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Machine: Lowenstein Luisa Mask Type: Full face mask Mask Make & Model: Resmed Quattro FX Humidifier: separate F&P humidifier CPAP Pressure: Epap 4-20 PS 4-20; "auto" rate CPAP Software: Not using software
Other Comments: Using 45 degree angle upper body wedge (36"x36") and 4.5"soft cervical collar; 500 assured tidal vol
Great points by cmpman. With Vaps (Ivaps or avaps) you basically have a hospital grade ventilator. You can control 2 of the most important variables in breathing: respiratory rate and tidal volume. Hospital ventilators have more bells and whistles and can reach higher epaps and higher ipaps (have higher PS maxes), but if you have a neurological disease that is progressing, it may not get any better than ivaps IMO. Ivaps probably has a rise time setting also. I am not a Dr. Your Dr.'s may have a different plan for you in the future.
Advisory Members serve as an "Advisory Committee" to help shape Apnea Board's rules & policies.
Membership in the Advisory Members group does not imply medical expertise or qualification for advising Sleep Apnea patients concerning their treatment.
Unfortunately I had a terrible night last night. Oxygen dropped like a stone from approximately 3:50am to 4:15 am at which point I woke up with my mask off of my face which I almost NEVER do.
Here's a screenshot of the first couple of hours of my therapy. My target volume here was on the order of 580 ml if I recall correctly. So the pressure kicked in when my tidal volume started dropping right around 1:55 am. And the venilator kept me "afloat" for a while. But then it's like the ventilator got "tired" of helping me so it backed off the pressure. Look at the difference at 2:30 am - my tidal volume is only 493.51 and the machine is giving me only 12.90 IPAP. Why isn't it kicking in more pressure to get my tidal volume back up?
It gets even worse at 4:00 am - my tidal volume is 483 and change and the machine is pissing along at Ipap of 10 and epap of 4.
What is going on here guys? Can anyone make sense of this?
(04-29-2023, 08:21 AM)Sleeprider Wrote: Your tidal volume varies withing a very normal range, and the median is high. You have not failed CPAP or your Vauto and have a low AHI. While you have created considerable arguments about your health and respiratory issues, none of them actually appear in the Oscar data. There are occasional centrals or breathing pauses, however the incidence falls below clinical guidelines for medical necessity, and in spite of testing and some theories, you don't have a medical diagnosis of any qualifying condition for ASV or AVAPS. I have rarely seen iVAPS or AVAPS deliver comfortable, effective therapy with the majority of individuals that come here with more severe respiratory issues, and cmpman eventually changed away from iVAPS for that reason. He is probably much more qualified than I am to discuss what this therapy is like, but I know you are imagining riding on a machine that produces perfect breaths of even volume and rate without ever thinking of it, but that is almost never the case with iVAPS. It looks ragged, uncomfortable and invasive. I have said it before, and I'll say it again; your therapy is very good and effective. The fact you are tired may come from outside that therapy and you need to focus on finding a solution(s) that looks at root causes that may not be respiratory or have anything to do with EPAP, IPAP and PS, or a normally variable tidal volume, because those issues appear to be resolved and not likely the problem. You are certainly feeling fatigue and pain and it's not my intention to argue that, but to suggest you may be too focused on your PAP therapy as a solution.
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.
Machine: Lowenstein Luisa Mask Type: Full face mask Mask Make & Model: Resmed Quattro FX Humidifier: separate F&P humidifier CPAP Pressure: Epap 4-20 PS 4-20; "auto" rate CPAP Software: Not using software
Other Comments: Using 45 degree angle upper body wedge (36"x36") and 4.5"soft cervical collar; 500 assured tidal vol
I totally agree with Sleeprider. And with cmpman's assessment also. Your tidal volume numbers are not bad at all. Compare them to mine from my PSG. My lowest was 60. I had one at 120. Another 190. Some in the 200's. Some in the 300's etc. I am 6'2 male. 500's and high 400's is fine. Respiratory rate and minute vent not bad either. I had a 5 recorded respiratory rate on my PSG. Your Dr.'s also have a say in this, too. Hopefully their assessments match ours.
Advisory Members serve as an "Advisory Committee" to help shape Apnea Board's rules & policies.
Membership in the Advisory Members group does not imply medical expertise or qualification for advising Sleep Apnea patients concerning their treatment.
05-22-2023, 10:28 PM (This post was last modified: 05-22-2023, 11:42 PM by cmpman1974.)
