1st 2 weeks ever on ASV-SleepyHead Data

[NateS]

I was diagnosed in Nov/Dec with Sleep Apnea as follows: "Central Sleep Apnea complicating CPAP treatment of Obstructive Sleep Apnea; (AHI=29.0 events/hour; Nadir SO2=67.0%; Periodic Limb Movement Disorder PLM Index 15.9 events/hour; Physiological Hypersomnia ESS 16/24; Nocturmal premature ventrical contractions; Nocturmal premature atrial contractions.

On the night of the diagnostic study, the patient's sleep efficiency was low
at 79.8%. The patient had 37 awakenings and 177 arousals. The degree of sleep
fragmentation and disruption of sleep architecture places the patient at risk for
cognitive impairments and metabolic seguelae including hypertension, cardiovascular
disease, diabetes, and the metabolic syndrome.

I was prescribed the S9 ASV described below with directions that: "the patient should be maintained on nasal PAP at the final setting of the following: Min PS (Pressure Support) of 3 cm ii20, Max PS of 15 cm H20, and EEP (End Expiratory Pressure) of 5 cm H
the patient should be maintained on nasal PAP at the final setting of the following: Min PS (Pressure Support) of 3 cm H20, Max PS of 15 cm H20, and EEP (End Expiratory Pressure) of 5 cm H2O
The patient should return for download of treatment data every 2. months, etc.

After two weeks on the machine, including a missed night with a very bad cold, I can respectfully submit the following Sleepyhead data thanks to our resident genius Breathe Jimbo!





Since this is all new to me, now I would be grateful to hear from our resident experts as to what does this all mean? Should I be happy, discouraged and/or patient with these early results?

Edit/ Forgot the lead page:



Edit 1/14/12 1:36AM to correct "Nocturmal premature ventrical contractions; Nocturmal premature ventrical contractions" to:
"Nocturmal premature ventrical contractions; Nocturmal premature atrial contractions."

[NateS]

Just to explain, I had three sleep studies - the first with no titration; the second with continuous AP; and the third with an S9 Tx simulating an S9 ResMed VPAP Adapt.

In the middle study with only continuous air pressure, here is my chart from the Sleep Lab report:



Does this mean that I started out with an AHI of 62.6 before therapy was applied!?

[avi123]

Since it's a Resmed machine that you're using are there any chances that you could also post graphs from Rescan software? If you do it then besides the regular stuff of graphs we could also see the respiration wave shapes and try to decide if there are any indications for Cheyne Stokes. Periodic Breathing, etc.

[timbalionguy]

Very interesting, NateS!

I think that you are one of a group (which includes me) that have a lot of interesting things going on during sleep, without any clearly defined pattern. My inital AHI was higher, around 96, but you have a wider variety of sleep problems than I did. In both cases though, we both wound up with ASV machines, maybe not so much for traditional syndromes treated with ASV (Periodic breathing, for one), but because these machines respond rapidly to a wide variety of sleep problems. And it looks like you got yours right away!

First off, I will state that I am not a medical doctor, and are offering the following observations and opinions only as a fellow ASV user interested in making their therapy work optimally.

The first thing I noticed about your results are, that despite reservations about one of the settings, it would appear you are getting at least partially effective therapy. The second, is that things could be better.

The previous model of ResMed, the VPAP Adapt SV, would attempt to regulate IPAP such that you maintained a target minute ventilation. I do not know how different the S9 VPAP ASV is, but I bet that it is not that much different. I do know that ResMed has a novel algorithm of detecting clear airway apneas, and this is an improvement over what they used before. However, I suspect that this machine is still intolerant of mask leaks, like the previous machine.

You first need to work on your mask leaks. And since this is your first foray (I think) into the world of xPAP, you probably don't have the mask that is right FOR YOU. It may take trying several masks before you find one that works for you. Another possibility is that you are mouth-breathing. A chin strap, taping the mouth shut, or a full face mask may be what is really needed. This will have to be determined by trial and error. (I can recommend the Hybrid full face mask as combining the best features of nasal pillows and a full face mask.)

Looking at your sleep study results and the recommended pressure settings has me wondering what the doctor was thinking. He gave you an EPAPmin of just 5 inches/H2O. For most people, this is an uncomfortably low setting, and prescribing this low of a setting is a common problem. Your PSG, on straight CPAP, shows your best results are right around 10 cm. And your average IPAP seems to verify this number. But that said, it looks like the IPAPmin and IPAPmax settings are working for you.

