommended them.

The zoomed images above show an individual that is having considerable airway resistance or flow limitation resulting in flattened inspiration flow. There are long pauses in breathing typical of central apnea, that result from hypocapnea, followed by recovery breathing with panting up to 30 breaths per minute. This alternating pattern of central apnea and recovery breathing or hyperventilation is extremely bad and a direct consequence of not having a backup rate to maintain respiration during central apnea. If you doctor will take the time to look at this, he will realize, this is not just a false signal from a CPAP, but real respiratory distress that can be fixed. If this doctor is not willing to respond with appropriate concern, it is time to find one that will.

[SonofBiPAPuser]

Thank you.  I sincerely appreciate the information and the advice.  I had read that document once (I came across it in a different thread) and have been highlighting it for a couple weeks now.  I shall read it again.  I will work with my father to set up an appointment with the doctor - which I will attend - and discuss this further.  In the meantime I sent the doctor an email with an image of OSCAR showing the SpO2 curve and asking questions.

Agreed that if this doctor is not able to sort this, it is time to switch doctors.  The thing is this one is seemingly well qualified to help: he is a pulmonologist at a nearby hospital and the Director of their Sleep Disorders Center.  I shall try working through him for a while, but eventually we'll have to switch if he can't help us figure this out.  Thank you again.

[Sleeprider]

I'm sure he can understand the issues and should be ready to resolve the problems with an advanced device. I guess it is a matter of whether he is truly engaged in the therapy and well-being of his patients, or if this is just a side-line to his pulmonary medical practice.

[SonofBiPAPuser]

Some images from last night.  SpO2 (not shown) was fine - no extended drops under 88%.  AHI still not good.  I have a note into the doctor's office yesterday, still have not heard back.  Will ask my father to call them this afternoon.  

Respiration rate is very low on average.  Periods of time where RR is quite high.  An apnea that lasts 46 seconds long.  Lots of unsteady breathing, even when not classified as apnea/hypopnea.  Long spaces between breaths.  This does not look right to me.  But what do I know?

Thank you for all of the help.  I will continue reading the ResMed Sleep Lab Titration Guide.