RE: Sorry to start new thread but need nap
I have to say I'm just at a loss with all of it as others indicated. It seems like no matter what your doctors (assume includes your wife who is a doctor) ascertain as a non-diagnosis/rule-out, you just won't buy into any of it. At some point, you need to accept or get a new medical team if suffering immensely. You're going back to the same well looking for an answer and that rarely happens. Simply show your neuro your sleep stats and ask if his/her MD, MG, ALS, or patients with other debilitating diseases kick out your nice tidal volumes and other stats. Show them low and high ranges. AHI of < 1.0. When you say O2 'tanked', elaborate? I hope you don't mean from 98% to 95%.
I have to assume your medical doctor has seen more patients with these diseases than any of us here.
As Sleeprider said, to be on IVAPS, there should be a damn good reason. I'm not even sure how any doctor approved the machine given your performance on the previous one. Feelings and perceptions do not make insurance companies bend. Facts do in my experience.
I wish I had more to offer. Again a HUGE question to ask yourself and your doctors in my viewpoint is why are you sleeping such a crazy amount of time per night? 12+ hrs is excessive for any adult. That's in the range of 1-2 year old I believe. I know that alone would concern my spouse greatly and they aren't so caring to dig into my medical stuff at all. Yours IS a doctor so that would be a major issue to figure out. Just another thought.
I am not sure you fully understand how IVAPS works. In fact, I'm not sure most of us do as ResMed seems to have gone to great lengths to limit info. A web search yields hardly anything which astounds me. I put copies of a few paragraphs from ResMed's clinician manual providing a little more info. I think it's kind of pathetic a more detailed explanation isn't there.
If you think you're going to be running a straight pressure most of the night on IVAPS, you have the wrong machine! It's a roller coaster ride as it adjusts for multiple factors compared to BPAP S mode. Generally if you're taking your own breaths and getting adequate Vt on a straight BPAP, no need for IVAPS. Doctors don't give IVAPS out to get your O2 from an undesirable 96% to your previous 98-99% level. That's like giving a runner steroids because they only run a 4.25 min mile and once did it in 4.0 min. lol.
You never presented anything new or telling concerning your CO2 levels after you ascertained faulty equipment. Didn't the sleep doc run appropriate tests to figure out once and for all if this is any issue as we know you're not hypoxic. If your PACO2/PAO2 is OK and CO2 levels OK on the serum test, low odds.
I realize this video is on AVAPS and not IVAPS, but I believe principles are close. Jay51 knows much more about the differences, but Morgannon pay close attention to some of this guy's comments:
This seems like a good 'blueprint' to follow for yourself when evaluating your doctor's work-ups possibly. I am not a medical professional in any way and just trying to offer info to get you headed to a better place possibly mentally:
Yes, I do have good tidal volumes - while awake. I usually respire in the 700-800 range. I'm a former asthmatic with extensive airway remodeling. We tend to breathe deep and slow to get enough air into the airways. So going in, you need to understand that if I'm just sitting breathing quietly, I'm pulling in a lot more air than a normal person:
In addition to exhibiting increases in respiratory drive and minute ventilation, patients with asthma may display a number of other abnormalities in the pattern of breathing: an increased tidal volume, or a shortened fractional inspiratory time, while respiratory frequency may be normal or increased.
So, base tidal volume for me is 750-800 range. When asleep, tidal volumes shouldo only drop by 25% or so:
The breathing pattern during all stages of sleep was significantly more rapid and shallow than during wakefulness, tidal volume in REM sleep being reduced to 73% of the level during wakefulness.
73% of 750-800 brings me to roughly 547.5 - 600 of tidal volume in deepest REM sleep. As you gents can see, I am well below that many times during the night.
My tidal volumes hit the low 400s last night and lower in spots. My O2 dropped into the low 90s. And the mid 80s for several minutes at a time. While on 1 liter of oxygen. With no apneas - just shallow breathing. It's possible this is due to unconrolled asthma. It's also possible this is hypoventilation due to a neuromuscular disease. Still being worked up for both. I should have some definite answers one way or another by the end of June.
This is the reason I got the AVAPS from my neurologist. She doesn't like what she's seeing on OSCAR. And on my O2 meter. Just in the last month my average O2 has dropped from 98% to 96%. Right now my O2 meter is oscillating between 93 and 95. It's very unnerving.