I wouldn't change anything right now. Start by getting your mask leaks as low as you can get them. Effort spent on this task will IMHO, buy you more in terms of effective therapy than anything else. Once you have mask leaks under control, pay attention to how comfortable these settings are for you. If they are comfortable, and you are getting a good nights' sleep, and your AHI is consistently low (5 or under), these settings may indeed be what you need.

Now, since ASVs can be very tricky to set up, work with your doctor before changing anything! If you feel that your therapy could be more effective or comfortable, try raising your EPAPmin by 1 cm at a time, going no farther than 8 cm (which by then I don't think you will be seeing any improvements, anyway) Your graphs are showing a median IPAP (which I am guessing is EPAP plus PS plus auto IPAP adjustment) of 10.48, and I suspect that with an EPAP of 7 or 8, you will be getting optimal therapy.

Now, if you choose to do this, be aware that an increase in EPAP will make mask leaks quickly be worse, so make sure you mask is not leaking before going any further. Make sure you move slowly-- a week or more between changes-- so you can see if there are any statistically significant changes, either good or bad. Be especially alert for major changes in IPAPmax, or in your average IPAP. (Ideally though, your IPAPmax should decrease a bit, and it looks like it already is dropping) A significant increase in AHI, especially 'clear airway' or 'central' apneas (if you machine shows these) is another sign you need to back off a bit.

Good luck! It looks like you are off to a good start!

[avi123]

Nate, I am looking over the results that you have posted for a validation of Central Apnea but I don't see it. At the begining you posted this: I was diagnosed in Nov/Dec with Sleep Apnea as follows: "Central Sleep Apnea complicating CPAP treatment of Obstructive Sleep Apnea; (AHI=29.0 events/hour; Nadir SO2=67.0%; Periodic Limb Movement Disorder PLM Index 15.9 events/hour; Physiological Hypersomnia ESS 16/24; Nocturmal premature ventrical contractions; Nocturmal premature ventrical contractions.

But any of these does not comply with the AASM definition of Central Sleep Apnea Sleep Syndrom in its diff forms.

[NateS]

Nate, I am looking over the results that you have posted for a validation of Central Apnea but I don't see it. At the begining you posted this: I was diagnosed in Nov/Dec with Sleep Apnea as follows: "Central Sleep Apnea complicating CPAP treatment of Obstructive Sleep Apnea; (AHI=29.0 events/hour; Nadir SO2=67.0%; Periodic Limb Movement Disorder PLM Index 15.9 events/hour; Physiological Hypersomnia ESS 16/24; Nocturmal premature ventrical contractions; Nocturmal premature ventrical contractions.

But any of these does not comply with the AASM definition of Central Sleep Apnea Sleep Syndrom in its diff forms.

avi, it's probably my fault in unskillfully selecting what to copy.

My first sleep study report , covering my first night with no titration and my second night with CPAP was 11 pages long, and my second sleep study report, covering my third night with ASV, was five pages long. I tried to select pertinent quotes from each but likely left out what you may be looking for.

Does Medicare follow the AASM definition of Central Sleep Apnea Sleep Syndrome which you refer to? My prescription and VPAP Adapt machine were approved by Medicare.

If you could tell me where to look in these two reports for the criteria you are looking for, I will try to find and quote from those portions.

Nate

[NateS]

Very interesting, NateS!

I think that you are one of a group (which includes me) that have a lot of interesting things going on during sleep, without any clearly defined pattern. My inital AHI was higher, around 96, but you have a wider variety of sleep problems than I did. In both cases though, we both wound up with ASV machines, maybe not so much for traditional syndromes treated with ASV (Periodic breathing, for one), but because these machines respond rapidly to a wide variety of sleep problems. And it looks like you got yours right away!

First off, I will state that I am not a medical doctor, and are offering the following observations and opinions only as a fellow ASV user interested in making their therapy work optimally.

The first thing I noticed about your results are, that despite reservations about one of the settings, it would appear you are getting at least partially effective therapy. The second, is that things could be better.

