ASV vs CPAP - and the winner is...

Pugsy wrote:. . . making excuses for someone that does a half assed job . . .

Well, in a world full of full-assed docs, the half-assed doc is king.



The system is broken. I blame docs, RTs, techs . . . but most of all insurance bean-counters.

If only all patients were fortunate enough to find cpaptalk and have your helpful observations. I mean that.

Don't point at yourself. You do good work.

From what I read dynamic CO2 therapy[2] is held back by issues of reliability in the control systems. Yes I suppose this would be hard to do.

EERS[1] tends to be hard to control. Use too much and hypercapnia is likely. Too little and apneas form.

So what if you vented at many points along the tube. Say 15 liters per minute at the 400 ml mark, then 5 liters per minute at the 300 ml mark, then 2 liters per minute at 250 ml, 200 ml, 150 ml, and 100 ml. Then 1 liter per minute at 50 ml and 0 ml. The size of the vents would be set to the CPAP pressure to be used.

One could analyze the flow wave forms of the person to determine the optimum spread of the venting process to cover the range from normal breathing (no re-breathed air or very little) to moving toward central apnea over breathing (much carbon dioxide rich re-breathed air). This spread of holes could be transferred to a flexible plastic strip and added to a small section of hose plugged into the non-venting mask.

Perhaps the vented air could be directed to a separate hose so the holes never got blocked and the vented air bothered no one.

[1]: Gilmartin G, McGeehan B, Vigneault K, Daly RW, Manento M, Weiss JW, Thomas RJ.
Treatment of positive airway pressure treatment-associated respiratory instability with enhanced expiratory rebreathing space (EERS).
Source: J Clin Sleep Med. 2010 Dec 15;6(6):529-38. Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Link: http://www.ncbi.nlm.nih.gov/pubmed/21206741

[2]: Dynamic CO2 therapy in periodic breathing: a modeling study to determine optimal timing and dosage regimes
Yoseph Mebrate, Keith Willson, Charlotte H. Manisty, Resham Baruah, Jamil Mayet, Alun D. Hughes, Kim H. Parker and Darrel P. Francis
J Appl Physiol 107:696-706, 2009. First published 23 July 2009; doi: 10.1152/japplphysiol.90308.2008
Link: http://www.ncbi.nlm.nih.gov/pubmed/19628721

Hi all. I appreciate all the help I'm getting. I did have a second sleep study about 2 weeks after the first one. They tritrated me at 18/22. So they set up my machine at 16/24 with a
ps of 4. based on the tritration at 18/22 my residual ahi was 2.6. I used the machine for about 3 months and it was very difficult to say the least. No follow up from my doctor and
the only thing my dme could tell me was she had been doing this for over 20 years and with my pressures it would be difficult. No follow up from the dme either. I then came across
this forum (thank god) and started reading and learning all I could. I determined at about 2 months into this my ps changed from 4 to 0.(around that time I took my card into the
dme and she told me that everything looked good) she then told me that she had been doing this for over 20 years. (make me puke hearing that) So I got sleepy head and started
looking at my data. That's when I figured out the ps changed. (as pugsy said the aliens must of did it) So in an attempt to get my leaks under control. I lowered my pressures. Leaks
very well managed now. Mirage liberty was my salvation. once I got the leaks under control I started raising my pressures back up. No success. Then started lowering pressures and
carefully watching obstructive side of things. Currently have my settings at 7/13 very minimal obstructives and almost all centrals. I then went to the dr and met with a new pulmologist about a month ago, I took all my reports with me. I told him that I think I need another sleep study with an asv machine. He looked at the reports for about 5 minutes
then looked at me and said I will order another tritration with an asv immediately. End of appointment. I had my study last week. RT totally shut down on me when I started talking
to her about what i have been doing. The next morning she was pretty meek and mild and said she tritrated me at 7 and 12. Thank you to pugsy, with out her I would probably not
be here today. I was quietly saying my goodbye"s. So I hope to get my new asv soon. I'm taking full resposibilty for this and just want to get better. To be continued. Bennnny.

Benny...I totally missed the part about you getting in with a new doctor. For some reason I thought you were seeing the old doc and I didn't realize you had the follow up study last week. I am going to shut my big mouth now since I have confused myself.
Good job...things are moving along in the right direction and that's all I care about.
I want you to feel better.

Excellent report. Even though I had nothing to do with any of this I love it when a plan comes together.

Benny, all I know is this: Between your efforts and Pugsy's help, I am absolutely SURE you are going to figure it out and make your treatment a success.

Nice explanation. Please do keep us all informed.

Pugsy wrote:Those leaks weren't huge at all.

As much as I hate to be contrary (HAHAHAHAHAHAHAHAHAHAHA!!!!!), I would respectfully disagree and offer that they are, in fact, "huge".

BP's profile offers that they are using a Liberty (hybrid-style) interface. I would offer that leaks in this case would tend to come primarily from one source (either nasal or oral) but not both at any one given point in time.

Consequently, anatomical washout (of both the mask and the oropharynx) would become instantly toxic and totally destabilizing (see recent thread on ETCO2).