Anyway, I'm off to figure out how to make the AVAPS prioritize tidal volume over minute volume. I'm thinking of futzing around with rise times, etc. to make myself breathe more slowly in my sleep. Or if I can't do that, I might just have to set higher baseline pressures in an attempt to keep my tidal volumes higher. My neuro should be weighing in today to offer some advice. I'll let you all know what we discuss.
05-23-2023, 04:49 PM (This post was last modified: 05-23-2023, 04:58 PM by cmpman1974.)
RE: Sorry to start new thread but need nap
(05-23-2023, 04:00 PM)Morgannon Wrote: Hey there guys, I appreciate all of the input!
Yes, I do have good tidal volumes - while awake. I usually respire in the 700-800 range. I'm a former asthmatic with extensive airway remodeling. We tend to breathe deep and slow to get enough air into the airways. So going in, you need to understand that if I'm just sitting breathing quietly, I'm pulling in a lot more air than a normal person:
In addition to exhibiting increases in respiratory drive and minute ventilation, patients with asthma may display a number of other abnormalities in the pattern of breathing: an increased tidal volume, or a shortened fractional inspiratory time, while respiratory frequency may be normal or increased.
So, base tidal volume for me is 750-800 range. When asleep, tidal volumes shouldo only drop by 25% or so:
The breathing pattern during all stages of sleep was significantly more rapid and shallow than during wakefulness, tidal volume in REM sleep being reduced to 73% of the level during wakefulness.
73% of 750-800 brings me to roughly 547.5 - 600 of tidal volume in deepest REM sleep. As you gents can see, I am well below that many times during the night.
My tidal volumes hit the low 400s last night and lower in spots. My O2 dropped into the low 90s. And the mid 80s for several minutes at a time. While on 1 liter of oxygen. With no apneas - just shallow breathing. It's possible this is due to unconrolled asthma. It's also possible this is hypoventilation due to a neuromuscular disease. Still being worked up for both. I should have some definite answers one way or another by the end of June.
This is the reason I got the AVAPS from my neurologist. She doesn't like what she's seeing on OSCAR. And on my O2 meter. Just in the last month my average O2 has dropped from 98% to 96%. Right now my O2 meter is oscillating between 93 and 95. It's very unnerving.
Anyway, I'm off to figure out how to make the AVAPS prioritize tidal volume over minute volume. I'm thinking of futzing around with rise times, etc. to make myself breathe more slowly in my sleep. Or if I can't do that, I might just have to set higher baseline pressures in an attempt to keep my tidal volumes higher. My neuro should be weighing in today to offer some advice. I'll let you all know what we discuss.
Morg
Well I'm glad you have a neuro evaluating you carefully. The fact she gives OSCAR reports any credibility honestly blows my mind. This statement is not a knock on OSCAR, but based on my experience with sleep specialists. I have never had a doctor blink at my O2 being 92-94% awake ever. Maybe they have other reasons to believe my baseline should be lower than others though.
I'm perplexed why you personally have to play with settings when you have a specialist on board though. She should be making adjustments as appropriate.
Best of luck on the work-up. I hope you get some useful answers by the end of June. I'm not sure the math is always as clear cut as you wrote out with % of REM sleep and such, but if your doctor believes that is true, makes sense to me.
You are only showing small snapshots of some of your recent OSCAR data and SPO2 numbers so there's no way to understand the full picture. Example - you clipped a 2 hr period last attachment. You sleep 11-13 hrs a night so that was 20% of your sleep window.
FYI, you do not have a shortened inspiratory time. It is over 2 seconds - more than me. Your ratio of I/E is pretty normal as well. Didn't you at some point say your PFT's showed you output normal or higher than normal levels relative to predicted for your height? It has been a long time so I may be wrong there. Many of these publications you included are literally two paragraph abstracts with not much context so I'm not sure if fully applicable. I do not have any significant knowledge of asthma so I'd leave those details to the expert physicians of course.
I have something very very interesting to report - the IVAPS has absolutely demolished my obstructive and central apneas. I haven't gotten a SINGLE ONE of either since I got that machine. However, I DO get hypopneas now. And more events than I got on my BIPAP on average. What gives? Is that a fluke of IVAPS, it doesn't report apneas correctly?
Bump and hoping the gurus take a look at weigh in on hypopneas etc. I need to figure out if these hypops are obstructive or central events is waveform analysis.
Need a zoomed image of the event progression to see if it is obstructive. Please include mask pressure so we see the breath by breath machine response and pressure support.
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.
