This VPAP Adapt is beyond me, sorry to say.

[PhyllisBalboa]

Good points, Retired Guy. I might consider a chin strap, although I do hold my tongue behind my upper teeth, but that doesn't stop the air going down. The problem is that mostly this air problem happens when I'm awake. Last night I was awake, getting jammed by air, breathing normally, and my machine showed the pressure at 15.6. I could try CPAP, but have quite a problem breathing against pressure.

You are probably right about my EPAP and ps. I still don't get how it really works. My max ps won't let me lower it beyond 8, and there's no place I can limit the max IPAP. There must be some magic spot I haven't hit yet with the settings. I think I need this machine because of the centrals. I just want it to be more gentle.

Thanks for the well wishes. And I miss the Oregon coast….

[retired_guy]

Good points, Retired Guy. I might consider a chin strap, although I do hold my tongue behind my upper teeth, but that doesn't stop the air going down. The problem is that mostly this air problem happens when I'm awake. Last night I was awake, getting jammed by air, breathing normally, and my machine showed the pressure at 15.6. I could try CPAP, but have quite a problem breathing against pressure.

You are probably right about my EPAP and ps. I still don't get how it really works. My max ps won't let me lower it beyond 8, and there's no place I can limit the max IPAP. There must be some magic spot I haven't hit yet with the settings. I think I need this machine because of the centrals. I just want it to be more gentle.

Thanks for the well wishes. And I miss the Oregon coast….

Well for one thing I was misreading your earlier post as to max, min and so forth. You were talking about what you've done with pressure support both min and max, not necessarily max/min ipap.

But what I believe is true is your statement "My AHI is regularly under 1, usually .3, almost always hypopneas." That is a very good result and one you are achieving in spite of the aerophagia difficulties. So I'll hang my hat on that and say that if it were my machine, and my cute little schoolboy figure of a body, I would set the thing to straight CPAP mode with a pressure of 8 or 9, so probably 8.5, and see what happens. After a couple nights of that if my ahi comes back up, then I would slowly look at other things.

.....and I would get a chinstrap.

[me50]

If she sets it to straight CPAP on her machine, will that help her if she has centrals?

[PhyllisBalboa]

If she sets it to straight CPAP on her machine, will that help her if she has centrals?

Yes, that's a good question. My second sleep study showed a calculated rate of 90/hr centrals. Now, centrals rarely show up (usually under .2), no obstructives show up at all, and almost all apneas are hypopneas. If I have no obstructives since therapy started, would I need to keep my airway so open while exhaling? Maybe all that air swallowing is happening during exhalation as well as inhalation.

Sigh, everything is perfect except the air jamming down my throat.

[vsheline]

KHi PhyllisBalboa,

I think you may need to install the ResScan program and start looking over your data and perhaps posting some detailed data (showing plots of when events happen) so we will be better able to see what is happening.

Here is a link: http://www.apneaboard.com/forums/Thread-...397#pid397

Here's what I've done so far: stopped the ramp completely; lowered max ps from 15 to 8.2; raised min ps from 3 to 3.2; lowered epap from 8 to 7.4; fiddled with pillows enough to fix leaking.

On your machine, the Max PS must be at least 5 higher than the Min PS.

Because you raised Min PS to 3.2, now the machine won't let you lower Max PS lower than 3.2 + 5 = 8.2

If you lower Min PS you would be able to lower Max PS by an equal amount.

Because you are having great difficulty from swallowing so much air, I suggest you try lowering Min PS to 1, and lowering Max PS to 6, in order to see if this lessens how much air you are swallowing.

The problem which lowering both Min PS and Max PS is meant to reduce is the problem of swallowing too much air.

The problem which lowering both Min PS and Max PS might cause is your machine might not be able to adequately treat/prevent centrals.

The only way our machines can completely treat centrals is by raising PS enough to do for us some or all the work of breathing. Raising the PS to 6 sometimes might not be enough, and if the highest it is allowed to raise PS is only 6 we might get central apneas which the machine might be able to only partially treat, only able to change the central apneas into hypopneas.

