Switched to ASV

[KatieW]

Great job Katie - it looks like the ASV was the right decision for you. Do you notice any difference in how you feel?

Yes, I feel rested when I wake up now. And I think my general health will improve, now that i am getting good sleep again.

[Pugsy]

Just where would you want to improve anything?

Looks like the current settings are being maxed out consistently right now, specifically PS. Machine wants to run a bit more but letting it do so will likely cause worse aerophagia.

Does raising EPAP min, PS min or a combo of the two help reduce flow limitations with ASV similar to what you would do with a bilevel or is it best to just let them happen and let PS run wild to compensate the disruption on the following breaths?

ASV machines make huge mountains out of mole hills when it comes to the flow limitation graph.
They won’t normally reduce all that much with more EPAP or IPAP via higher PS.
Even if they weren’t exaggerated FLs would be last on the list of things to worry about in this situation.
You fight the worst enemy the best you can using the tools available. FLs were never Katie’s big problem.
The central apneas and aerophagia and plain ordinary OSA are the main problems and not FLs.
I thought you might be concerned with the appearance of the FL graph but I have never seen a Resmed ASV FL graph that wasn’t ugly as hell. It’s just the way they seem to get reported.

[palerider]

Just where would you want to improve anything?

noise

I thought you might be concerned with the appearance of the FL graph but I have never seen a Resmed ASV FL graph that wasn’t ugly as hell. It’s just the way they seem to get reported.

Nah, he's just pretending like he knows everything because he's an engineer (reportedly) (who's never even seen an asv).

[Jas_williams]

Because a machine generated breaths tend to have a flatter top for each machine generated breath these are shown as flow limited on the FL graph. Perfectly normal and I am not aware of a machine setting change that will help. A flow limited breath is much better than no breath.

[Pugsy]

Because a machine generated breaths tend to have a flatter top for each machine generated breath these are shown as flow limited on the FL graph. Perfectly normal and I am not aware of a machine setting change that will help. A flow limited breath is much better than no breath.

Makes sense. When I was using the ASV I always wondered why I got the massively ugly FL graph and saw no FLs to speak of on other ResMed machine reports.
FLs don't always have to be killed anyway.

To those following Katie's story:

We did start Katie out at higher EPAP and IPAP with wide open PS but the aerophagia issues were just too much to expect her to live with them when she didn't just have to. We lowered EPAP as the first step in fighting the aerophagia monster and the restricting of PS was a last resort effort to ease her belly issues. We had to make compromises. We know it isn't ideal but it gets the main job done without causing bad belly issues.

I remember Katie from years ago when she first started on cpap.....she had belly issues even back then and had to make compromises even back then.
Now her PS has to be limited but it's still enough to deal with the central issue (and the obstructive issue) and while it is limited now...when it was wide open it never really wanted to go much higher than it is set to now anyway. It would maybe hit max PS of 10 or so...it never consistently used full PS available anyway when we had PS wide open. Not everyone needs a full 15 cm PS max to deal with centrals.

When we started the self titration we started with the usual settings which are higher and wide open and what is shown now is the result of backing up in small stages which had to be done because of the belly issues. It's not like we started lower and more restricted.
A lot of small tweaking was tried first in an effort to deal with the centrals and not cause more belly issues.
If it hadn't been for the belly issues and their effect on sleep....we had the settings working quite well the very first night but we weren't so lucky in that regards because of the aerophagia problems which were significant.
So we had to do some backing up until the aerophagia issues didn't pop up and crossed our fingers that the backing up didn't created therapy effectiveness issues in the process. Luckily we found an acceptable combination of settings that did a very acceptable job and not open the door inviting the aerophagia monster in.

[KatieW]

I remember Katie from years ago when she first started on cpap.....she had belly issues even back then and had to make compromises even back then.
Now her PS has to be limited but it's still enough to deal with the central issue (and the obstructive issue) and while it is limited now...when it was wide open it never really wanted to go much higher than it is set to now anyway. It would maybe hit max PS of 10 or so...it never consistently used full PS available anyway when we had PS wide open. Not everyone needs a full 15 cm PS max to deal with centrals.

