Periodic Breathing wierd SH graph

[richb]

I have been dealing with Periodic Breathing and Central Apnea since my sleep study back in Feb 2015. I am now on my 3rd machine a ResMed S9 ST. Previous machines were ResMed S10 Vauto. The S10s did nothing for Hypopnea Central Apnea AHIs of 20 to mid 40s. Dr did a new titration and found some relief at EPAP 11 IPAP 15. The Sleep Tech said she thought I would benefit from a backup setting but none was requested for the study. Then out of the blue I get a call that I am to get a replacement machine that can be set up for a backup rate. (A backup rate is a pre-set number of breaths per minute that the machine supplies if you don't breathe voluntarily for a few seconds. ASV machines adjust the breaths per minute based on your last 4 minutes of breathing.) The Dr recommended a setting of EPAP 11 IPAP 15 and a backup rate of 8. I told him that I didn't think this would work based on recommendations from ResMed but that i would try it anyway. Got the new machine and tried it. I couldn't use it because it had no ramp setting activated. The 11 - 15 pressures were too high for me. It was night so i just reduced the pressure to 9 - 13 and spent a miserable night. Checked my stats in the AM and had an AHI of 28 all Hypopneas. (This machine doesn't have the FOT technology that can distinguish Centrals.) I was ready to give up when I realized that the S9 that I had did not have a modem and built in phone. I also read the manual and found the 2 settings I needed to change to set a backup rate. I then changed the backup rate to 13 BPM. Woke up and found an AHI of 7. This was lowest ever. I have finally settled on a backup rate of 14 and now have an AHI of 2.7. Still, all is not well. I am sleeping poorly and have mildly elevated BP in the AM. I am convinced that I need an ASV machine as others have suggested from day 1. I am trying to make some sense of data that might help with my case for an ASV machine. When looking at my Sleepyhead graphs I see an interference pattern in my flow graph. It shows a rising and falling pattern similar periodic breathing. I zoomed on a several minute section of the flow graph to see what was causing the strange pattern and found that I was taking 2 breaths in quick succession instead of a single breath during the rising and falling periods in the graph. These 2 breath rising and falling patterns are separated by periods of normal looking breathing. I have linked to the graphs for members to look at and offer ideas. (I do have an appointment with a University Sleep Center in October.) http://s173.photobucket.com/user/richb14...g.html?o=0 http://s173.photobucket.com/user/richb14...g.html?o=1

[Sleeprider]

Rich, I can't really interpret your flow rate and respiration rate graphs in a meaningful way. You have a pretty darn high resp rate for sleep during that time period. Overall your average rate of 19 is fine, but in a 2-minute snapshot your rate varies from 20 to 35 bpm. What I notice is this is a big improvement over the periodic breathing and CA events you had before. Still I'm a bit surprised you are not using the VPAP Adapt SV rather than the ST.

[PaytonA]

.........(A backup rate is a pre-set number of breaths per minute that the machine supplies if you don't breathe voluntarily for a few seconds. ASV machines adjust the breaths per minute based on your last 4 minutes of breathing.)

My understanding is that the ASV machine bases your breathing requirements on keeping the minute ventilation in control.

.........(This machine doesn't have the FOT technology that can distinguish Centrals.)

The clinicians manual at least implies that the ST can differentiate between OAs and CAs by means of fot. Under Sleep Report one of the displays listed is Central AI subject to the following proviso. "Only shown if CAI is greater than the threshold and patient received message".

Best Regards,

PaytonA

[richb]

.........(A backup rate is a pre-set number of breaths per minute that the machine supplies if you don't breathe voluntarily for a few seconds. ASV machines adjust the breaths per minute based on your last 4 minutes of breathing.)

My understanding is that the ASV machine bases your breathing requirements on keeping the minute ventilation in control.

.........(This machine doesn't have the FOT technology that can distinguish Centrals.)

The clinicians manual at least implies that the ST can differentiate between OAs and CAs by means of fot. Under Sleep Report one of the displays listed is Central AI subject to the following proviso. "Only shown if CAI is greater than the threshold and patient received message".

Best Regards,

PaytonA

When set in ST mode my machine does not report Centrals. It calls them UA unclassified apneas. In ST mode the machine is providing breaths at a fixed rate and pressure to overcome my lack of breathing during Centrals and Hypopneas.

