Help with ASV Device, CSA

General Discussion on any topic relating to CPAP and/or Sleep Apnea.
tfletch159
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Joined: Sat Jun 27, 2015 1:51 pm

Help with ASV Device, CSA

Post by tfletch159 » Sat Jun 27, 2015 2:39 pm

Had my 3rd sleep study last year and they determined that I don't have OSA, but CSA. They split the nite up into 3 parts, no device, then cpap, then an ASV device. Previous to this I had been prescribed a cpap device for the past 10+ years but had never been able to tolerate it. Spent many, many nites trying, but just never could fall asleep, or stay asleep with it. When I tried, it just made me feel worse. I am 44, from the last study -- AHI of 11, with a RDI of 17. my o2 saturation drops down as low as 81% during REM. Almost all of my apneas are during REM, one sleep study, it said they were near continuous during REM sleep. I now have an ASV device (Respironics System One ASV) with an Oxygen Concentrator hooked up to it.

The problem I am having is that I end up having a lot of abrupt awakenings with the device, just like I did with regular CPAP, and like I do sleeping without any device, and I am not seeing any benefits from it when I do fall asleep with it. When I am able to fall asleep for a time (last night I was able to get 4 hours of sleep on the device, whcih is outside the norm, usually it's about 2 hours, and then I wake up). Even with 4 hours last nite on it, I still feel like crap this morning, like most every day. I have taken it in to the doc since the sleep study last year, to have them adjust it but that didn't seem to help.

Does anyone have any tips for what I can try to make this work for me? They set the ramp time to the furthest setting out, and I believe the device is still set for what worked in the third stage of the sleep study (End expiratory pressure set at 5??). When they put me on the ASV then, my REM apnea's dropped to zero, for the 7 1/2 minutes I was in REM, and my 02 was good at 91% .

If anyone can give me any ideas or pointers on things to try or settings on the machine that would be great, thank you!! Or if you know of any other treatment options out there to try, experimental or not.I have been struggling with this most likely since I was born. I had a mild stroke then, which they attribute the CSA too. As I get older, it just seems to be getting worse. And I really just don't know what to do now. I know it's not an extreme case of apnea, but I rarely feel good most days because of the poor sleep quality. Thanks again for any help you can give me!!

- Tom

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OSAHell
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Re: Help with ASV Device, CSA

Post by OSAHell » Sat Jun 27, 2015 3:40 pm

Hi tfletch159,

To be effective, ASV (or any xPAP) should be use all nights, even during nap. I feel you on your CPAP experience... Even with really good compliance on CPAP (but no so good AHI) I was getting worst. I'm now on ASV and it proved to be effective as long as I use it! I'm still not where I want to be, but a lot better than before any other xPAP and I finally starting to see some end to this hole bad story of mine. In my case, my progress are on a weekly basis and slow, but constant. I've not yet waking up with the refresh feeling but I’m to the point where I don't feel the need to go back to sleep or lack of sleep when waking up in the morning. Late PM is a bit hard but no more nap. I also had problem waking up because of the ASV when I started... Those machine (ASV) can quickly go to high pressure territory in a matter of a couple of breathe. I made some pressure adjustment and that helped a lot. I was also monitoring the effectiveness of the ASV with a software called Sleepyhead, intimidating at first but really not that hard when you start using it. And there is a buck load of really good infos for Sleephead on this site.

I'll be glad to help with your ASV, but you should first fill in the equipment section of your profile. Also we need some starting point like your ASV settings to work on. They are in the clinician menu of your device, hidden from you but accessible. You also need to use a software like Sleephead (free), to be able to see what your ASV is doing and when.

Start by updating your profile and post your setting. Accessing your setting is not that hard with a good google search! Post your setting well see how high your pressure can get and might be able to do a quick temporary fixe to, at least, get you thru the night.

How long have you been on ASV?

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Mask: AirFit™ P10 Nasal Pillow CPAP Mask with Headgear
Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control
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JDS74
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Re: Help with ASV Device, CSA

Post by JDS74 » Sat Jun 27, 2015 3:41 pm

Your Respironics 960 ASV is a great machine.
I think that what wakes you up is the machine detecting a central event an shifting into ventilator mode and breathing for you. This can cause the pressure to swing pretty dramatically breath-to-breath.
Setting the ramp to the max time will be no help. It just delays therapeutic pressures but doesn't delay the response to central events.

So, let's get started on getting you to a compliant patient with effective therapy. Here are some things to do.

