ASV titration specialists? Any thoughts about developing a list of providers?

[ignorant1]

Question: Being that ASV titrations can be more complex than others, what are your thoughts about compiling a list of doctors and labs which are known to possess high skill levels (specifically) in ASV therapy and titrations?

In the past I have been fortunate enough to work with one doctor who trained his lab technicians on a specific methodology for ASV titrations, and the results were phenomenal. Unfortunately that particular doctor is retiring, which leads me on a search for a new provider. Maybe if we post our experiences we can develop a nice thread of resources for ASV specialists from which to draw upon in the future?

Personally, I am hoping to find a doctor in the Los Angeles area (or anywhere in Southern California) but have no idea how to suss out a truly exceptional doctor from the 100's of 'sleep specialists' in the region.

Thanks for your consideration, and Happy New year to all!

[palerider]

Question: Being that ASV titrations can be more complex than others,

In my experience, ASV machines are so smart that all that's usually needed is to set the thing at, or near, factory defaults and let the machine work it's magic.

[squid13]

I did my own titration and I started out using factory defaults. All I needed to adjust was the Min Epap and the Min PS. the rest I left at factory defaults. I played with those two until I got good results which is zero AHI most nights. I'm using the ResMed Auto ASV 36037 in auto mode. If your in auto mode you use Min Epap + Min PS = Min IP, Max Epap + Max PS = Max IP Asv"s are smart machines and they'll only go to where they need to. As PR said let them work it's magic.

[chunkyfrog]

No list is as reliable as it could be, as tampering is rife.
It is far safer to become the expert you need.

[ignorant1]

First, Thank You for your responses and input!

Please know that I do NOT disagree at all with the premise of learning to be your own best advocate, and to gain as much expertise as possible; that is of paramount importance! This forum is an exceptionally rich resource, and has no doubt actually *saved* people's lives - in addition to helping countless others. Although I have not been active here for quite a while, I learned much here, and hopefully helped provide some help too. That being said...

My own personal experience & history with ASV therapy wasn't quite so straight forward. Utilizing the machine's automatic algorithms yielded AHI numbers that were almost always zero... and at worst, always still far less than one. Same thing after two different titration studies.

An AHI of zero is perfect, right? Unfortunately it was not that simple. The PSG's showed evidence of disruptive (sub-cortical?) arousals, but they were declared as being unrelated to SDB due to the fantastic AHI numbers. (I also have some mild PLMS/PLMD issues, but I am speaking of the spontaneous arousals that were *not* related to movement issues or SDB.)

Still suffering from non-restorative sleep, I traveled out of state to have another titration done. This particular practitioner had the lab techs trained to pursue what he colloquially called a "normalized" breath curve. In reading the PSG, I could see where very subtle pressure changes were being performed. The end result was nothing less than transformative, both from a PSG perspective, as well as from the subjective results. THAT is why I'm hoping to find another doctor/lab tech who can help dial in the pressure settings to achieve the best possible results.

I was hoping to accomplish an ongoing compilaton of outstanding ASV resources with this thread, but I realize now that it may not be a viable goal. If by any chance someone knows of an appropriate doctor in the Los Angeles area, I would be eternally grateful for any recommendations!

(BTW, I was started on an S9 series ASV a long time ago, and have been using an Aircurve 10 ASV for several years now.)

[palerider]

The end result was nothing less than transformative, both from a PSG perspective, as well as from the subjective results. THAT is why I'm hoping to find another doctor/lab tech who can help dial in the pressure settings to achieve the best possible results.

What were the differences in the machine settings, if I may ask?

[/quote]

“Ignorance” is not pejorative; it is simply a lack of information. “Stupidity” is an inability to utilize available information.

Couldn't agree more.

[slowriter]

... My own personal experience & history with ASV therapy wasn't quite so straight forward. Utilizing the machine's automatic algorithms yielded AHI numbers that were almost always zero... and at worst, always still far less than one. Same thing after two different titration studies.

An AHI of zero is perfect, right? Unfortunately it was not that simple. The PSG's showed evidence of disruptive (sub-cortical?) arousals, but they were declared as being unrelated to SDB due to the fantastic AHI numbers. (I also have some mild PLMS/PLMD issues, but I am speaking of the spontaneous arousals that were *not* related to movement issues or SDB.)

Still suffering from non-restorative sleep, I traveled out of state to have another titration done. This particular practitioner had the lab techs trained to pursue what he colloquially called a "normalized" breath curve. In reading the PSG, I could see where very subtle pressure changes were being performed. The end result was nothing less than transformative, both from a PSG perspective, as well as from the subjective results. THAT is why I'm hoping to find another doctor/lab tech who can help dial in the pressure settings to achieve the best possible results ...

Interesting. I presume you're talking about Krakow?

