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I'm late to the party here; I've read a bunch on the ASV issues (low EF), talked to several doctors, and I've watched the You Tube conference. I recall hearing in the conference is that when you take out the healthy patients and put in more sick patients (to the study) the results will be worse. It sounded to me like the doctor was suggesting a (serious) flaw with the study.
Can anyone explain why ASV is bad for patients with low EF? It seems to be related to the reduction in venous return from the positive pressure. If that is the case then what about all you folks on a constant CPAP of 20, wherein those on ASV see a drop in pressure during exhale and it seems that perhaps there must be something else going on. Another question, if ASV is so bad, then why put a patient on a ventilator in the hospital that has CHF and low EF, I'm sorry, I'm having a difficult time with the ASV/EF study.
I had the ST titration study and it did NOT help me with central apneas, it clearly showed I needed ASV and that is what I'm on now. When first starting ASV therapy, as you fall asleep you will feel the machine 'kick in' and give a breath. It may wake you up initially, but I'd rather wake up to a breath being given than never wake up again because I stopped breathing. Furthermore, I find the feeling very relaxing and I quickly ease back to sleep. The push of air that is given (at least for me) is not hard, it is an easy increase in pressure/volume and then drops, making it very easy to breath with, wherein I could not tolerate a constant high pressure. As is, I'm only on a pressure of 4 and wish it could be lower but it isn't bad.
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
(01-28-2018, 11:23 PM)Spy Car Wrote: Right. Because many consider SERVE-HF "junk science" and they see improved quality of life in their ASV patients. The risk warnings have to be broached due to risks of malpractice suits, but these doctors obviously don't believe they are endangering the lives of their patients.
Bill
No. Read the presentation I linked. That doctor was willing to prescribe ASV because the patient understood that it might increase his risk of dying and was willing to accept that risk in order to have a better quality of life.
There are a lot of times when doctors allow patients to risk their own lives in order to have a better quality of life. Patient autonomy is an important value to doctors.
I've not seen a single published article that implies that SERVE-HF is junk science. The article you linked certainly does not do so.
One thing you and I can agree on is that SERVE-HF had too many limitations to be the final word on this issue and that it is good that they are doing additional studies to clarify the safety of ASV in patients with heart disease.
-Amin
Nothing I say on the forum should be taken as medical advice.
(01-28-2018, 11:23 PM)Spy Car Wrote: Right. Because many consider SERVE-HF "junk science" and they see improved quality of life in their ASV patients. The risk warnings have to be broached due to risks of malpractice suits, but these doctors obviously don't believe they are endangering the lives of their patients.
Bill
No. Read the presentation I linked. That doctor was willing to prescribe ASV because the patient understood that it might increase his risk of dying and was willing to accept that risk in order to have a better quality of life.
There are a lot of times when doctors allow patients to risk their own lives in order to have a better quality of life. Patient autonomy is an important value to doctors.
I've not seen a single published article that implies that SERVE-HF is junk science. The article you linked certainly does not do so.
One thing you and I can agree on is that SERVE-HF had too many limitations to be the final word on this issue and that it is good that they are doing additional studies to clarify the safety of ASV in patients with heart disease.
The operative word here seems to be *might*. Making medical decisions on a study as flawed as this one should give no physician high confidence of the correctness of those decisions, especially when the conclusions conflict will all other previous smaller studies, the meta-data analysis, and clinical experiences.
If a bad study is preventing some patients from getting the best therapy for their condition due to bad science, then this study does a disservice.
We do agree on the point that SERVE-HF had too many limitations to be the final word and that's it is a good thing follow up studies are being done.
Kiwee, the recommended decision flow-chart, when centrals are present (BPAP failed) is in this graphic. In general, ASV is recommended for central and complex apnea, while ST or iVAPS is indicated for pulmonary disease. This is the current thought on deciding if ASV is appropriate.
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
(01-28-2018, 07:11 PM)zzzZorro Wrote: ASV will most certainly prove to be a brick wall for LVEF<45% at this time..