When we started the self titration we started with the usual settings which are higher and wide open and what is shown now is the result of backing up in small stages which had to be done because of the belly issues. It's not like we started lower and more restricted.
A lot of small tweaking was tried first in an effort to deal with the centrals and not cause more belly issues.
If it hadn't been for the belly issues and their effect on sleep....we had the settings working quite well the very first night but we weren't so lucky in that regards because of the aerophagia problems which were significant.
So we had to do some backing up until the aerophagia issues didn't pop up and crossed our fingers that the backing up didn't created therapy effectiveness issues in the process. Luckily we found an acceptable combination of settings that did a very acceptable job and not open the door inviting the aerophagia monster in.

This was over a period of 9 days, as the aerophagia went from all-day nausea and bloating, to no nausea and acceptable gas. From 2 naps during the day to an occasional one now.

I was sleeping on a wedge pillow, and on my side to try and minimize gas. And tried endless combinations of pillows to prop myself up. Also ate a light dinner, and nothing after 6 pm. Tried the usual remedies, ginger tea, Maalox, Gas-X, no caffeine, no spicy foods, which I think helped some. I kept a daily record of "how I felt/how I slept" which help me see patterns.

A week ago, I bought a Tempur-Pedic Adjustable Bed. The first 3 days, it was like breaking in a a new pair of shoes. Now it is my comfy little nest, and I wonder why I waited so long. Yes, it is pricey, but no-interest payments for 30 months is helpful. It has also alleviated most aches and pains, which were also disturbing sleep.

I am so grateful to Pugsy, for her compassionate coaching along the way. She is a treasure.

[Geer1]

Makes sense. When I was using the ASV I always wondered why I got the massively ugly FL graph and saw no FLs to speak of on other ResMed machine reports.
FLs don't always have to be killed anyway.

To those following Katie's story:

We did start Katie out at higher EPAP and IPAP with wide open PS but the aerophagia issues were just too much to expect her to live with them when she didn't just have to. We lowered EPAP as the first step in fighting the aerophagia monster and the restricting of PS was a last resort effort to ease her belly issues. We had to make compromises. We know it isn't ideal but it gets the main job done without causing bad belly issues.

I noticed that as well in the other ASV threads I have been following (other forums). ASV seems to report flow limitations more as I would expect a flow limitation to be reported as in it reports a flow limitation even if there is just a smaller breath, it doesn't seem to need to see what is generally considered a flow limited breath waveform. With Autoset I have seen many breaths I consider to be very flow limited that only get scored as minor flow limitations (especially in my grandfathers data).

Pugsy thanks for the information and confirming my thoughts. Hopefully the aerophagia will sort itself out and then can slowly take the handcuffs off. I assume these ASV machines work off a PID feedback control style system and if you limit the machine my guess is it causes (or could cause) underdamping which means the system will take a little bit longer to correct breathing issues (so instead of being able to react in 1 or 2 breaths might take 4 or 5). Great for aerophagia since you aren't getting blown up like a balloon but probably leaves a little room for improvement sleep wise. Then again if significant desaturations or arousals aren't occurring maybe it doesn't really matter.

I'm still hoping the doctors can figure out what is the underlying cause of these centrals and that it can be corrected or will correct itself over time so Katie doesn't even need the ASV permanently.

[Pugsy]

Then again if significant desaturations or arousals aren't occurring maybe it doesn't really matter.

I'm still hoping the doctors can figure out what is the underlying cause of these centrals and that it can be corrected or will correct itself over time so Katie doesn't even need the ASV permanently.

We pick our battles and fight the ones that are more important. In Katie's situation it was more important to deal with the centrals and not cause worsening belly issues because they were causing major sleep disruptions as well as simply being ill the entire next day.
Those were/are worse issues than some maybe FLs.