1) Get a copy of all your sleep studies so you can see what is actually happening during sleep.
2) Get a copy of software so you can monitor your sleep every night.
3) Post your settings on your machine so we can see what you are working with. To get to the providers menu so you can see the settings, turn the big knob until Setup is highlighted. Then hold down the ramp button and the dial button at the same time until the system beeps. Turn the knob again to Setup and press it once. Now, as you turn the dial, you can see each of the settings. Make a list and write them down. Dial back to Back, press the dial and you are out of the providers menu.
4) Make sure to use the bubbler on your concentrator to get adequate humidity. Oxygen concentrators deliver totally dry air into the system without it.

It may be that your pressure range is too big so the ventilator mode swings too much and wakes you up.

Next let's work on sleep hygiene.

When you get awakened in the night, what do you do? Do you take off the mask and try to get back to sleep? Do you get up for the day and try to soldier through? What would be good to do is to just try to get back to sleep. Press the ramp button if that will help at this stage. If you can't do that, then get up, turn everything off, go to another room and read something non-stimulating or watch a boring TV program - just something to fill in about 30 minutes. Then, as soon as you feel sleepy, go back to bed, mask up, and go back to sleep.

What this helps is to develop a habit of "I'm in bed, I'm masked up,I'm going to sleep".

When you get additional information or even have any questions at all, post again. It will all work.

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Mask: Oracle HC452 Oral CPAP Mask
Humidifier: DreamStation Heated Humidifier
Additional Comments: EverFlo Q 3.0 Liters O2 PR DSX900 ASV
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Settings: EPAP Min-10.0, EPAP Max-17, PS Min-3, PS Max-10, Max Pressure-20, Rate-Auto, Biflex-1.
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Re: Help with ASV Device, CSA

Post by Guest » Sat Jun 27, 2015 6:04 pm

Thanks for the great feedback. I will get the current settings off the device and post them. Will also install SleepyHead again, and get some data off it. I am a very light sleeper and sleep with earplugs because of it. Had to move the oxygen concentrator to a room down the hall also so I could shut the door because it was too loud. As far as sleep hygience I feel like I have been doing a lot of it. Like last nite, waking up for two hours, and then going back to the machine and sleeping for another 4, but no benefits. I've been using the machine for about a year, and the first few weeks I had it, I had about a 3 or 4 days where it worked -- I felt truly like a new person, I felt normal for once. But outside of those four days at the beginning, its been the same poor results, even while using the device regularly (even with awakenings). I haven't been able to get it to work again like that 4 day stretch, even though nothing changed on the device until I brought it in 8 months later to. I know it is capabe of working for me somehow, I just don't know how to get it working again, and having it consistent (without all the awakenings). Will post settings and get software loaded soon. Thanks!!

tfletch159
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Re: Help with ASV Device, CSA

Post by tfletch159 » Sat Jun 27, 2015 7:35 pm

Here are the settings from the setup menu:

Max Pressure = 25.0
EPAP Min = 5.0
EPAP Max = 5.0
PS Min = 3.0
PS Max = 15.0
BPM = Auto
Flex-Type = Bi-Flex
Bi-Flex = 3
Ramp Time = 0:30
Ramp Start = 4.0
Tubing type lock = off
Tubing type = 15H
System One Resistance = 0
Lock System One = off
Heated tube humidification = on
Humidity level = 1
Tube temperature = 4
Auto on = on
Patient disconnect alarm = 0
Apnea alarm = 0
Low min vent alarm = 0
Mask fit check = off
Humidifier LED backlit = off
Show AHI/Leak/PB = on
Setup parameter displayed = none
Language = EN

As far as equipment I have the Respironics 960 ASV, the system one humidifer to go along with it, and an Airfit P10 for the mask. Thanks and let me know if you need any other info that might help in evaluating, like sleep study results, etc... I will go ahead and get SleepyHead working. Thanks!!

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tfletch159
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Re: Help with ASV Device, CSA

Post by tfletch159 » Sat Jun 27, 2015 8:03 pm

Got SleepyHead working and reading data, just don't know how to interpret it all...lol. If anyone wants to take a look and advise, well I've got some data to start with. I will also look around the forum to try and see what it all means.

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Additional Comments: Machine: ResMed AirCurve10 ASV, Heated Humidifier, Heated Tube

JDS74
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Re: Help with ASV Device, CSA

Post by JDS74 » Sat Jun 27, 2015 8:04 pm

Great that you posted the machine settings.
A couple of things:

With EPAP MIN = EPAP MAX = 5 cm H2O the machine has no latitude to adjust to meet your pressure needs.
With ramp starting at 4 (the minimum it can be), you will not experience any effect at all from the setting.