My sleep report mentioned 8 as the best pressure for me, but my machine regularly hits over 15 (90% IPAP=15.6), even when I'm awake and breathing normally. I feel like this is way too high, but I don't know how to keep it down with the settings available for my vpap. With the high pressure my cheeks are puffing out and air is forced down my throat. My mouth is staying shut, and I have plenty of air, and haven't had any obstructive events since starting therapy. My AHI is regularly under 1, usually .3, almost always hypopneas.

Was this a fixed pressure titration of 8, with CPAP mode therapy rather than bi-level mode therapy?

With EPAP set to 7.4 and with Max PS set to 8.2, the highest IPAP would be able to go is 15.6.

If the 90% pressure was 15.6 this means your machine was at or below 15.6 at least 90% of the time. It also means the pressure was at or above 15.6 for at least 10% of the time.

Since your machine is spending at least 10% of the time maxed out at 15.6, one might think the Max PS should be increased. However, this would make the air swallowing worse. Also, your observation that the problem may be occurring mostly when you are still awake would seem to indicate that raising the Max PS might not be called for.

So why am I getting blasted all the time, enough so that my abdomen is distended and hard, and my chest hurts, and I have to get up and walk around several times during the night? My trouble is mostly centrals, and I don't think I need these powerful pushes to keep breathing. Does anyone know how I can make this machine behave nicely? I hope I wasn't given the wrong machine because I'm in insurance limbo now.

Regarding your chest pain, if you had health insurance I would suggest getting a chest x-ray, to verify you are not getting a collapsed lung. But it doesn't quite sound like you are having collapsed lung.

Is it your chest muscles which get tired and sore from the exercise of breathing against pressure, or are you actually unable to inhale as deeply after stopping PAP therapy? If it is just sore muscles, that is normal until we build strength, but if you are unable to inhale as much air as before, that might indicate some problem.

If after turning off your machine you are unable to breathe in as much air as you normally can, it might be because air is trapped in the chest cavity. Trapped air in the chest cavity is called pneumothorax. I think it is called spontaneous pneumothorax if it was not caused by a physical trauma or impact.

http://en.wikipedia.org/wiki/Pneumothorax

The problem is that mostly this air problem happens when I'm awake. Last night I was awake, getting jammed by air, breathing normally, and my machine showed the pressure at 15.6. I could try CPAP, but have quite a problem breathing against pressure.

Whenever you are jammed by air when you are awake, just reach over and turn the machine off for a second and then back on. This will reset the PS back to Min PS.

My max ps won't let me lower it beyond 8, and there's no place I can limit the max IPAP. There must be some magic spot I haven't hit yet with the settings. I think I need this machine because of the centrals. I just want it to be more gentle.

IPAP always equals EPAP plus PS. In your present ASV therapy mode there is no setting for Max IPAP, because the Max IPAP will be equal to the EPAP plus the Max PS. On your machine, the Max PS must be at least 5 higher than the Min PS. Min PS can be adjusted as low as zero, but I suggest not setting Min PS lower than 1 or 2, because PS helps us breathe more easily.

You can lower the maximum possible IPAP either by lowering EPAP (which may increase obstructive events) or by lowering Max PS (which may compromise your machines ability to treat centrals).

However, patients on ASV machines can sometimes get by okay with less EPAP than would be needed if using CPAP or APAP or standard bi-level (non-ASV) therapies. Because of the automatic "backup" respiration rate feature, the machine may be able to use PS to prevent obstructive apneas and hypopneas even if the EPAP pressure is a little too low and allows the airway to collapse during exhalation, as long as the higher IPAP pressure is able to re-open our airway and allow us to inhale. (On an ASV machine the higher IPAP pressure starts automatically even if our airway is closed and we are unable to start inhaling on our own.) After inhaling with the help of the high IPAP pressure, the pressure drops to the EPAP pressure and, even if our airway closes, the air in our full lungs will gurgle past the obstruction allowing us to exhale at least partially. When we are done exhaling the backup respiration rate kicks in and IPAP starts, opening our airway and helping us breathe in again. Then the cycle repeats. If the gurgling during exhalation does not bother us too much (does not wake us up), we might be getting enough air and do fine, even though the EPAP is clearly lower than needed to keep the airway open.

