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

zonker · Post by **zonker** » Tue Aug 13, 2019 5:18 pm

Smargie wrote: ↑
Tue Aug 13, 2019 7:35 am

Lastly, since you all have been sooooo helpful I'd like to contribute when I can. Obviously my knowledge is limited, but there are some easy questions I've chimed in on. I don't want to step on anyone's toes, though. Are there any general rules or am I free to use my own judgment?

have you SEEN some of my blithering?

everyone pitches in here. and not everyone who comes on regularly will see every post. and when they see every post, they might not think to post a response that YOU would. so i hope you feel confident enough to jump in.

"welcome to the zoo!" is MY shctick, copyrighted and patent pending.

so please leave that to me.

other than that, DO EEEET.

palerider · Post by **palerider** » Tue Aug 13, 2019 6:33 pm

Smargie wrote: ↑
Tue Aug 13, 2019 7:35 am
Lastly, since you all have been sooooo helpful I'd like to contribute when I can. Obviously my knowledge is limited, but there are some easy questions I've chimed in on. I don't want to step on anyone's toes, though. Are there any general rules or am I free to use my own judgment?

It's a nice thing if you don't answer things that you're not *really* sure of.... because it's quite annoying to frequently have to correct mis-information, and there's a few that spew that.

Also, giving your opinion about things is fine, but please make it clear that it's an opinion, and you're not trying to necessarily represent something as fact.

"this works for me" or "in my opinion".. etc.

zonker · Post by **zonker** » Tue Aug 13, 2019 8:40 pm

and you know? thanks for being kind enough and wise enough to ask the question.

i get SO tired of people coming here and just shouting at forum members that they are right and the rest of us don't know anything.

pretty much what my sig says.

ajack · Post by **ajack** » Tue Aug 13, 2019 10:19 pm

Smargie wrote: ↑
Tue Aug 13, 2019 7:35 am
I'm still doing really well! I haven't made it to my follow up appointment with the doctor yet between her cancelling and then me, but I'm not too anxious about having changed the settings anymore. Pugsy, I wish I had followed your advice to just postpone treatment until seeing the doc the first time around back in March, when my charts were so ugly...I guess I've made some progress with my good girl complex as well.

I have a couple of questions. I haven't had a single (flagged) OA since starting the ASV. I guess that's not really a question...I'm just wondering if some people tend to have only hypopneas (and UAs or centrals in my case) when on ASV and why that would be.

How unusual is it to develop treatment related complex sleep apnea? I understand that if pressure is too high it can cause centrals, but what about this more permanent situation that happened with me?

When we first lowered my pressures to ease the aerophagia the plan was to raise them again slowly, as tolerated. Since my AHI has averaged .75 over the last 30 days, is there any reason to start titrating back up? The Rx was min EPAP 10, max IPAP 30, and PS 6 - 15. We eventually changed the settings to min EPAP 4, max IPAP 23, and PS 3 - 8. There is still a tolerable amount of aerophagia, so I'd rather not raise any of the settings unless there is a good reason to. My EPAP readings stay surprisingly low-- for example last night the med was 4.26, 95% was 5.16, and the max was 5.52, and that's pretty typical. IPAP averages for past 30 days are min 4.04, med 9.43, 95% 12.68, and max 17.68.

Is there a way to tell how much PS is being used and when? What is the difference between pressure support and back up? ASV vs. ASVAuto?

After reporting back what my doc says during my follow up appointment (unless it's anything radical), it seems like a good point to end my therapy thread and post further questions in new threads if and when they come up. Does this make sense?

Lastly, since you all have been sooooo helpful I'd like to contribute when I can. Obviously my knowledge is limited, but there are some easy questions I've chimed in on. I don't want to step on anyone's toes, though. Are there any general rules or am I free to use my own judgment?

OA are counted in the UA, H are counted as H, CA aren't counted at all because of the way a resmed ASV works. How is the gas going, are you able to increase the max PS a bit. You can tell by looking at the peak pressure that tend to be a flat line across the top, that more PS is needed. Are you able to turn the ramp off, the H was during the ramp time.

Lozaman · Post by **Lozaman** » Wed Aug 14, 2019 12:37 pm

Hi all this is lozaman popping in on Smargie’s thread again. Just wanted you to know I started my own thread “Lozaman’s therapy thread” and I would appreciate any help from you experienced contributors. Smargie I’m glad you’re doing better.

Sent from my iPhone using Tapatalk

Smargie · Post by **Smargie** » Tue Aug 20, 2019 5:06 pm

Thank you all for your responses to my last round of questions. My appointment with the sleep doctor is now scheduled for Sept 30, so it will be a while before I see her for my follow up.

I have had a steady increase in my AHI for the past 8 days. I went from a weekly average of about 0.8 to 5.4. and it consists of mostly hypopneas.

Any ideas on why my therapy would become less effective after 5 weeks of successful treatment? The only things I can think of that are different are that I'm having increased leaking (it's rarely significant, but it's new), and I've caught myself putting my hand or finger over the vent in the nasal piece, which wakes me up.

Is it now time to increase the IPAP?

Pugsy, you said 2 things about increasing it:

In your case if I was going to do anything at all...maybe increase PS max and let the machine sort it out. It won't go up unless it has a need.

and...

So what is the easiest way to get more IPAP....you can either add more minimum EPAP or you can add a little more PS (like change from 3 to 4 minimum PS

Which would be the least likely way to avoid increased aerophagia? Increase min EPAP, min PS, or max PS?

