Rreffner Therapy Thread

[SarcasticDave94]

Sorry I thought I explained my abbreviation of TECA, that is Treatment Emergent Central Apnea.

The test results just shown gives 0 Obstructive Apnea, 18 Central Apnea and 122 Obstructive Hypopnea. But in most cases they don't separate Hypopnea events into Obstructive and Central. Yes if Central is the issue, ASV is the right answer.

Those numbers are from a Titration it seems, the somewhat blurry charts.

[Rreffner]

Thank you so much. I'll update the thread tomorrow, following my doctor visit.

[Rreffner]

Clearer scans

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Clearer scans #2

[Sleeprider]

Rreffner, thanks for the other pages of your sleep titration study. The titration shows you had very high AHI at 12/6. 14/6, 20/6, and lower AHI at 17/7 and 18/8. The decision on 17/7 is based on only 41.5 minutes when your AHI calmed down. As we have told many members, central apnea is consistently inconsistent, and this test shows that to be true because your AHI was near 20 at pressures above and below what was judged effective. This kind of non-linear result is typical in complex and central apnea, and does not demonstrate a successful titration. Even if we accept the 17/7 result, the AHI was 5.8 and would not suggest a successful titration.

Your current Vauto results have already demonstrated failure on bilevel PAP therapy without a backup rate. You might as well get your doctor to move forward to the next logical step which is bilevel with backup rate HCPCS Code E0471. It is fairly common for sleep doctors to try ST bilevel, but it is not designed for complex and central apnea. You need to insist on ASV. To help you discuss the machines with your doctor and understand why ASV is the correct therapy, please read the sections of the Resmed Clinical Titration Protocol on bilevel VPAP S and Vauto (Page 24), ASV (page 28) and (ST Page 37). Note in particular the intended use of ASV is for central and complex apnea, and that ST is intended for pulmonary or neuromuscular diseases and hypoventilation. A sad fact is, ST is cheaper than ASV and they will try to pass it off on you. https://document.resmed.com/en-us/docume...er_eng.pdf Your current machine has no backup rate (breaths per minute) and cannot help your condition beyond the range of efficacy you are seeing.

[Rreffner]

Thank you very much SleepRider.

[Rreffner]

"Pressure support (PS) in positive air pressure therapy, is the difference between inspiratory positive air pressure (IPAP) and expiratory positive pressure (EPAP). For example, if IPAP is set at 12 and EPAP is set at 8 the PS is 12 - 8 = 4.0."

My settings are IPAP 17 and EPAP 7, therefore my PS would be 10. Correct?
My sleep doctor's PA went into settings this morning and only changed PS from 10 to 5. This I don't understand. Can someone provide some clarity? Thanks

[Sleeprider]

Hi Rreffner, I merged your last post into your therapy thread because we were discussing your phenomenal pressure support yesterday. Reducing pressure support is one of the measures we typically recommend to people experiencing central apnea to reduce the number of events. In my last response, I told you your titration showed non-linear results and was not a successful titration. By changing PS to 5.0 and leaving the machine in Vauto mode at EPAP min 7.0 and IPAP max 17.0 your machine is no longer at fixed pressure and can move between pressure of 12.0/7.0 to 17.0/10.0. This would normally be more comfortable and should reduce the number of CA events. Oddly enough, your titration never evaluated a lower pressure support and did not incorporate a backup rate. I have to question the professionalism of a person that would perform a titration in that manner. You can see in the Resmed Clinical Titration Guide I linked to yesterday that your titration was at best unconventional or at worst designed to fail.

With PS 10.0 we would expect hyperventilation which would significantly alter your natural CO2 in your bloodstream, which in turn would suppress respiratory drive and result in more central apnea events. Very simply put, when individuals become hypocapnic, they stop breathing until carbon dioxide in the blood stream triggers a signal from the chemoreceptors in the brain to breathe. This is briefly described in this paragraph: https://www.ncbi.nlm.nih.gov/books/NBK482414/

Central chemoreceptors in the ventral surface of the medulla and the retrotrapezoid nucleus hold most of the remaining control over the respiratory drive. They primarily sense pH changes in the central nervous system caused by alterations in arterial carbon dioxide. Carbon dioxide is a lipid-soluble molecule that freely diffuses across the blood-brain barrier and forms hydron ions within the cerebrospinal fluid. Chemoreceptors, in turn, respond to pH changes as they become more acidic and send sensory input to the brain to stimulate hyperventilation. The result is a slow and deep breathing pattern that helps eliminate carbon dioxide from the body. Likewise, when arterial PCO2 drops, pH in the cerebrospinal fluid becomes alkalotic, and hypoventilation ensues. Therefore, arterial PCO2 is the chief determinant of the respiratory drive under normal conditions

I think the new, lower pressure support will be effective in reducing obstructive events, but you will continue to experience CA without having a backup rate or ASV.

[Rreffner]

Thank you for your prompt professional response. I have a sleep study and titration scheduled for next week and follow up with a new doctor having the following Board Certifications:
- American Board of Internal Medicine (Sleep Medicine)
- American Board of Internal Medicine (Pulmonary Disease)
- American Board of Internal Medicine (Critical Care Medicine)

I’ll have my initial visit on March 31 to discuss findings and treatment plan. 

I’ll update the thread when I know more. Thanks again

[Rreffner]

Reset my PS from 10 to 5. Breathing was much better, although I didn't sleep long enough. I am encouraged by last night's results.

[Sleeprider]

That result exceeds my expectations given your central apnea in the diagnostic test. With regard to your next titration, you should specifically discuss including bilevel with backup and especially ASV as one of the modes to be evaluated.