I'm losing it! Please help - switching from APAP to BPAP. Need settings.

[IUsedToSnore]

First of all. THANK GOODNESS FOR THIS BOARD AND THE PEOPLE HERE. How the heck people ever get functional treatment through their physicians is totally beyond me.

I'm here today asking for help for my mom. She is a 74-year-old woman who has been getting "treatment" for complex sleep apnea. We need help getting her settings right on her new bi-pap machine. (I also have Apnea and you all have helped me tremendously.)

Here's the scoop.

She's been on a Resmed Autoset for her since December with an additional oxygen concentrator feeding in at 3 LPM since about March. WE LIVE AT HIGH ALTITUDE, so we're dealing with that issue as well. Her primary doc added the oxygen after a home pulse ox test was showing a pretty bad situation. Since she started the APAP and even with the addition of the oxygen, she's remained exhausted all the time with significant sleep-onset insomnia.

After months of basically begging, she finally had an overnight sleep study where her oxygen was dumping into the high 50's and low 60's.

I've uploaded her last night's sleep on the Resmed Autoset for Her as well as the statistics page. 

After the sleep study they recommended switching to a bi-pap. She's on Medicare, so they wouldn't just go for the ASV even though she has consistent central apnea. We have to go through the entire rigamarole. I've contacted the Dr. but it could be weeks before they get back to us about adjustments, or more likely we will get lost in their system and not get a proper response at all.

I've attached last night's sleep results too. She's an absolute dysfunctional mess today. I can't understand why on earth they would give her set pressure settings and why they wouldn't use the auto feature. It's clearly not right for her. If anybody has some ideas about how we could make adjustments that would be more functional for her, I'm happy to go into clinical settings and make the switch.

Thank you in advance for any help you can give.

[SarcasticDave94]

The OSCAR screenshots show the CA went higher on the VAuto, indicating this will soon be a failure if it in fact goes as my ASV path did in 2017. The best you can do is set it with minimal pressure swings to AVOID CA. The problem is that if you do that and it works reasonable, the doc and Medicare may see it as the answer and ASV paths end. So this leaves us with the dilemma to produce good therapy results for you Mom but still produce bad results to call this a fail, continuing onto ASV.

Possible plans of attack:
1. for good therapy on the VAuto, pressure swings need to be minimal, the pressure range needs to be narrow, or CA occur. This rules out Ramp period. Min-Max needs small range and small PS as well. Start by using same pressures as the AutoSet. You didn't have a PS to work with prior, so the EPR is the equal here, but PS needs to be small or we induce CA. Let's have get feedback from pressure gurus on this as well.

Pressures currently are 7-11 EPR 2; maybe copy these. I do know the VAuto settings aren't great now at 9-13 with PS 4 on VPAP S.

2. for moving onto ASV fast, most anything that has pressure swings...current VAuto settings would have me state it's a fail if I were on it.

Take notes of complaints/chronic ongoing sleep symptoms. Your mom isn't sleeping well, so note it. Get a big list of all the aspects that are wrong, all the CA, discomfort, lack of sleep, daytime fatigue, and all the rest. Tell Doc why it's not working and you demand ASV on the ASAP. I know you're expected to wait this out for months on the VAuto before consideration to move on to an ASV. I didn't. I was packing up the BPAP in a week. I made an urgent need visit to pulmonary office and said I am not accepting this very bad CA as normal or acceptable. NOPE. It's OK to be pushy, upset, angry. Be polite and very firm at the same time. You may have to plug in the docs settings when given to try for 1 night, when it fails note it down. It doesn't need a full night to grade it as a failure. Unfortunate you may have to swap back and forth with good therapy and bad therapy settings to say you tried it. Again note it all down. When it comes time for the ASV, you will not accept anything but resMed AirCurve 10 ASV. Tell 'em to chuck it if they say Respironics anything.

[staceyburke]

I am no expert but this is what one of the experts told me (This is copied from his message to me)

we add PS to EPAP to get IPAP with the Vauto.  With the Airsense 10 CPAP we subtract EPR from IPAP to get EPAP.  We nearly always refer to the Airsense 10 in bilevel terms so it does get confusing.

So what that is saying is you have a Min set at 9 and a ps at 4. That gives you a min of 13.  To high and she is getting centrals.  If you want the pressure to be at 9, you would the min at 5 and the ps would bring it up to 9.  I would think that just moving the ps down to 1 or 0 would do it.  Again, someone who really knows what he is doing will come along but this will give you something to consider.

[staceyburke]

I also live in Colorado and I'm on O2 24/7.  I would invest in an O2 recorder for night time use.  I use the cheapest one on the market right now - $100 at amazon and about 75-80 on Ebay.  It is called a CMS 50F and can be downloaded to its own program or put into OSCAR.  It gives O2 levels all night as well as pulse.  I put in a screenshot so you can see what I mean.

[Sleeprider]

Your mom needs an ASV machine. Bilevel therapy will only make the central apnea worse. We can duplicate the therapy she got on the Airsense 10 Autoset, but the Vauto will not trigger breaths when no spontaneous effort occurs. ASK YOUR DOC why she was not prescribed ASV.

With the Airsense 10 Autoset For Her, her settings were minimum 7.0, maximum 11.0 with EPR 2. These settings are equivalent to Vauto mode, EPAP min 5.0, PS 2.0 max pressure 11.0 (EPAP max 9.0) on the Vauto. We can help her a little in Vauto mode by also setting the trigger sensitivity to High.

Her current settings are VPAP-S mode with IPAP 13, EPAP 9.0 (fixed bilevel pressure). This is a pressure support of 4.0 and I will guarantee she will have a higher event rate with these settings. I would take her back to the Airsense 10, or set her up as I suggested above. Her problem with centrals will not resolve with this machine, and I can't even imagine what the doctor is thinking.

Talk to me! Will you tell your doctor your mom needs ASV? Your doctor took an oath to "do no harm"...well he is making her condition worse, and that will continue until he takes his head out of his ass and prescribes ASV therapy. Bilevel without a backup rate will not treat complex apnea. If she has been diagnosed with complex apnea, the Resmed Aircurve 10 ASV is the correct machine. Perhaps there was a mistake in dispensing the Vauto? Meanwhile reset her pressure to EPAP min 5.0, PS 2, Max pressure 11.0 and trigger sensitivity High.

[Gideon]

I support SR's settings.  The current settings are making things much worse.
EPAP min = 5
PS = 2
Max IPAP (Pressure) = 11
Trigger Sensitivity = High.