Pugsy · Post by **Pugsy** » Tue Aug 20, 2019 5:46 pm

Smargie wrote: ↑
Tue Aug 20, 2019 5:06 pm
Which would be the least likely way to avoid increased aerophagia? Increase min EPAP, min PS, or max PS?

Max PS increase would be the least likely (at least in theory) because the machine is only supposed to go up only when needed.

The other 2 would involve more pressure with every breath all night long.

Smargie · Post by **Smargie** » Tue Aug 20, 2019 8:03 pm

And that would help decrease the hypopneas? Theoretically?

Pugsy · Post by **Pugsy** » Tue Aug 20, 2019 8:13 pm

Smargie wrote: ↑
Tue Aug 20, 2019 8:03 pm
And that would help decrease the hypopneas? Theoretically?

Yes.

In theory more IPAP is what is needed for hyponeas....allowing the machine to go a bit higher with more PS max will give you more IPAP IF (big IF) the machine makes use of its new found ability. Whether it will do it or not...dunno. Whether it will help or not with such a small maybe increase....dunno.
It is the least likely to cause you problems though and having a little more PS might also come in handy when dealing with the centrals.
As we have talked about before...limiting the PS to 8 is really borderline in terms of being optimal for centrals.

And to complicate things even more...there is the chance that the hyponeas are more central in nature than obstructive and if that is the case then definitely need more PS. It's damn near impossible for me to try to determine central vs obstructive in nature when it comes to hyponeas so I gave up trying. The changes are simply too subtle.

Smargie · Post by **Smargie** » Tue Aug 20, 2019 8:21 pm

Ok, I'll give it a try tonight and report back. Thanks.

Smargie · Post by **Smargie** » Tue Aug 20, 2019 10:23 pm

Why is it a big if that the machine would make use of its new found ability? Just trying to follow along here...

Jas_williams · Post by **Jas_williams** » Tue Aug 20, 2019 11:50 pm

Smargie wrote: ↑
Tue Aug 20, 2019 10:23 pm
Why is it a big if that the machine would make use of its new found ability? Just trying to follow along here...

In my mind I don’t think there is any if involved. The ASV will try and treat hypopnea with more pressure increased PS will provide the more pressure for your machine to do its thing when needed.

Blasts of PS can be disruptive so don’t go mad take your time raising the PS otherwise the PS may be more disruptive than the increased AHI

Pugsy · Post by **Pugsy** » Wed Aug 21, 2019 7:28 am

Smargie wrote: ↑
Tue Aug 20, 2019 10:23 pm
Why is it a big if that the machine would make use of its new found ability? Just trying to follow along here...

Because I don't know the exact criteria for all the little nuance of things that drive the auto adjusting algorithm
I don't know if part of the criteria for more PS is a hyponea here and there or do we need more than one within a certain time frame or something. Heck, I don't even know for sure that the machine will respond to hyponeas with the general rule of thought of "more" ipap is built into the algorithm.

There are several ways to get more IPAP than just having more PS available....but this way is the way that is less likely to feed the aerophagia monster.

Hyponeas are usually fairly easy to kill though. Meaning normally doesn't that huge increases in anything to get them under control.
Sometimes as little as 1 cm will get the job done.

idlewire · Post by **idlewire** » Wed Aug 21, 2019 3:01 pm

The ASV will respond to any drop in ventilation, regardless of cause, with increased pressure support (assuming it is not already at PS Max).

Whether or not it hits PS Max during hypnopnea will depend on the duration of the hypnopnea, how much air you're taking in during it, and your breathing pattern leading up to it. You can zoom in on these events and check the Pressure graph and see if it is hitting your PS Max. If it is, increasing your PS Max by 1 might be beneficial.

Smargie · Post by **Smargie** » Thu Aug 29, 2019 10:25 am

I changed the setting for PS to 3 - 9, up from 3 - 8 on 8/20, so it's been 9 days so far. The results have been so-so... Average AHI for this period is 2.61.

: Snip AHI.PNG (30.15 KiB) Viewed 1387 times

The settings that initially made such a significant improvement started on 7/7 and were kept there for 44 days. Average AHI was 1.4. How long should I stay at my current settings before I consider bumping something up?

To be honest I've been driving myself crazy by pretty much going over every single breath daily, trying to figure out which events are mismarked, as well as which should have been marked but weren't. Doing this has made me observe weird periods of breathing that look like hyperventilation, and others that seems strangely ragged. I even went back to days of low or perfect AHIs and looked at those charts breath by breath to try and spot strange breathing patterns. I haven't come back to report how I'm doing on the new settings until today because I wanted to spare you all from my OCD ramblings.

idlewire wrote: ↑
Wed Aug 21, 2019 3:01 pm
The ASV will respond to any drop in ventilation, regardless of cause, with increased pressure support (assuming it is not already at PS Max).

Whether or not it hits PS Max during hypnopnea will depend on the duration of the hypnopnea, how much air you're taking in during it, and your breathing pattern leading up to it. You can zoom in on these events and check the Pressure graph and see if it is hitting your PS Max.

Even though this may add to my OCD behavior, would you please elaborate on what you said about the breathing patterns leading up to hypopnea and how I'd be able to tell how much air I'm taking in, idlewire?

Also, I know that every night is different and that I had some high AHIs along with the really low ones during those 44 days, but does anybody know why someone would have a fairly significant increase so suddenly when they were doing so well before? I'm obviously an anxious person, but after my first experience with the CPAP I worry even more.

If anyone can help me get out of crazy town I'd be very appreciative!

But some simple advice about when to consider if and when I should increase pressure again would also be very hellpful.

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

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