The PS Min of 3 and PS Max of 15 tells the machine to vary the pressure from 5 cm H2O on inhale to 8 cm H2O to 20 cm H2O for inhale. When you experience a central event, the pressure can suddenly switch from from 5/8 to 5/20 cm H2O and you wake up pretty abruptly.

I suggest that you talk to your doctor and explain what is happening (yes again) and suggest that it may be more comfortable for you to have the machine allow the EPAP to float a little; to adjust PS Max down a little
; and move Max Pressure down so the range when in ventilator mode is more like 10 cm H2O. It might be OK to have EPAP Min moved up a little as well.

Turn off the ramp setting as it is doing nothing at all for you.

Please note that dial winging with an ASV unit is quite risky so don't do it without talking to your doctor.
When I wanted to modify my settings, I asked for a range of settings that would be safe and we agreed on a safe range to adjust my EPAP Min which was the parameter I was concerned with. I had, and stll do, lots of hypopneas and I wanted to see if controlling them better would help.

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Last edited by JDS74 on Sat Jun 27, 2015 9:54 pm, edited 2 times in total.

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palerider
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Re: Help with ASV Device, CSA

Post by palerider » Sat Jun 27, 2015 8:05 pm

tfletch159 wrote:Got SleepyHead working and reading data, just don't know how to interpret it all...lol. If anyone wants to take a look and advise, well I've got some data to start with. I will also look around the forum to try and see what it all means.
read the first post in the announcements section, then ask questions about what that doesn't clear up.

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Get OSCAR

Accounts to put on the foe list: dataq1, clownbell, gearchange, lynninnj, mper!?, DreamDiver, Geer1, almostadoctor, sleepgeek, ajack, stom, mogy, D.H., They often post misleading, timewasting stuff.

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OSAHell
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Re: Help with ASV Device, CSA

Post by OSAHell » Sat Jun 27, 2015 8:38 pm

Did your sleep doc investigate into what might be the cause of your abrupt awakenings? Since it happen even when you're not using the machine there might be something else going on... It might be cause by low desat or many others things. My desats weren't that bad so I can't really tell if it can cause that kind of thing.

Benefits from PAP therapy come with good compliance and most of the time after many consecutives nights of good sleep with the machine. People that see the benefits after only one good night with xPAP are the lucky one not the norm. There's a poll in the threads somewhere here about that if I remember correctly. Have your heart been check recently? Many years of badly treated sleep apnea can have worsen your heart problem and many others things.

There might also be something with your Oxygen therapy/concentrator. If you use your ASV but don't get the O2 you need, it won't be as effective.

Pressure might still be a problem and we might be able to help. BUT as you can see, there is many possibility and it's probably a good time to have a serious talk with your sleep doc, cardiologist and others Dr that treat you.

Best of luck

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OSAHell
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Re: Help with ASV Device, CSA

Post by OSAHell » Sat Jun 27, 2015 9:01 pm

Oops, was writing when you post your setting.

I would not change any EPAP setting until we see some Sleepyhead data. Max pressure can stay at 25, with you current setting it doesn't go there anyway.

Can you post a screenshot of the Statistics view in Sleepyhead?

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Mask: AirFit™ P10 Nasal Pillow CPAP Mask with Headgear
Humidifier: S9™ Series H5i™ Heated Humidifier with Climate Control
Additional Comments: SleepyHead on Mac OSX, Resmed S9 VPAP Adapt (36037), EPAP 5 fixed, PS 4-10

tfletch159
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Re: Help with ASV Device, CSA

Post by tfletch159 » Sat Jun 27, 2015 9:45 pm

Thanks! I will definitely give the doc a call and setup another appointment to try some different settings. Here is hopefully a pic of the statistics screen:

http://imgur.com/MuKdfEG

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JDS74
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Re: Help with ASV Device, CSA

Post by JDS74 » Sat Jun 27, 2015 10:11 pm

Looking at the statistics, it appears that after your awakening in the middle of the night, you aren't getting back on the machine at all. Average usage seems to be around 3 to 4 hours. You need to work on that.

I see that hypopneas for you are the big driver for AHI. That's the same for me. Do you have a copy of the sleep studies?
If so, can you look and see if they report spontaneous arousals not related to breathing?

