Waking up every 15 minutes ASV

[jamadu]

Hello, I was diagnosed with severe OSA back in 2006 via an overnight home study. I was prescribed a cpap machine with a pressure of 16 and have felt terrible for the last 10 years(until now). I talked my VA pulmonary doc into a proper overnight titration study at a facility in order to find out why I was feeling so bad. My request was granted and the sleep study concluded that I needed another sleep study using a bipap instead of cpap. My doctor decided to put me on a Respironics sv auto bipap instead of having another overnight study. I wanted to know if anyone can help me figure out why I keep waking every 15 minutes or so(especially in the early morning hours).
Here are a few screen shots
1 Last night of CPAP
2 First night of Bipap SV with doctor prescribed settings
3 Lowered Bipap SV settings
4 BPM setting off and zoomed into portion of flow

[Holden4th]

When I was initially on CPAP, my mouth fell open and this breathing woke me up about every 15-20 minutes.

Not sure if this is the case for you.

[JDS74]

Please edit your Subject line to include "ASV" to get you to the right audience.

Suggestions:
1) Set BPM to Auto and let the machine decide.
2) Set the ramp to either 5 min or off. Your pressure settings are not high enough to get benefit from a 30 minute ramp time.
3) Stop fiddling with the pressure settings for a while.

Your small window sample shows classic Cheyne-Stokes respiration so your doctor made a good choice to move you to an ASV machine. BUT, fiddling with the settings on a daily basis is not a good idea. You need some time to get adjusted to how the machine actually works. Without the data surrounding some of the wake-ups, it's hard to be sure but it may be the machine switching back and forth between auto BiPap mode and ventilator mode. Rapid changes in pressure needed to cope with central apneas can disturb sleep. It's one of the things that time and adaptation can help.

[Pugsy]

Looks like Thurs April 21 was using the CPAP/APAP machine and not ASV.
Were you sleeping better with that machine? I know it wasn't doing such a great job but I am trying to figure out if the waking up has been going on a long time or just started with the introduction of the new ASV machine.

Did they tell you why you needed bipap? and any explanation as to why going to ASV bipap instead of just a regular bipap?

April 22 was first night on the ASV and I can't really see the pressure graphs (you have mask pressure in there and only the tip tops of pressure graph showing..we don't need mask pressure graph at this point) but it does seem that the pressure went a bit higher at the doctor's settings than it went with the new lowered settings. Not much maybe but a little...but comparing something to a first night on ASV is kinda pointless. It takes some time to get used to ASV.
Who decided to lower the settings and why the choice to lower and limit the machine's response capability?

The waking up in the wee hours of the morning could possibly be from the clusters of events that are shown.
Could also simply be from needing time to adjust to ASV way of doing things.

So...did the wake ups start with the start of ASV or were you having that problem before ASV was started?
Why were you given ASV bipap? Any mention of centrals? Cheyne Stokes Respiration?

The zoomed in flow rate from Wed May 4 ...don't know what to make of it except that it looks cheyne stokes respiration ...sort of .... but with out central flags which could very well be from the machine addressing any central issues that were hitting the 10 second mark and now just small leftovers below 10 seconds are remaining.

Could you show the full detailed report from Wed May 4 where you took that flow rate snippet?
Need the top events graph, flow rate, pressure (not masked pressure) and leak graphs...that's all we need to see.
Looks like another pressure change was made. Who is advising these changes? Anyone or are you just dial a winging on your own?

[jamadu]

Thanks for your prompt response! The first graph is of my last night on Auto cpap which I was using for about 9 years. You are absolutely correct about the fact that I've been waking frequently and unrefreshed on CPAP. The VA gave me an overnight sleep study a couple months ago, but it was inconclusive because at CPAP pressure 15cm many Rera and Central apneas occurred. It was suggested that I have another overnight study using bipap but my pulmonary Doctor decided to forgo the sleep study and decided to put me on a respironics bipap sv instead. Here is the Doctor's settings..

Ipap max 22
Epap max 16
Epap min 12
Ps min 3
Ps max 10
Auto BPM

I lowered the numbers because my mask was leaking and I thought I would let the machine decide which settings were appropriate.
I will leave the machine alone from now on so I can get use to it. I suffered for 10 years because I believe I was misdiagnosed and was prescribed a cpap machine with a pressure if 16cm.I kept telling the Doctor's that I felt horrible and they refused to listen to me. I finally switched Doctor's and now I'm dreaming and feeling much better even though I'm still waking up so often. The graph of of the zoomed in flow was with the BPM off and I think it freaked the machine out. I will leave the settings alone and hope that the frequency of awakenings will subside. Thanks again for your imput.

[Pugsy]

Word of caution about when you changed those pressures to lower. You pretty much tied the machine's hands in terms of how well it could respond to the centrals. When you lower IPAP max that effectively limits the machine from perhaps going as high as it might need to for central therapy.

ASV therapy does take some time to adjust to even under the best of circumstances and if the clustering of hyponeas continues...if they are obstructive in nature you may need a little more EPAP minimum (which by default will also increase IPAP minimum depending on Pressure support setting.
The clustering in those wee hours points to the settings not quite being optimal and I know you probably don't want to hear this but you may have needed a little more pressure minimums instead of that reduction.
Leaks are quite a challenge at these pressures with especially the wide variation that we end up using with the ASV machines because centrals need to quick and high bursts of pressures so that the machine can actually breathe for you when a central occurs.