I also hope that she will eventually get all this sorted out but the beauty of the ASV machine....if she doesn't have any centrals then it won't do anything all that different from her apap except make mountains out of mole hill flow limitations. There's no reason in the world to have to switch machines again unless she just wants to. I used an ASV (S9 Adapt which is the older big brother to the AirCurve 10 ASV) for probably 3 years just because I liked it. I never had a problem with centrals and it never did really do anything in terms of PS changes except on a rare occasion when I might have a rare sleep onset central.
We have a forum member here who is a sleep doctor and a cpap user himself and once he got a chance to use and see ASV in action....he thinks everyone should have one and thinks its a shame that insurance throws up such road blocks due to cost.
The only reason I quit using my ASV was because someone came along here that really needed ASV and had no way to get one due to price...so I sold her mine for cheap. She needed it worse than I did. I sold it and got the AirSense 10 AutoSet for Her because I was wanting to test out the for her mode anyway.

[palerider]

I ASSsume these ASV machines

OR you could read some patents and other literature that describes how they work.

And no, I'm not going to feed you patent numbers.

[Jas_williams]

I noticed that as well in the other ASV threads I have been following (other forums). ASV seems to report flow limitations more as I would expect a flow limitation to be reported as in it reports a flow limitation even if there is just a smaller breath, it doesn't seem to need to see what is generally considered a flow limited breath waveform. With Autoset I have seen many breaths I consider to be very flow limited that only get scored as minor flow limitations (especially in my grandfathers data).

I am getting fed up with some peoples fixation on Flow Limitations you need to help the user in front of you and not just the data.

Flow limitations are not always an indication of an issue in fact Philips machines just raise a flag no graph like a resmed. There is no indication also that the flow limitation graphs are comparable between different machines or modes.

For example
For Her Mode flow limitations look more severe than normal Autoset Mode
VAuto flow limitations always look less than the Autoset. (Does it treat them better or are they under represented I don’t know)


I use the Flow limitation graph as an indication of where to look in more detail at the flow waveform for analysis

[zonker]

I am getting fed up with some peoples fixation on Flow Limitations you need to help the user in front of you and not just the data.

applause.gif

and not just flow limitations. there is MUCH more to this therapy than the data. so much IS down to individuals and how they react.

very well said, sir!

[Pugsy]

I hear you and totally agree with you about FLs. People tend to put all this data under the microscope and overthink it way beyond what it was ever designed to be used for which was trends and patterns first.
We don't treat one specific event (or even one night) but instead treat the overall trends and patterns.
FLs don't always present a problem that needs to have anything done about it. If it ain't broke why do people persist on wanting to fix it?
Nasal congestion FLs can't be fixed with cpap pressures anyway.....the underlying cause of the nasal congestion needs to be addressed.
I know a lot of people like the ResMed FL graph way of presenting the data but I actually prefer the Respironics way of just flagging it.
Much easier for me to review what is going on if I wanted to when I can see exactly what the machine is flagging and where it is flagged and go from there....if I want to go anywhere which usually I don't.

I noticed that as well in the other ASV threads I have been following (other forums). ASV seems to report flow limitations more as I would expect a flow limitation to be reported as in it reports a flow limitation even if there is just a smaller breath, it doesn't seem to need to see what is generally considered a flow limited breath waveform. With Autoset I have seen many breaths I consider to be very flow limited that only get scored as minor flow limitations (especially in my grandfathers data).

I am getting fed up with some peoples fixation on Flow Limitations you need to help the user in front of you and not just the data.

Flow limitations are not always an indication of an issue in fact Philips machines just raise a flag no graph like a resmed. There is no indication also that the flow limitation graphs are comparable between different machines or modes.

For example
For Her Mode flow limitations look more severe than normal Autoset Mode
VAuto flow limitations always look less than the Autoset. (Does it treat them better or are they under represented I don’t know)


I use the Flow limitation graph as an indication of where to look in more detail at the flow waveform for analysis