[richb]

Rich, I can't really interpret your flow rate and respiration rate graphs in a meaningful way. You have a pretty darn high resp rate for sleep during that time period. Overall your average rate of 19 is fine, but in a 2-minute snapshot your rate varies from 20 to 35 bpm. What I notice is this is a big improvement over the periodic breathing and CA events you had before. Still I'm a bit surprised you are not using the VPAP Adapt SV rather than the ST.

I will be speaking with the techs and eventually the Doc. I will try to get an ASV machine. I think the fixed pressure and BPM of the ST machine severely limits its therapeutic value. I was hoping that someone had a similar breathing pattern that was somehow resolved. I still think I need an ASV machine, medication, or both to resolve my Central Apnea periodic breathing problem. I also see the high respiration rate during the double breath episodes. I think that is the Central Apnea rise and fall breathing showing through the supplied breaths from the machine. Thanks for the reply.

Rich

[Sleeprider]

Rich, if you look at the intended use of the ST machine, it does not fit your problem. It is intended for COPD and people with hypoventilation as a result of obesity or other disorders. The ASV is for centrals and complex apnea. It should be a no brainer, which apparently fits your professional's thought process.

[richb]

Rich, if you look at the intended use of the ST machine, it does not fit your problem. It is intended for COPD and people with hypoventilation as a result of obesity or other disorders. The ASV is for centrals and complex apnea. It should be a no brainer, which apparently fits your professional's thought process.

I fully agree. I was looking for more ammunition for my appointment in a couple of weeks. I am hoping for an ASV machine soon. It might be possible that the Doc gave me the ST machine so that I could tinker with it. The machine can't communicate with the outside world.

Rich

[Sleeprider]

For additional argument, I think you need only do a comparison between the two machines. Unfortunately the chart below comes from a site that might be deemed a commercial link but you may find it by searching "Resmed VPAP Comparison: VPAP Auto, VPAP S, VPAP ST and VPAP Adapt"

What stands out is the the ST is not an "adaptive servo ventilator", it is a spontaneously timed bilevel. It does not have the "Easy-Breath waveform" which would be more comfortable for you and might avoid some of the anomalies you noted in your waveform chart above. The ST does not auto-adjust pressures to deal with your OSA. It does not learn and adapt to your breathing pattern, minute vent rate or backup rate. For the right person, the ST is a great device, but it's the wrong application for you.

VPAP Comparison VPAP S VPAP Auto VPAP ST VPAP Adapt
Continuous Positive Air Pressure X X X X
VAuto X
SPONT (S) X X X
Spontaneous/Timed (ST) X
Timed (T) X
Adaptive servo-ventilation X
Operating pressure range (cm H2O) 3-25 3-25 3-25 4-25
Enhanced Easy-Breathe Motor X X X X
Easy-Breathe waveform X X X
Climate Control X X X X
SmartStart™/Stop feature X X X X
Vsync automatic leak management X X X X
Adjustable breath trigger/cycle X X X X
TiControl™ (Ti Max/Ti Min) X X X
Auto-adjusts bilevel pressure for OSA events X
CSA detection X X
Optional integrated oximetry X X X X
Leak alert X X X X
3 meter tubing X X X X
Learns and adapts to breathing pattern X
Learns and adapts to minute ventilation X
Learns and adapts to backup rate X
Humidification Option: Fully integrated X X X X
SD data card X X X X
Detailed data on SD card (30 sessions) X X X X
High resolution flow pressure on SD card
(7 sessions) X X X X
Sleep report on screen (365 sessions) X X X X
Compliance and summary data on SD card
(365 sessions) X X X X
Compliance and summary data on device
(365 sessions) X X X X

[richb]

For additional argument, I think you need only do a comparison between the two machines. Unfortunately the chart below comes from a site that might be deemed a commercial link but you may find it by searching "Resmed VPAP Comparison: VPAP Auto, VPAP S, VPAP ST and VPAP Adapt"

What stands out is the the ST is not an "adaptive servo ventilator", it is a spontaneously timed bilevel. It does not have the "Easy-Breath waveform" which would be more comfortable for you and might avoid some of the anomalies you noted in your waveform chart above. The ST does not auto-adjust pressures to deal with your OSA. It does not learn and adapt to your breathing pattern, minute vent rate or backup rate. For the right person, the ST is a great device, but it's the wrong application for you.

Thanks for the suggestion. I think I will have a good argument about the ST being the wrong machine for my Central Apnea. I had a lot of those double time breathing episodes last night. I will try a call to the sleep cener today.