The previous model of ResMed, the VPAP Adapt SV, would attempt to regulate IPAP such that you maintained a target minute ventilation. I do not know how different the S9 VPAP ASV is, but I bet that it is not that much different. I do know that ResMed has a novel algorithm of detecting clear airway apneas, and this is an improvement over what they used before. However, I suspect that this machine is still intolerant of mask leaks, like the previous machine.

You first need to work on your mask leaks. And since this is your first foray (I think) into the world of xPAP, you probably don't have the mask that is right FOR YOU. It may take trying several masks before you find one that works for you. Another possibility is that you are mouth-breathing. A chin strap, taping the mouth shut, or a full face mask may be what is really needed. This will have to be determined by trial and error. (I can recommend the Hybrid full face mask as combining the best features of nasal pillows and a full face mask.)

Looking at your sleep study results and the recommended pressure settings has me wondering what the doctor was thinking. He gave you an EPAPmin of just 5 inches/H2O. For most people, this is an uncomfortably low setting, and prescribing this low of a setting is a common problem. Your PSG, on straight CPAP, shows your best results are right around 10 cm. And your average IPAP seems to verify this number. But that said, it looks like the IPAPmin and IPAPmax settings are working for you.

I wouldn't change anything right now. Start by getting your mask leaks as low as you can get them. Effort spent on this task will IMHO, buy you more in terms of effective therapy than anything else. Once you have mask leaks under control, pay attention to how comfortable these settings are for you. If they are comfortable, and you are getting a good nights' sleep, and your AHI is consistently low (5 or under), these settings may indeed be what you need.

Now, since ASVs can be very tricky to set up, work with your doctor before changing anything! If you feel that your therapy could be more effective or comfortable, try raising your EPAPmin by 1 cm at a time, going no farther than 8 cm (which by then I don't think you will be seeing any improvements, anyway) Your graphs are showing a median IPAP (which I am guessing is EPAP plus PS plus auto IPAP adjustment) of 10.48, and I suspect that with an EPAP of 7 or 8, you will be getting optimal therapy.

Now, if you choose to do this, be aware that an increase in EPAP will make mask leaks quickly be worse, so make sure you mask is not leaking before going any further. Make sure you move slowly-- a week or more between changes-- so you can see if there are any statistically significant changes, either good or bad. Be especially alert for major changes in IPAPmax, or in your average IPAP. (Ideally though, your IPAPmax should decrease a bit, and it looks like it already is dropping) A significant increase in AHI, especially 'clear airway' or 'central' apneas (if you machine shows these) is another sign you need to back off a bit.

Good luck! It looks like you are off to a good start!

timbalionguy, thank you very much for your detailed reply AND your encouragement!

Yes I am trying to deal with the leakage problem. I assume the Swift FX nasal pillow mask was prescribed for me because I have a beard and a mustache and was also exhibiting some situational claustrophobia during the second and third sleep study nights. I want to try hard to solve the leakage problem and make this mask work because I know I am going to have an even bigger adjustment problem with xPAP if I have to go to an enclosing type mask. Needless to say, accepting the present setup was a big adjustment in itself, as I'm sure it was for all those here before me.

I like the way the nasal pillows set up under my nose, but as I move around in my sleep, the blue band on the back of my head rides up, causing the pillows to drop down or to the side. I have ordered Karen's solution to hold the back band down in place and am hoping this will solve the leakage problem. No only does the slippage cause leaking but it also causes my VPAP to crank the pressure so far up that what still gets in my nose shoots way up to making me feel like my nose is attached to the air pressure hose at the gas station!. When I finally wake up to the noise and nasal soreness, I pull the back headband down, the nasal pillows slip back into place and the pressure drops down to something more tolerable and quiet.

I just wish I'd wake up faster, before it starts to hurt. Instead, my mind invents all kinds of dreams trying to work the noise and intense air pressure into various crazy story lines! I'm Pinocchio. I'm Cyrano de Bergerac. I'm my car's left front tire at the pump! etc. Only when I run out of ridiculous alternate explanations does my mind finally tell me to "Wake up Dummy and pull the band on the back of your head back down!"

PS - I don't think I am mouth breathing. But anything's possible.

Regards, Nate

[NateS]

Since it's a Resmed machine that you're using are there any chances that you could also post graphs from Rescan software? If you do it then besides the regular stuff of graphs we could also see the respiration wave shapes and try to decide if there are any indications for Cheyne Stokes. Periodic Breathing, etc.

