Newbie AutoSV Help Needed

Have been visiting the room about 6 weeks and really appreciative of the dedication and info of the participants. Now its time to jump in and get things under control.

Was Dx OSA 3/2010 with AHI 48, Arousal index 47 secondary to OSA, CA, and Hyp. Began with BiPAP @ 16/12. Various mask choices led to final adoption of Quatro FX with chin strap. Still insufficient improvement led to dental advancement device which, when tested alone was AHI 78 and combined with Bipap 14/9 accepted at 44. Continued this therapy until 3/2013 based on every 6 month surveillance visits with SleepDoc and card downloads. Then machine stopped writing to card, and I started a manual nightly AHI log. I discovered wide range of nightly readings. First discovered no difference with and without dental device so stopped using it. I refused to accept ".. ignore the bad nights because you feel OK" and got a second opinion which suggested ASV. That test reported abolished OSA and CA with following settings: EPapMin-6, EPapMax-15, PSMin-0, PSMax-17, MaxP-25, rate auto and Biflex 2. That test also noted Arousal Index of 27 not associated with respiratory events (and later determined to not be leg movement or external arousals either). Began therapy with Resp SystOne BiPap AutoSV Adv 960P early June. First week AHI between 41 and 24 led to following settings: MaxP 25, EPMin 10, EPMax 15, BPM auto, PSMin-0, Max 13, BFlex 2, Rise 2, Ramp 0. Now Average AHI holding at 12.7-13.5 but with multiple nights still 25-35 and about same number of nights <5. Sleep Doc says "... as good as it gets". Can we do better?

Don't know which data choices most helpful for you guys.
My worst recent night:


My best recent night:


All of my nights are characterized by early events which look like the following, and go away on a good night, or stay on a bad one.

Most recently I have developed large leaks, where the machine high pressure limits and I leak a lot. Is the machine actually over breathing for me and forcing me into Chayne-Stokes to compensate? Any thoughts on what might be going on will be appreciated. I would be glad to tailor the screen shots for the most useful data.

This week I have off, so will be able to check in and update regularly. Thanks in advance for the aid and comfort.

Things that you can try:
(But first, check with your doctor about what experiments you are going to do to see if he says they are safe and if he agrees with you doing the experiments. He doesn't need to agree that they will work just that its OK to try.)

You are using a full face mask and a chin strap. You might try to use a soft cervical collar instead of the chin strap. A cervical collar will prevent jaw drop while you are sleeping but won't move your jaw backwards and increase the likelihood of obstructive events. For that reason, my mask manufacturer indicates that chin straps are not allowed with the Oracle 2 mask. With a full face mask, the need is to prevent the jaw from dropping and causing leaks not to keep the mouth closed as would be the case for a nasal mask.

The bulk of your AHI index seems to be Hypopneas (it would be nice if you posted the report part that shows the various indices) and that seems to support the view that the minimum EPAP pressure is too low. So the experiments might be to gradually increase the PSmin from 0 t0 8 cm H2O checking along the way for any improvement in the stats. Secondarily and separately, gradually increase the EPAP min from 10 to 12 cm H2O doing the same checking. Each of these experiments should be done with the parameters returned to the starting point before starting the next series. That keeps from confounding the results.

Edit:
Have you looked in detail at the CA events? Are they just a breath or two in length. Then your machine is handling them well.

Multiple arousals not related to breathing can be the cause of the many CA events as you pass through the sleeping-awakening-sleeping cycle. Take a close look at some of these to see if you can determine if that is what is going on. I have that problem but my frequency is dramatically lower than your - perhaps 1 per hour not 27 per hour.
End Edit:

Question:
Do you breathe through your nose most of the time but through your mouth some of the time? Or are you primarily a mouth breather? If mouth breather, then I suggest that you read my post (link in signature block) on Oracle 2 mask experience. It may be that switching to the Oracle 2 mask can eliminate your leak issues and clarify what else is going on.

Tks JDS. Will for sure try out the collar thing. Is the jaw drop this for sure, and your suggestion may help the mask seal at the same time. Am nose breather except when I clog up which could be part. Of the high pressure leaks I'm getting now. Thanks again.

just edited my previous reply so you might want to look again.

it would be better if you'd post the whole screenshot,

hit f8 and f10 to turn off the dreaded calendar and right sidebar.

see if you can adjust the sizes of your charts, or take multipe screenshots, to get

events, flow, pressure, leaks on a chart, with snore and flow limitation also nice to have.

Thanks Pale and JDS.

Had massive leaks for several days, and had to reduce Max Pressure to 20 for sleep partner. Also raised ePAPMin to 11. Here's my last night.

As you see, much of the active time is maxing out on my pressures and I don't know why. I am including some event shots to try and unpack whether these events need to be addressed, or, as my sleep doc suggested, should be ignored. Finally, Pale, I included the Central Events detail to get your opinion.



And finally, a "periodic" period.

Any insight would be helpful.
Thanks, Arkis26

it looks like your asv isn't doing it's job and preventing centrals, why did you lower max ipap again?

arkis26 wrote: Most recently I have developed large leaks, where the machine high pressure limits and I leak a lot. Is the machine actually over breathing for me and forcing me into Chayne-Stokes to compensate?

Hi Arkis
There could be an element of this certainly. As Palerider says the main problem at the moment is the machine is not fully managing your central events and this is where any changes in your settings should be targeted. You are having large numbers of central events with periodic breathing and relatively few obstructive events.

In many people these central events are 'pressure sensitive' and the first thing I would recommend is reducing (not increasing) your EPAP MIN. Philips Respironics suggest an EPAP MIN of between 6 and 8 for the 960 in their titration study recommendations. I would suggest reducing it to 8 in the first instance and leaving the EPAP MAX where it is. This will leave plenty of room for the machine to respond to any obstructives if necessary but may reduce your tendency towards the central periodic breathing.

There are further changes we can consider but would need further information, such as your BMI, any history of lung or cardiac disease and preferred sleeping position. Anyway it is best to make just one change at a time.
Ian

arkis26 wrote:Am nose breather except when I clog up which could be part. Of the high pressure leaks I'm getting now. Thanks again.

Missed this first time around. Nasal obstruction can be a cause of poor response to ASV treatment of central events and result in higher ASV pressures. With a full face mask, this only applies if you are not opening your mouth to compensate when the nasal obstruction occurs. It might be worth allowing your mouth to open in your FFM to see if your numbers come down (although you may get a very dry mouth). Pursuing treatments such as nasal steroids (in the short term) and saline rinses in the long term may help to reduce the congestion and result in lowering both the ASV pressures and the number of central events. JDS's suggestion of an oral only mask is a good one and may be needed if the nasal congestion cannot be relieved.
Ian

Took a while to get it together, but your "ditch chinstrap and use soft c-collar" advice was spot on. AHI from mid teens to <1!! Now looking at leaks and comfort. Switched to Quattro Air as part of adjustment. Amy idea what the expected leak rate should be?

Again thanks a bunch for your help thus far.

Normal leak rate for that mask and your pressures should be in the 40-50 L/min range.
Take a look at page 8 in your user guide for a graph that will help in understanding how normal leak rate works.