At this point it is unknown if your unwanted wake ups are related to the sub optimal therapy in those wee hours of the morning or simply part of the adjustment process needed for ASV users.
I would suggest getting with your doctor if those clusters continue and see what the doctor says about them because they potentially could be a factor in those wake ups. If they weren't present then we might think just more time is needed for adjustment but if they persist even after given a couple more weeks I think the doctor needs to be made aware of their presence and the unwanted wake ups (if you weren't complaining of the wake ups we might let those clusters slide if sleeping well).

Self titration on ASV therapy when centrals are part of the problem requires a little more finesse than is usually needed for self titration (at home with or without doctor input) for plain jane vanilla Obstructive sleep apnea.
You have a doctor available and is current with your therapy...use him if at all possible. That is always preferable place to start in these situations whenever possible.

[jamadu]

Here is my overnight sleep study results.
http://i.imgur.com/3K7YuQx.png
http://i.imgur.com/Xwc7c6s.png
http://i.imgur.com/cATpPxU.png

[Pugsy]

Odd...while your sleep study does show some centrals (and that's pretty much all it shows)...the overall average was only 4.8 per hour.
The RDI was 9.1 in REM and a bit higher in NonREM.

Not a horrible sleep study result and I couldn't enlarge the Oxygen stats enough to see real well but it didn't appear that you had a lot of bad desats at all.

Your reports on the machine look worse than your sleep study does.

Any chance you take any meds that might suppress respiration....usually the pain meds family?

[jamadu]

No Meds other than armour thyroid for my Hypo. I'm wondering if the bipap SV is appropriate for my situation? I noticed that the centrals occurred at 15cm pressure on cpap. Do you think it's possible that my cpap pressure was too high and was causing centrals?

[Pugsy]

When you had the recent sleep study without cpap/apap had you been off the cpap/apap for a few nights or did you use it up until the night before the sleep study? There are some that think that there's a holdover effect after prolonged cpap use and they advocate being off cpap for a few nights prior to any repeat sleep studies without cpap to get a better baseline to start with.

Per this sleep study results I don't see even a need for the cpap/apap...3 hyponeas over the entire night and no OAs....sure wouldn't warrant cpap. You are borderline for needing ASV at least according to the sleep study unless you have some other medical condition along with the barely diagnostic central sleep apnea.

I am scratching my head over this sleep study result.

Could have the prior higher pressures caused the centrals...there's always that possibility but it isn't nearly as common as people think it is....and you did have some centrals with no cpap use.

[jamadu]

I didn't take a break from apap before having my sleep study. Now I'm wondering if my hypothyroid was causing apnea and now that my levels are normal, perhaps I don't even need cpap anymore. I'm perplexed!

[Pugsy]

I don't know how much that "hold over" effect (if it even much of an issue) might really impact a follow up sleep study. Just in case it could I usually suggest that people abstain for a few nights if at all possible...just as an extra layer of precaution to make sure the repeat sleep study is as accurate as possible.

Hypothyroid doesn't usually cause airway tissue restriction but an enlarged thyroid can sometimes restrict the airway. I know of a few people who had large goiters removed who found that they no longer needed cpap.

Your centrals on this last sleep study...borderline in terms of diagnosis...with the RDI added in (couldn't tell what caused the slightly elevated RDI on the study pages you posted) you get the "mild" diagnostic category and whether treatment is needed becomes something to really talk to the doctor about because he may have seen something else going on also that caused him to want to go the ASV/bipap route.
ASV is treatment of choice for the centrals though.

Sounds like your sleep is worse now...makes me wonder what you would feel like not using the machine for a few nights. I strongly suggest that you have a heart to heart discussion with your doctor about these results.

Have you by chance lost some weight since the original OSA diagnosis many years ago?

[jamadu]

Actually, I've gained weight. Here is the interpretation of my sleep study in March. Just thought about the fact that titration started at 10cm and I didn't see any OA at that pressure. With lower pressure settings on the bipap sv, I noticed that the Epap pressure doesn't go over 8cm. I'm still perplexed! I'll try sleeping without the machine and let you know how I feel. Your feedback is MUCH appreciated. Thanks again
http://i.imgur.com/RhptyKk.png

[Pugsy]

Hmmm...well they certainly straddled the fence with that summary.
I don't know what to tell you other than what I said previously about having a good sit down with the doctor.
AHI of 5 per hour is considered diagnostic but only barely fits into the "mild" category so I don't know where they came up with the "severity" side of things unless there was something else found that was alarming that is not mentioned or necessarily seen on this report. Clinical correlation covers a lot of things.

Treating the central aspect though will most likely require the machine being able to go higher but if you don't have obstructive sleep apnea going on too then the EPAP may not need to be up around that original suggestion.

Can you still give me that daily detailed report for the one night where you turned off the BPM and showed the zoomed in flow rate? I would still like to see it as a whole and not zoomed in. I can't tell what was on the events graph or the pressure results. It might be a good place to "give it some time" at those settings if things don't look too wild in terms of clusters and AHI stuff.

[jamadu]

No problem, I'll attach a zoomed out version as soon as I get home this evening.