Smargie’s Therapy Thread...in Need of ASV Advice

[Pugsy]

FWIW I am in agreement with Jay and idlewire. We gotta get you to sleeping and being more comfortable (kill the aerophagia monster).

[Smargie]

Thank you idlewire!! You explained it all very clearly and I understand the theory behind the plan. I love this idea! I think I'll opt for starting low and adjusting up.

Jay, thanks for explaining the red line and the space between it and the green one. That fills in an important piece of the puzzle for me.

Pugsy, it's very reassuring that you agree with this bold plan.

Last night I turned the EPAP down to 7 and was much more comfortable for most of the night. I did have the usual aerophagia starting on the second round, but I wasn't fighting with the pressure nearly as much. The AHI was higher, but as usual most of the hypops occurred during the ramp time. But some of that 10 minute ramp time looked a lot like sleep breathing, even though I know that I wasn't asleep during the first round. How do you determine which of these events are "real"?

ASV snip 6.PNG (77.37 KiB) Viewed 3062 times

[Jas_williams]

I would do what I suggested a week ago, set min EPAP to 6, but don’t change anything else. During ramp the ASV will not do the wild pressure swings and will not fix the hypopnoea, not sure why it even records them As its not attempting to treat them so ignore any data during ramp.


I don’t use ramp at all and would just turn off ramp

[Smargie]

Jas, I’ll just turn the ramp off. But even though the ASV does not attempt to fix hypopnea during the ramp period, does that necessarily mean they aren’t actually occurring? I’ve heard many people on here say not to count them, and I assumed the rationale was that we are most likely not sleeping yet and our awake breathing is not steady. Since you don’t use ramp do you count all of your hypopnea?

BTW, does ASV prevent obstructives? I haven’t had a single one yet and that seems odd. I wonder why they call centrals UAs...

[Jas_williams]

Jas, I’ll just turn the ramp off. But even though the ASV does not attempt to fix hypopnea during the ramp period, does that necessarily mean they aren’t actually occurring? I’ve heard many people on here say not to count them, and I assumed the rationale was that we are most likely not sleeping yet and our awake breathing is not steady. Since you don’t use ramp do you count all of your hypopnea?

BTW, does ASV prevent obstructives? I haven’t had a single one yet and that seems odd. I wonder why they call centrals UAs...

I often have nights of 0.0 on my ASV. The main events if I have any are Hypopnoea or UA’s and if i look at the mask pressure graph I see the ASV reaching its maximum pressure (25) without encouraging any breath scores a UA if the pressure causes a partial breath then it gets scored as a hypopnoea.


But on the whole my AHI is usually well less than 1.0 (often only one event)


Full 10 seconds of no breathing is scored as a UA the ASV does not differentiate between Obstructive Apnoea or Central Apnoea both would be scored as a UA if the occur.


I suggest you replace the Pressure graph with the mask pressure graph it’s more useful in tuning the ASV

[palerider]

BTW, does ASV prevent obstructives? I haven’t had a single one yet and that seems odd. I wonder why they call centrals UAs...

EPAP is what prevents obstructives, if your EPAP is high enough, you won't have any UAs (Unknown Apneas) on the ASV.

[Smargie]

Last night was pretty wonderful. It was the longest I've slept with the ASV and the lowest AHI (.29). Only 2 hypops and no UAs. No fighting with the pressure and much less aerophagia. Hopefully this wasn't a fluke...I'll have to give it a few more nights and see what happens, but I'm pretty excited!

ASV snip 7.PNG (84.81 KiB) Viewed 3022 times

[Pugsy]

Hot damn. Crossing my fingers that this will be your new normal result.

[Jay Aitchsee]

Last night was pretty wonderful...

Great!!

[Jas_williams]

Great result, I am not sure about the reduction of max PS to 8.0 it looks like your machine is maxing out at that level often last night, so if you start getting events whilst sleeping I suggest you will need to raise the max PS higher, but for now numbers look great and you were comfortable.



Jason

[Pugsy]

Great result, I am not sure about the reduction of max PS to 8.0 it looks like your machine is maxing out at that level often last night, so if you start getting events whilst sleeping I suggest you will need to raise the max PS higher, but for now numbers look great and you were comfortable.