I don't understand how you say, on one hand, that they titrated you effectively, and then on the other that you are seeking alternatives for further titration?

I would also think that normalizing the airflow curve would actually be reasonably straightforward, given the data that the machine provides?

Krakow demonstrates what he's talking about in this talk, with PSG examples of CPAP, ABPAP, and ASV. This is an ASV example that he says demonstrates this "normalized airflow." I'm curious what it'd look like in OSCAR. I also think for a lot of patients, standard ABPAP will get them here.

Screenshot from 2019-12-27 18-32-26.png (315.78 KiB) Viewed 532 times

[ignorant1]

What were the differences in the machine settings, if I may ask?

I believe that dialing in the settings is similar in concept as to when an auto-pap unit is constrained to a tighter window of pressures instead of being run in a factory "wide open" manner. If someone has a (straight CPAP) titration pressure of 8cm, then allowing an autopap to run between 6cm's to 10cm's will still provide a buffer zone to allow for night-to-night variances, while keeping the unit closer to the nominal 8cm pressure to allow for faster response times with less sudden or intensive pressure variability - which itself can be disruptive. Much better than simply allowing a machine to run anywhere between 4cm's and 20cm's (or whatever the machine's upper limit is). But I'm not telling you and all the other "old pro's" here anything that you don't already know.

Regarding my particular ASV settings, the concept (IIRC) is trying to get the *shape* of the inhalation curve to emulate a natural curve/pattern as much as possible. The titration sets the baseline at those pressure settings, then provides a limited amount of upside to allow for nightly variability or to get through difficult transitional periods such as REM onset. Although not formally diagnosed with UARS, it seems likely that my spontaneous arousals may correlate with UARS issues. Please note the caveat that this is all IIRC... and this is from several years ago, plus I don't trust my memory too much anymore.

Interesting. I presume you're talking about Krakow?

I don't understand how you say, on one hand, that they titrated you effectively, and then on the other that you are seeking alternatives for further titration?

I would also think that normalizing the airflow curve would actually be reasonably straightforward, given the data that the machine provides?

Krakow demonstrates what he's talking about in this talk, with PSG examples of CPAP, ABPAP, and ASV. This is an ASV example that he says demonstrates this "normalized airflow." I'm curious what it'd look like in OSCAR. I also think for a lot of patients, standard ABPAP will get them here.

Yes - you nailed it - Dr. Krakow! The problem is Dr. Krakow is retiring. I initially got notice that the entire facility was going to be shut down, but apparently someone else will be taking over *after* finishing his Sleep Medicine fellowship. Yikes. No insults intended, as everyone needs to start learning about anything at some defined point in time, but I'd prefer to work with someone whom has already developed a high degree of experience and expertise in complicated SDB cases. (Not to mention that I'd prefer to not travel hundreds of miles for services that are disallowed by insurance due to being out of network.) I also recognize, and dare I say, that the sleep lab techs are seemingly more important than the doctor in some instances! If Dr. Krakow's facility retains his lab techs, then perhaps it would be best to go back there and roll the dice. (?) IDK.

As for doing it DIY style: I could look at the curves myself and try to tweak the settings accordingly... but I'd be missing out on other critical info from a PSG - such as knowing the sleep staging at any given time, and more importantly for my case, seeing when spontaneous EEG arousals dissipate.

And THANK YOU for the excellent link! Rest assured (ahem... sorry) that I will watch that video in it's entirety right after I send this response...

[slowriter]

What were the differences in the machine settings, if I may ask?

I believe that dialing in the settings is similar in concept as to when an auto-pap unit is constrained to a tighter window of pressures instead of being run in a factory "wide open" manner. If someone has a (straight CPAP) titration pressure of 8cm, then allowing an autopap to run between 6cm's to 10cm's will still provide a buffer zone to allow for night-to-night variances, while keeping the unit closer to the nominal 8cm pressure to allow for faster response times with less sudden or intensive pressure variability - which itself can be disruptive. Much better than simply allowing a machine to run anywhere between 4cm's and 20cm's (or whatever the machine's upper limit is). But I'm not telling you and all the other "old pro's" here anything that you don't already know.

Regarding my particular ASV settings, the concept (IIRC) is trying to get the *shape* of the inhalation curve to emulate a natural curve/pattern as much as possible. The titration sets the baseline at those pressure settings, then provides a limited amount of upside to allow for nightly variability or to get through difficult transitional periods such as REM onset. Although not formally diagnosed with UARS, it seems likely that my spontaneous arousals may correlate with UARS issues. Please note the caveat that this is all IIRC... and this is from several years ago, plus I don't trust my memory too much anymore.

Can you not check your machine and note the settings?

AFAIK, there actually aren't a lot of settings on an ASV; really just talking min and max EPAP and PS.

Interesting. I presume you're talking about Krakow?

I don't understand how you say, on one hand, that they titrated you effectively, and then on the other that you are seeking alternatives for further titration?