Further, I would submit that the same thing will happen on ASV. However, in that case, the machine will mount an attack and make the AHI "look" nice.

However2, underlying destabilized respiratory (and sleep) pattern may still be underfoot (if the machine is spending the night attacking, then one may not necessarily be having refreshing sleep).

amazing

Pugsy wrote:I couldn't agree more and that's why I say "talk to the doctor"....and why I am still seeing red about 108 centrals on a diagnostic study with 12 OAs and he's given an OSA diagnosis and sent home with a machine and had no follow up and no mention as to "BTW those 108 centrals might mean something else is going on that needs investigating because that number of centrals isn't exactly something everyone has so we ignore them"
They aren't pressure induced if they occur without cpap pressure. They are either from something else or maybe idiopathic centrals but they needed to be investigated and at least followed up on.

I think we should try to get a hold of the raw data and analyze it with the new New and Improved Muffinalysis.

With 86.7 minutes of sleep, I'm thinking sleep-onset and/or SWJ is the culprit here.

However3, the point is well taken, that if it isn't "junk", then it could be REAL important.

Sludge wrote:... if it isn't "junk", then it could be REAL important.

How's that for helpful information?

"persistence of sawtooth pattern".

Whatever the heck that means...

The Latinist wrote:...his...

Or not...

amazing

Bennnyp wrote:Hi all. I appreciate all the help I'm getting.

I hope it works out very well for you.

Bennnyp wrote: I did have a second sleep study about 2 weeks after the first one. They tritrated me at 18/22. So they set up my machine at 16/24 with a ps of 4. based on the tritration at 18/22 my residual ahi was 2.6. I used the machine for about 3 months and it was very difficult to say the least. No follow up from my doctor and the only thing my dme could tell me was she had been doing this for over 20 years and with my pressures it would be difficult.

I have some cooking in my work history and am watching “Kitchen Nightmares” (Gordon Ramsay). Gordon deals with restaurants that are on the edge of folding. A common response from an owner is to tell about how many years they have “in the business”. What is clear is that being in a business does not mean that you are doing well in it or at it.

I wish we had a Gordon Ramsay for the sleep industry. We could use one!!!

Bennnyp wrote: No follow up from the dme either.

Not a shock. I think this whole part of the system should be reviewed.

Bennnyp wrote: I then came across this forum (thank god) and started reading and learning all I could. I determined at about 2 months into this my ps changed from 4 to 0.(around that time I took my card into the dme and she told me that everything looked good) she then told me that she had been doing this for over 20 years. (make me puke hearing that)

During the show “Kitchen Nightmares” Gordon Ramsay has been moved to that state several times.

Bennnyp wrote: So I got sleepy head and started looking at my data. That's when I figured out the ps changed. (as pugsy said the aliens must of did it) So in an attempt to get my leaks under control. I lowered my pressures. Leaks very well managed now. Mirage liberty was my salvation.

The testing is so short (one or half a night) and in the lab rather than the home. Titration same thing.

But the body changes and they do not monitor for those changes.

I am very very very very very glad you have learned to use data. It has saved my life several times.

Bennnyp wrote: once I got the leaks under control I started raising my pressures back up. No success.

Anyone with emergent centrals needs to monitor data carefully, especially if they raise pressure!!!!

Bennnyp wrote: Then started lowering pressures and carefully watching obstructive side of things. Currently have my settings at 7/13 very minimal obstructives and almost all centrals. I then went to the dr and met with a new pulmologist about a month ago, I took all my reports with me. I told him that I think I need another sleep study with an asv machine. He looked at the reports for about 5 minutes then looked at me and said I will order another tritration with an asv immediately. End of appointment.

It is very hard to find good doctors these days. It sounds like you may have had some success.

Bennnyp wrote: I had my study last week. RT totally shut down on me when I started talking
to her about what i have been doing. The next morning she was pretty meek and mild and said she tritrated me at 7 and 12. Thank you to pugsy, with out her I would probably not
be here today. I was quietly saying my goodbye"s. So I hope to get my new asv soon. I'm taking full resposibilty for this and just want to get better. To be continued. Bennnny.

What the little study shows is that at 90 days your brain health will likely improve (due to the lack of “emergent” hypocapnic central apneas) but your quality of life may not (apparently due to excessive arousals as the machine dances the pressure about to control those centrals).

One of my basic strategies has been to use lifestyle changes to help my CPAP therapy work better.

My “emergent centrals” are directly related to life stress. This has been a very clear pattern for years now. So I believe that anything that you can do to reduce life stress is likely to help your xPAP machine help you better.

I have found that working with a dietitian and a personal trainer has helped my CPAP therapy work better. For one thing it is part of why I can use half the pressure that I used to.

Foot reflexology, acupressure, and Buddhist meditation I have found to be wonderful stress reducers.

With emergent centrals I do believe you would do well to widen the field way beyond our “health care system”. Simply, I believe that they do not have good answers for emergent centrals at this time.

Sludge wrote:

The Latinist wrote:...his...

Or not...

Bennnyp wrote:My wife suggested ...

Sometimes, I think it's me...

Anyway, while your lifestyle is your own beeswax, just so I can run a little statistical analysis, can you share some demographic data?

TIA.