Jason

I asked Jason (the one over on the freecpapadvice forum) about what PS is needed to adequately do the breathing for a person with centrals. He said minimum of 8 available PS...sometimes 10..... when using auto adjusting PS.

I was a bit concerned about the PS max of 8 but figured it might just work out fine. It's borderline for taking care of the breathing when a central happens.
Given the aerophagia issues and the sleep quality issues that the OP here has been having....I think that limiting the max PS for right now isn't going to hurt anything after seeing last nights results and I am no longer concerned unless last night was a fluke.

[idlewire]

Happy that the plan to "jump into the low end of the pool" worked out so well!

As said, if apneas appear, the first line of attack would be to raise Max PS.

Keep us posted!

[Smargie]

So, last night wasn't quite as wonderful, but it was still pretty good. I had a very hard time falling asleep and getting in sync with the pressure. I'd say that I was awake during that first hour, so I don't know if I should count those hypopnea.

ASV snip 7.8.PNG (85.37 KiB) Viewed 2986 times

I don't know what to make of the events between 5:40 and 6:00. The pressure and the leak rate increased substantially and I had 3 UAs and 2 Hs. What is the relationship between leaks and mask pressure? I can't tell if the pressure went up to try to prevent the events or if it sensed the leaks and pushed harder. Any tricks for reducing leaks?

Thank you for all of the help and support! Imagine where I'd be if I were relying on the doctor's office and the DME...certainly not making this kind of progress. (Hopefully the doctor will be so impressed by my numbers that she doesn't look at all the times I went into clinician mode and made changes.)

Should I stay at these settings for a few more days, or does the increase in events merit adjusting the PS max up?

[Pugsy]

Stay at these settings for a while. We know they can work but we don't know if the night before last was a fluke or if last night was the fluke.

The machine won't increase the pressure trying to fix the leaks...it increases the pressure because it sensed the airway closing.
We don't know if the mask leaked at the higher pressures simply because it broke the seal or if maybe those apnea events disturbed your sleep a bit and maybe caused some tossing and turning which might have dislodged the mask. We really can't tell from the data that is available for sure which caused what.

No, increasing PS max isn't what we would do for those hyponeas and I suspect those UAs were probably OAs....
For obstructive stuff we would increase EPAP minimum but in your situation more EPAP causes aerophagia issues.
This is where we say that the machine has to learn what it needs to do and the only way it learns is when you have an OA or hyponea.
It learns that it needs to increase the pressure for a while...and that is mainly EPAP because EPAP does the bulk of the work for obstructive stuff.

In a nut shell....the only for sure way of killing the hyponeas and OAs that are obstructive in nature is more EPAP all night long.
More EPAP creates a big aerophagia issue....so you may have to accept/compromise and let a few hyponeas happen until the machine learns it needs to increase EPAP for a while....so that you don't have the belly issues.

The first cluster at around 2:45...you probably were awake...the machine didn't try to do anything either.
The second cluster right before 6:00....maybe REM related and causing a little more pressure to be needed to prevent whatever it was that caused those events to slip past the defenses. Up until that point things were going great.

Once the machine senses an obstructive in nature cluster....it will respond with higher EPAP pressures until it decides you don't need higher EPAP anymore.
One or two little clusters through the night like that is an acceptable compromise when the alternative is having to use a higher EPAP all night long which we know causes significant aerophagia issues.
You have a choice between 2 evils....aerophagia or maybe a couple of small clusters happening until the machine realizes it needs to go higher.

In my book the aerophagia issues are the worst evil...it's bad news and pretty much a certainty....the clusters are maybe they will happen and they won't mess with how you feel nearly as much as the aerophagia messes with you.

[zonker]

So, last night wasn't quite as wonderful, but it was still pretty good. I had a very hard time falling asleep and getting in sync with the pressure. I'd say that I was awake during that first hour, so I don't know if I should count those hypopnea.

we don't sleep the same every night. there can be just that much difference that it can show up in our ahi.

please stay with your settings for a few nights. it gives your brain and body time to settle in.

good luck!