My report says:
Brain arousals per hour averaged 18, with many of these arousals appearing to be spontaneous and not triggered by respiratory events.
When that happens, I get either an hypopnea or a central apnea. However, the scoring of the study discounts these because it is very common the have either of these during the sleep-wake transition and so the reported AHI is very low. Perhaps that is the case with your study. In my case, these arousals translate to fully awake about once per hour all night long. I've been searching for a diagnosis since 2004 and haven't found it yet

Do you notice any symptoms that occur as you are waking up during the night? Headache, sweating, etc.?
When you wake up, it is just sudden and you are awake?? Nothing gradual?
Are you on any blood pressure meds? If so, are they helping or do you still get spikes?
Your arousals may not have anything to do with sleep apnea. That is another area to be discussed with your doctor.

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Mask: Oracle HC452 Oral CPAP Mask
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Additional Comments: EverFlo Q 3.0 Liters O2 PR DSX900 ASV
Oracle 452 Lessons Learned Updated
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Settings: EPAP Min-10.0, EPAP Max-17, PS Min-3, PS Max-10, Max Pressure-20, Rate-Auto, Biflex-1.
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bwexler
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Re: Help with ASV Device, CSA

Post by bwexler » Sat Jun 27, 2015 10:36 pm

Here are some thoughts I would run past your sleep doctor. I do use the same machine plus oxygen that you do.
here are my settings

Philips Respironics System One (60 Series)
BiPAP autoSV AdvancedModel 960P - P1245906725B9
PAP Mode: ASV (Variable EPAP)
Min EPAP 6.5 Max IPAP 17.6 PS 1.1-10.9 (cmH2O)

I have my O2 set at 3 L/min

When my Max pressure was allowed to get over 18 cm my mask would leak and wake me up.
We haven't asked you about leaks yet. So, can you determine from looking at Sleepyhead leak graph and the summary numbers under the daily pie chart what your min 95% and Max leaks are. That info may give us a clue as to one of your problems.

When you see the sleep doc does he print out the detailed reports from sleepyhead, or just look at how many hours/days you use the machine?

What mask are you using?

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OSAHell
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Re: Help with ASV Device, CSA

Post by OSAHell » Sun Jun 28, 2015 5:37 am

Good morning tfletch159,

Thanks for the graph and as JDS74 pointed out, hypopneas are a big driver for your AHI. And those can be a b**ch if they’re not obstructives in nature. So I would be really careful before playing with the EPAP setting at that point. But your AHI isn't that bad and I wouldn't focus on that right now. Leak, from Stats view anyway, seem be under control but we'll see in detailed view.

As suspected, your main problem is not using your machine enough... There's also the abrupt awakening and the fact that you seem to have hard time falling asleep with the machine.

I was like bwexler when I started ASV, when the IPAP pressure hit the 17-18 or more range, I would wake up. I wouldn't call them abrupt awakening but definitely waking up. When those happened, I would stop and restart the machine to reset the pressure be able to fall back at sleep. I did some research and lower some pressure setting and Voilà. We might be able to help you with that.

For the problem to fall asleep with your machine, why do you think you’re not able to fall asleep with it?

I would like to have an other screenshot that will help me select a few days to look in more details. The the screenshot I want is the Overview view for the past 3 months with the following graph from top to bottom: AHI, Pressure, Usage, Session Times.

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Mask: AirFit™ P10 Nasal Pillow CPAP Mask with Headgear
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Additional Comments: SleepyHead on Mac OSX, Resmed S9 VPAP Adapt (36037), EPAP 5 fixed, PS 4-10

tfletch159
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Re: Help with ASV Device, CSA

Post by tfletch159 » Mon Jun 29, 2015 8:46 pm

Thanks again for all the help and good info and I definitely need to start looking at the data from SleepyHead to see if I can see what is going on. I do see from some of the graphs that the pressures definitely spike up quick when I have an apnea, so maybe that is causing an issue. I do need to work harder at trying to use it for longer periods thru the night than I have. I think about half the time, I end up consciously take it off after I wake up so I can fall back asleep. And then the other half, I don't even remember taking it off, but I do. Will work at it for sure. Not on any blood pressure or other medication. One question I do have is, for any pressure mod's that you guys think might help me, I am not able to change myself right, I need to take that in to have doc reset? Thanks!!

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Mask: AirFit™ P10 Nasal Pillow CPAP Mask with Headgear
Additional Comments: Machine: ResMed AirCurve10 ASV, Heated Humidifier, Heated Tube