Not all docs feel that way. Some are willing to prescribe ASV anyway if the patient fully understands and accepts the risks. For example, the specialist who gave this presentation - see "Patient example 3" on page 58):
Shin; Thanks for posting that link I found it most informative.
You overlook the fact that it refers to a patient with a foot ALREADY in the door. Please note:
Patient example 3 •Patient on ASV already, been doing well for years •h/o severe CHF EF <25% •Explained patient risks and turned his ASV machine to CPAP mode •Patient trialed for 2 months, felt much worse on CPAP, decreased QOL •Switched patient back to ASV as he was willing to take the risk
IF a guy had 'years' of doing well on ASV and [apparently] owned or at least possessed 'his' own ASV machine and was 'willing to take the risk' I would bet there were a whole lot of Patient#3's out there who continued to sleep with 'their' ASV after the SERVE-HF study. Also bet a lot of sleep Docs SERVE-HF warnings were ignored. I would have too.
What would be interesting is just how many of those unknown recalcitrants out there actually had morbidity issues from ignoring warnings?
01-29-2018, 11:30 AM (This post was last modified: 01-29-2018, 11:32 AM by Shin Ryoku.)
RE: ST vs ASV - studies about risk
(01-29-2018, 11:22 AM)zzzZorro Wrote: You overlook the fact that it refers to a patient with a foot ALREADY in the door.
I did notice that. But look also at Patient Example 1 from page 56:
Quote:Patient Example 1
• Had patient with CHF who did fair with an ASV titration
(improved CSA somewhat, still persistnet cheyne-stokes,
but sats better), but the patient felt MUCH better after
study, EF borderline 3 years ago, family wants to take risk
of ASV.
• What would you do?
• I repeated Echo, EF is now <30%
• Decided to do trial of CPAP with positional therapy and
see if responds at home
Note that he mentions that the patient felt better after ASV study and that family (and presumably patient) want to take the ASV risk. This is someone who has not been on ASV at home.
The plan for that patient is to do a "trial" of CPAP with positional therapy to see if he "responds". What if he doesn't respond, feels poorly, and wants to do ASV? My reading of this particular doc, in the context of his presentation, is that he'd be open to prescribing this patient ASV as well.
I don't think the doc would mention that the family wanted to take the risk if he weren't open to the possibility of prescribing ASV. The conversation with the family likely wouldn't even have gotten that far. Nor would he have referred the patient for an ASV titration study.
-Amin
Nothing I say on the forum should be taken as medical advice.
Thank you for the flow chart, Sleeprider. I've written to my sleep doctor, although unable to send it yet. Pretty frustrated with myself at the moment, and don't feel like I can afford these ridiculous constraints I put on everything. I believe a therapist could help me with this, but even that is another case of "if I didn't have a problem, finding a therapist wouldn't be a problem." (it took nearly 4 years to find the last one) Deep breath. Gotta get a grip and just try again. And again.
01-29-2018, 04:28 PM (This post was last modified: 01-29-2018, 04:29 PM by ajack.)
RE: ST vs ASV - studies about risk
trying again is the answer. I don't know how your insurance works, but a therapy where you just talk for an hour on a weekly or even the daily basis may help. The reason I would suggest looking in to this, is because of the self awareness you had on the other thread, from just a forum post. You are able to have better clarity of thought.
01-29-2018, 06:11 PM (This post was last modified: 01-29-2018, 06:15 PM by kiwii.)
RE: ST vs ASV - studies about risk
That is true. It is my experience that therapy can be very beneficial, but it can also do more harm than good.
Oddly, every time I've gotten referrals (even when asking specifically for trauma), they have been based on location rather than expertise. Maybe we are too rural?? What's up with that?? It has occurred to me to try a different approach, and speak to some of the local first responders or the fire chaplain. Surely they would know who is experienced with trauma.
edit: I did put in a call to someone though, so maybe she will be a start. We shall see.
