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RE: afib and sleep apnea - ardenum - 04-21-2018
If your EF is under <45% you must have an ST device and not an ASV. Theres been a study out where people with heart failure were dying when placed on the ASV instead of the ST.
ST sounds also like a viable option. You say the first part of the treatment works then it stops working. ST has a backup rate so when your body makes the switch during the night ST would ideally go into the Secondary rate.
RE: afib and sleep apnea - poppypete - 04-21-2018
'EF' and 'ST' mean/stand for what???
RE: afib and sleep apnea - ardenum - 04-21-2018
EF is left ventricular ejection fraction. Basically how well our heart pumps.
ST is a Bilevel pap with 2 settings, eg. you start your sleep with different setting, and then when you start getting apneas the device switches to other setting. Not counting the atrial fibrilation, sounds what you'd need, if the other half of your sleep can be managed with a pap and not a heart issue
RE: afib and sleep apnea - Sleeprider - 04-21-2018
Bilevel machines use the proprietary names BiPAP (Philips) and VPAP (Resmed). The ST machine stands for Spontaneous/Timed. This simply means that it is s fixed bilevel machine with a set exhale pressure (EPAP) and fixed inhale pressure IPAP. In its simplest form this machine either triggers IPAP and cycles to EPAP using the patient's spontaneous respiratory effort, or if the patient fails to initiate a breath, it produces a timed trigger to IPAP. ST machines have become somewhat more intelligent and now can target aveolar volume using a mode called intelligent Volume Assured Pressure Support (iVAPS). This machine is capable of causing a breath when central apnea would otherwise cause the patient to miss a breath, and it can supplement breaths in hypopnea to increase the volume through pressure support.
The problem with the ST machines is that they are not intended or targeted to complex and central apnea patients or individuals suffering from Cheyne-Stokes Respiration, but instead are for patients with neuromuscular diseases, severe COPD and obesity hypoventilation that results in respiratory insufficiency. In this target group which needs constant pressure support to perform a significant part of the "work" of breathing, the ST works great; but in central and complex apnea patients ST is usually a colossal failure due to the constant presence of high pressure support (the difference in pressure between IPAP and EPAP) which will actually make the central apnea and periodic breathing worse!
The ASV (adapative servo ventilator) was specifically designed to treat complex, central apnea and Cheyne-Stokes Respiration. The ASV can use auto-adjusting EPAP pressure to stabilize the airway against obstructive apnea during exhale cycle, and can trigger intelligent, VARIABLE pressure support when needed, as needed to support inspiration and volume. In other words, the pressure support can be zero or 2-3 cm for comfort, but can rise as high as 15 cm to cause a breath during central apnea or support a breath during hypopnea or Cheyne-Stokes. This levels out the respiratory volume, stabilizes periodic breathing and resolves the kinds of issues you have. The problem is that a large study (SERVE-HF) found a significant risk of sudden cardiovascular death in subjects of the study that had left-ventricular ejection fraction less than 35%. The recommended practices for prescribing ASV then added a safety factor, and the current guidelines for prescribing ASV require patients to be screen for LVEF% and that they have greater than 45% LVEF. The SERVE-HF machine was done using a prior generation of ASV devices that did not have Auto EPAP and zero-PS capability; rather they more closely approximated current ST machines. The most recent evaluation of the SERVE HF study is reevaluating findings in light of the technological advances and some problems in the original study design. https://aasm.org/resources/practiceparameters/asv.pdf Currently there is no ASV therapy for individuals that fall in the risk group (<45% LVEF), however new studies are underway to try to evaluate if the original study can be verified or refuted based on changes in the technology or by modifying parameters of the original cohort compliance and titration efficacy.
So I've given you a lot to chew on, and will also leave a link to the Resmed Titration Protocol which describes the intended purpose of the machines and methods for establishing titration pressures. https://www.resmed.com/us/dam/documents/products/titration/s9-vpap-tx/user-guide/1013904_Sleep_Lab_Titration_Guide_amer_eng.pdf Good luck, and feel free to ask any questions.
RE: afib and sleep apnea - poppypete - 04-21-2018
Thanks Sleeprider...a lot of effort on my behalf...and appreciated.
I changed my pressure last night (8 - 12, not 10 as you recommended) so I'll post those results soon.
In the meantime, may I ask you
- for the dropbox link (into my PM area) to send you my sleep test report, and
- what qualification (eg Dr, Clinician, Technician) do you hold?
Once again, thanks...
RE: afib and sleep apnea - poppypete - 04-21-2018
[attachment=5477]
[attachment=5478]
RE: afib and sleep apnea - Sleeprider - 04-21-2018
I think this result is within expectations and I would think a 60% reduction in events is a relief. Did the way you feel reflect the improved results?
We have a ways to go, and we can try two different things. We can keep pressure the same, and use an EPR setting of 1. This makes exhale easier, but carries the risk of increasing the central events. It's worth a try, and the experience in using low EPR by other members with your situation has varied from increased comfort to increased events. I think you will be able to tell pretty quickly if you feel better or worse and either keep the EPR Full Time at a setting of 1, or turn it back off.
I think we might be able to lower pressure slightly and remain effective. Lets keep it where it is for a night or two longer to get a baseline, and then take a look at 8-10.
With regard to ASV, Afib is not a counter-indication or risk for the therapy. Only low left ventricular ejection fraction has been identified as a disqualifying risk. Large numbers of apnea are more stressful on your heart, so if you can get the echocardiogram and it works out, I will be glad to work with you to give you convincing arguments and documents for your sleep specialist. It is your cardiologists call and your decision to assume the risk; not the sleep specialist to create risks that don't exist.
RE: afib and sleep apnea - Sleeprider - 04-21-2018
I sent a URL for a Dropbox that is privately shared between you and I. Check your private messages.
RE: afib and sleep apnea - poppypete - 04-21-2018
Have attended to...file should be available to you now.
RE: afib and sleep apnea - poppypete - 04-21-2018
Sleeprider...
re: "We have a ways to go, and we can try two different things. We can keep pressure the same, and use an EPR setting of 1. This makes exhale easier, but carries the risk of increasing the central events. It's worth a try, and the experience in using low EPR by other members with your situation has varied from increased comfort to increased events. I think you will be able to tell pretty quickly if you feel better or worse and either keep the EPR Full Time at a setting of 1, or turn it back off."
Current settings:
EPR On
EPR Type Ramp Only ....change to Full Time tonight???
EPR Level 2 ....turn down to 1