I would also think that normalizing the airflow curve would actually be reasonably straightforward, given the data that the machine provides?

Krakow demonstrates what he's talking about in this talk, with PSG examples of CPAP, ABPAP, and ASV. This is an ASV example that he says demonstrates this "normalized airflow." I'm curious what it'd look like in OSCAR. I also think for a lot of patients, standard ABPAP will get them here.

Yes - you nailed it - Dr. Krakow! The problem is Dr. Krakow is retiring. I initially got notice that the entire facility was going to be shut down, but apparently someone else will be taking over *after* finishing his Sleep Medicine fellowship. Yikes. No insults intended, as everyone needs to start learning about anything at some defined point in time, but I'd prefer to work with someone whom has already developed a high degree of experience and expertise in complicated SDB cases. (Not to mention that I'd prefer to not travel hundreds of miles for services that are disallowed by insurance due to being out of network.) I also recognize, and dare I say, that the sleep lab techs are seemingly more important than the doctor in some instances! If Dr. Krakow's facility retains his lab techs, then perhaps it would be best to go back there and roll the dice. (?) IDK.

As for doing it DIY style: I could look at the curves myself and try to tweak the settings accordingly... but I'd be missing out on other critical info from a PSG - such as knowing the sleep staging at any given time, and more importantly for my case, seeing when spontaneous EEG arousals dissipate.

I'd encourage you to post your settings, per palerider's request, and also an example of your airflow curve in OSCAR per mine.

Even if you do find help from a sleep lab, certainly that info is valuable for you to have, and may be more generally interesting and useful to others (like me!).

[slowriter]

As for doing it DIY style: I could look at the curves myself and try to tweak the settings accordingly... but I'd be missing out on other critical info from a PSG - such as knowing the sleep staging at any given time, and more importantly for my case, seeing when spontaneous EEG arousals dissipate.

Just wanted to focus on this. It's a good point, except keep in mind sleep is variable over time, so not sure how valuable an individual night study is, other than to get you in the right range for the auto algorithms to work their magic.

I have been diagnosed with UARS. I'm using the Dreem 2 headband (my review) to try to get some insights into this nightly data. It doesn't currently give me access to the detailed EEG data, though the hyponogram info is useful. For example, I was just reminded when reviewing that video that Krakow uses a "REM consolidation index" to evaluate the effectiveness of the PAP treatment. This is something I can track with the Dreem.

[ignorant1]

My current settings are: EPAP 7.2, Min PS 6.0, Max 14.0

Thank you again for the video link which briefly explains Dr. Krakow’s concepts. Excellent!

My ASV settings have changed over the years, but those changes have all been quite minimal. Several years after my initial study with Dr. Krakow, I had gained a lot of weight. I went back for another titration and the EPAP and Min PS settings were raised a bit. (I don’t recall the initial settings.) I do remember that you could easily see substantial changes to the waveforms on the PSG, and the number of arousals was reduced dramatically.

Later on, I lost a lot of that weight and the EPAP went from 7.4 to 7.2 and the minimum PS went from 6.6 to 6.0. (My current settings.) Seemingly minor changes, but those subtle tweaks (again) made a big difference in the number of arousals and my subjective sense of sleep efficacy. The pressure reduction also helped with occasional aerophagia which I was getting after the weight loss. I guess I’m a real pain in the ass type patient, because if pressure is too high I get aerophagia or even some centrals (which is why I ended up on ASV) and I’ll get RERA’s and spontaneous arousals if the pressure isn’t perfectly set in the Goldilocks zone.

As mentioned above, most people probably can get away with less fine tuning. I also agree that a PSG showing only one night of data is very limited in scope. However, allowing a proficient tech to tweak the EPAP and Minimum PS to achieve that elusive “normalized” curve during critical sleep phases, and observing the results on the EEG seems to be a necessity for people like myself who are on a knife-edge regarding pressure settings.

I’m intrigued by the Dreem unit you posted about. It appears that they do allow access to raw EEG data for researchers for an additional fee. I wonder if there is any way at all they would allow an advanced user to view that data? With those tools, I could see how it would potentially be feasible to have a good shot at emulating what Dr. Krakow advocates.

I’ve been out of the loop in the SDB world for quite a while, and just now learned about the OSCAR software. I had been using Jedi Mark’s Sleepyhead software, but will look at installing OSCAR and do a data dump. I’ll post a couple pics of my current waveforms after that.

BTW, I was not *formally* diagnosed with UARS since I did not undergo the nasal plesmography. However, UARS was brought up as the likely culprit...

[slowriter]

I’m intrigued by the Dreem unit you posted about. It appears that they do allow access to raw EEG data for researchers for an additional fee. I wonder if there is any way at all they would allow an advanced user to view that data?

Good question; I'll check.