Okay, avi I will try to do that in a few days. My laptop of choice is a Mac, and I am awaiting an update of Parallels from NewEgg to run the Rescan Windows software, as my present version of the virtual machine stopped working with the advent of Lion OSX.

Regards, Nate

[Pugsy]

Mouth breathing....most of us will exhibit mouth dryness with mouth breathing so if you don't seem to have much mouth dryness your leak is most likely that back strap slipping. If you were mouth breathing in the amount of that reported leak I would think your mouth would be like the Sahara desert. I know sometimes I do wake up with a bit of dry mouth in the middle of the night with my mouth open and it doesn't even show as a tiny blip on the leak line. So surely not very long and not enough to impact therapy.

I would concentrate on that back strap problem first. Then consider mouth breathing secondary.

If you could show a daily detailed report from SleepyHead instead of the overview statistics, the ASV users here could see a little better what is going on during an individual night. From what you show here...the leak is the main thing right now and until leak is brought under control the other data is not as reliable as we would like for it to be.

[Pugsy]

I forgot to add that some members like to use a hose management system to route the long hose over their head and lessen the chance of movement dislodging those pillows.
Lots of ideas here.
viewtopic.php?t=10640

Many ideas based on this one...http://www.pur-sleep.com/products/prodD ... rch=&page=

I prefer my hose laying loose next to me so I don't use any hose management system and can't recommend one over another.

[JohnBFisher]

Some quick thoughts ..

From the data for the past few nights, it appears you are fairly quickly adjusting to the ASV. You had one night when the AHI was 6. The rest of the time it was well below that level. Good job.

It appears you definitely needed an ASV unit (from that second sleep study). The central apneas left untreated would continue to lead to serious problems. In fact, the failure of previous doctors to help me address my central apneas led to kidney damage (uncontrolled high blood pressure - due to the central apneas, combined with Ibuprofen damages the kidneys). I don't need dialysis or the like, but I certainly now have a new health worry that had not been an issue.

So, it's good that your doctor is being aggressive about treating your central apneas.

Also, I suspect you are right about mouth breathing. You might want to contact your DME and see if they have a full face mask. I use the Quattro FX. I find that I need a large mask, because my mouth does fall open when I sleep. The medium mask tends to fall right into my mouth.

Also, due to the wide pressure swings (from 5cm H2O to 20+ cm H2O) most masks will leak. I find that a "mask liner" helps reduce the leaks as well as the squeaking and squawking that masks often make. (Let alone the "face farts"). Some companies that make the mask liners are:

http://www.remzzzs.com/
http://quietusliners.com/
http://padacheek.com/

I've used both REMzzzs and Pad-A-Cheek. I can recommend both.

[JohnBFisher]

... Does this mean that I started out with an AHI of 62.6 before therapy was applied!?

As I understand that table, the pressure started at 4cm H2O ... almost nothing. At that pressure you had about 33 minutes of Non-REM sleep. During that time you had 35 apneas and hypopneas. Do the math and you find the AHI (average number of Apneas+Hypopneas per hour) is 62.6.

Plus, your central apneas START at the low pressure. You have obstructive and central apnea and not pressure induced central apneas, which is called Complex Sleep Apnea Syndrome or CompSAS). That's neither good nor bad ... I just thought you should know. I also have both. In fact, when I start to fall asleep I just STOP breathing. For more than a minute at a time. Yikes!

Sometimes you will see people with lower upper pressures, due to how poorly they react to higher pressures. They typically have ComplexSAS. They often struggle to keep their AHI down as a result of that balancing act. You will tend to see better results due to just having central apneas.

Hope that helps.

[JohnBFisher]

Nate, I am looking over the results that you have posted for a validation of Central Apnea but I don't see it. At the begining you posted this: I was diagnosed in Nov/Dec with Sleep Apnea as follows: "Central Sleep Apnea complicating CPAP treatment of Obstructive Sleep Apnea; (AHI=29.0 events/hour; Nadir SO2=67.0%; Periodic Limb Movement Disorder PLM Index 15.9 events/hour; Physiological Hypersomnia ESS 16/24; Nocturmal premature ventrical contractions; Nocturmal premature ventrical contractions.