So if lowering Min PS to 1 and Max PS to 6 does not reduce the aerophagia issue enough, do try lowering EPAP a little, perhaps to 6 or even 5 if need be.

If she sets it to straight CPAP on her machine, will that help her if she has centrals?

Yes, that's a good question. My second sleep study showed a calculated rate of 90/hr centrals. Now, centrals rarely show up (usually under .2), no obstructives show up at all, and almost all apneas are hypopneas. If I have no obstructives since therapy started, would I need to keep my airway so open while exhaling? Maybe all that air swallowing is happening during exhalation as well as inhalation.

In CPAP therapy mode, your machine would be completely unable to do anything at all to treat centrals.

Hey listen, you are going great - because you are still trying. Keep on persevering. Hang in there. It will get better.

Take care,
--- Vaughn

[PhyllisBalboa]

Thanks so much, vsheline, this is just what I hoped for, a detailed explanation of how this machine works in ASV mode, and why it might be causing me so much trouble.

After my first sleep study, the tech told me I had lots of centrals and would probably need a second study. During that first study a pressure of straight 8 seemed to help the obstructives. Unfortunately, the doctor missed the centrals, and that delayed everything. During my second study, they calculated the 90/hr centrals since I only slept for 30 minutes the whole night, and so prescribed the VPAP ADAPT in ASV mode, with the machine wide open at the default settings. By the time I finally got the machine, my insurance was gone, so no followup, and I had moved to Canada, where I'm a visitor with iffy medical care. In short, on my own except for you guys. Life savers, by the way.

Anyway, last night I had fiddled a bit, lowering epap and both min and max pressures. AHI was zero, the first time ever, with 4.5 hours of use. But still the air issue. This was before I got your advice, so I'll try your numbers and see what happens. I think I'm on the right track now, thanks so much! I feel like lower pressure is the way to go, and that my breathing is pretty much fine, it's just that I don't do it regularly like a good girl. Apparently I'm too caught up in my dreams to think about silly things like oxygen.

[journey]

Hi
Because you have central events you have to be treated with ventilation not pressure. There are some clinical support clinicians at Resmef that will help you. Call them.
Changing to a straight CAPAP will only increase your events.

[PhyllisBalboa]

Because you have central events you have to be treated with ventilation not pressure.

Thank you, Journey. Another piece to the puzzle.

And hurray! After making the changes suggested by vsheline, I was able to use the machine for 11 hours last night. No air swallowing!! And my AHI was .2, hypopneas only, all three of them happening right around when I was still somewhat awake.

My pressures stayed below 14, instead of the usual 16. The machine felt gentle to me, just a peaceful companion in a sense. I did notice again, maybe because I wasn't distracted by the pressure, that I regularly stop breathing when falling into the dreaming state. Don't quite know how that happened, but there you have it. I woke up this morning feeling refreshed. My lungs feel better, with a cool sensation that I like.

Thank you so much, everyone.

[jcarerra]

Just sticking my nose in here a moment...

I think it is important to be VERY careful about using the 90% pressure in deciding what settings to use. I am not saying to discount it entirely, but do some thinking.

For example, that 90% number means that 10% of the time it was ABOVE that number...and THOSE are the times that likely are the most important--when the machine was trying to solve apneas. The 90% number is not going to tell you how much above that number the machine thought it needed to be to help you. Consequently, I think you should look at the maximum pressures used (not the 90% number) as the starting point guide to what maxEPAP+maxPS should be allowed to range to.

[PhyllisBalboa]

Just sticking my nose in here a moment...

…that's perfectly fine with me….


Consequently, I think you should look at the maximum pressures used (not the 90% number) as the starting point guide to what maxEPAP+maxPS should be allowed to range to.

Yes, I agree, and I do. My max for the first 2 months of therapy was 23, with higher AHI's. Last week the max was 16, with terrible air swallowing. Last night, using vsheline's suggested numbers, max was 14, with no air swallowing and AHI of .2, and a great 11 hours of sleep. The only events (3 hypopneas) were when I was still half awake.

But you're right, and I will watch those max pressure numbers. I look at Sleepyhead everyday, so I'll be sure to notice them.