But any of these does not comply with the AASM definition of Central Sleep Apnea Sleep Syndrom in its diff forms.

avi123, see the second post in this thread by Nate. In it he presents the table showing apneas (of various sorts) at different pressures. Using that table and the following definition we can definitively state that Nate has Obstructive and Central Sleep Apnea.

Central Apnea Clinical Definition: Apnea is defined as a cessation of airflow for at least 10 seconds. The event is central if during
apnea there is no effort to breathe.

This definition comes from:

http://www.aasmnet.org/Resources/Practi ... graphy.pdf

Nate, the definition is from the AASM own products. Your doctor is on the ball and appears to have quickly and adequately defined your problems and addressed them with the most current and effective therapy possible.

[NateS]

Some quick thoughts ..

From the data for the past few nights, it appears you are fairly quickly adjusting to the ASV. You had one night when the AHI was 6. The rest of the time it was well below that level. Good job.

It appears you definitely needed an ASV unit (from that second sleep study). The central apneas left untreated would continue to lead to serious problems. In fact, the failure of previous doctors to help me address my central apneas led to kidney damage (uncontrolled high blood pressure - due to the central apneas, combined with Ibuprofen damages the kidneys). I don't need dialysis or the like, but I certainly now have a new health worry that had not been an issue.

So, it's good that your doctor is being aggressive about treating your central apneas.

**************************

... Does this mean that I started out with an AHI of 62.6 before therapy was applied!?

As I understand that table, the pressure started at 4cm H2O ... almost nothing. At that pressure you had about 33 minutes of Non-REM sleep. During that time you had 35 apneas and hypopneas. Do the math and you find the AHI (average number of Apneas+Hypopneas per hour) is 62.6.

Plus, your central apneas START at the low pressure. You have obstructive and central apnea and not pressure induced central apneas, which is called Complex Sleep Apnea Syndrome or CompSAS). That's neither good nor bad ... I just thought you should know. I also have both. In fact, when I start to fall asleep I just STOP breathing. For more than a minute at a time. Yikes!

Sometimes you will see people with lower upper pressures, due to how poorly they react to higher pressures. They typically have ComplexSAS. They often struggle to keep their AHI down as a result of that balancing act. You will tend to see better results due to just having central apneas.

Hope that helps.

**********************
avi123, see the second post in this thread by Nate. In it he presents the table showing apneas (of various sorts) at different pressures. Using that table and the following definition we can definitively state that Nate has Obstructive and Central Sleep Apnea.

Central Apnea Clinical Definition: Apnea is defined as a cessation of airflow for at least 10 seconds. The event is central if during
apnea there is no effort to breathe.

This definition comes from:

http://www.aasmnet.org/Resources/Practi ... graphy.pdf

Nate, the definition is from the AASM own products. Your doctor is on the ball and appears to have quickly and adequately defined your problems and addressed them with the most current and effective therapy possible.

John, I really appreciate your analysis/opinion and explanation about where I stand both in diagnosis and prescribed course of treatment with respect to my central apneas.

Needless to say, I am very encouraged.

I now have a hose mount which seems to be very good, and I am looking forward to getting the backstrap for my nasal pillow mask in the hope that I can get this leakage problem substantially reduced!

Best regards, Nate

[NateS]

Mouth breathing....most of us will exhibit mouth dryness with mouth breathing so if you don't seem to have much mouth dryness your leak is most likely that back strap slipping. If you were mouth breathing in the amount of that reported leak I would think your mouth would be like the Sahara desert. I know sometimes I do wake up with a bit of dry mouth in the middle of the night with my mouth open and it doesn't even show as a tiny blip on the leak line. So surely not very long and not enough to impact therapy.

I would concentrate on that back strap problem first. Then consider mouth breathing secondary.

If you could show a daily detailed report from SleepyHead instead of the overview statistics, the ASV users here could see a little better what is going on during an individual night. From what you show here...the leak is the main thing right now and until leak is brought under control the other data is not as reliable as we would like for it to be.

Pugsy, thank you for your suggestions! Yes, I am not waking up with mouth dryness. No Sahara desert. And the backstrap is on its way.

In the meantime, I am trying my best to keep the nasal pillows in place throughout the night, as they become displaced.

In about another week, I will try to follow your suggestion to run a daily detailed report from SleepyHead and post it. Thank you for all of your suggestions.

Best regards, Nate