ASV & fails- would side sleeping help?

[rosevader]

Finally got Sleephead installed (Norton no longer flags it, so hubby got it done today!). Anyway, I wanted to see what the heck is going wrong. I'd love some help getting a handle on this, so I'll try posting data from SH. (Please be tolerant of a newbie, I'm learning as fast as a sleep deprived zombie can!)

[Julie]

Bump up your low pressure to 8-9, maybe 10 - it's way low for what you apparently need (which may turn out to be closer to 12+) and see how things look tomorow. It's obvious it wants to go higher.

[rosevader]

I would love some help interpreting this data. When you look at it, what do you think is happening? I haven't had a single AHI in the single digits for almost a week now. I'm getting more and more discouraged, please help!

[Pugsy]

When you have some time take a look at this document
http://www.isetonline.org/yahoo_site_ad ... 190318.pdf
I think it will explain the mechanics behind your therapy

Your AHI is primarily obstructive (OA and hyponea) in nature now....when you were on the apap it was predominately central(Clear Airway) in nature when the pressure was high enough to deal with the obstructive stuff.
Unfortunately not only did the higher pressures, you needed to hold the airway open, cause the centrals to pop up but those same pressures caused the gastric issues.

Did they just give you an ASV machine and decide to do the titration at home or did you have a sleep study in a lab where they came up with your current settings?

Could you turn off the pie chart (Preferences/Appearance tab) so that the AHI and machine settings will be included in the image?
I can't tell if the machine just doesn't want to go past 15 max IPAP or it can't go past it because its hands are tied.

So can you tell us exactly what the current settings are?
And how did they come to want to use these settings?

[rosevader]

Here are the settings, original and changed:


The original settings were set because of a sleep study with an ASV in a sleep center. The first time the settings were changed I had intensely painful aerophagia (9 out of 10 pain scale, no kidding!)

Second change came after I got a couple of double digit AHI readings and the tech changed the settings slightly. I got one night at AHI 7 then back up to double digits ever since.

Here's a different day's data just to confuse us:

[Pugsy]

Can you get us a screen shot of your best night AHI with the original settings?

Here's the problem with the current settings...you aren't using enough EPAP to deal with the obstructive stuff and not enough IPAP to deal with the centrals.
Unfortunately what you likely need to deal with both is probably going to cause the gastric issues unless you can come up with a happy compromise.

[Sleeprider]

For the treatment of complex apnea, the IPAP needs to be allowed to go higher and utilize pressure support over 8.0 to over come centrals. The EPAP Min needs to be high enough to treat most OA. My suggestion on this would be to increase EPAP Min by 0.5 cm to 8.5 cm and set max IPAP to 20 cm. PS can continue to be 0.0 minimum but you need to set PS max to 10. The current settings for pressure support are too low to induce a breath, when you don't spontaneously breath, and the maximum IPAP has to be able to accomodate that pressure support from whatever your EPAP is at the time. Implement these settings and observe if OSA is adequately treated. These settings should fully treat your CA and most central hypopnea.

[WickedLoki]

I would set your max IPAP to 25 along with Sleeprider's settings to allow for full PS of 10 if your EPAP is 15.

[rosevader]

Here's the very best night I had with the second setting. When I looked back, there was no data available from the first setting (used only 21/4 nights). Maybe the sleep center deleted it???

[palerider]

Here's the very best night

please turn off the pie chart, your short screen hides a lot of the useful info

click 'file' on the menu, preferences, then appearance, and then uncheck 'show event breakdown pie chart.

[rosevader]

Thanks for the tips on display. Still learning the ropes (while semi comatose!)
Here's the same one again without the pie chart

[Pugsy]

You had 17 nights at the second change in settings which mainly was a reduction in IPAP max...it appears.
How many of those nights did you have AHI less than 5 like this 9/8 night? The overall average AHI for those 17 nights is 7.50...when it was higher was it higher mainly from CAs/Centrals or Obstructives & hyponeas?

Then the most recent change appears to be a small increase in max PS.
Is there a maximum EPAP setting available on your machine? SleepyHead isn't showing it and I don't remember if there is one. I thought there was both a minimum and a maximum EPAP setting. Could you go to the clinical setup menu and verify the settings? SleepyHead is known to be a bit buggy when it comes to the model 960 settings.

How has the belly pain been since they reduced max IPAP to 15?

[rosevader]

Max EPAP stayed at 15 all 3 settings.
Only night below 5 was Sept. 8. Next closest was Sept. 5 at 5.95. I have no data prior to September 2 for unknown reasons.
Okay here's the raw data and summary:
Sept. 2 AHI: 9.72 (OA 4.86 H 3.69 CA 1.17)
Sept. 3 AHI: 7.70 (OA 2.65 H 3.45 CA 1.59)
Sept. 4 AHI: 8.40 (OA 3.78 H 3.36 CA 1.26)
Sept. 5 AHI: 5.95 (OA 2.25 H 2.91 CA 0.79)
Sept. 6 AHI: 7.09 (OA 2.13 H 4.26 CA 0.71)
Sept. 7 AHI: 6.60 (OA 1.20 H 4.95 CA 0.45)
Sept. 8 AHI: 3.37 (OA 0.73 H 2.34 CA 0.29)
Sept. 9 AHI: 6.30 (OA 4.02 H 4.02 CA 1.61)
Sept 10 AHI: 6.31 (OA 1.73 H 3.47 CA 1.11)
Sept 11 AHI: 9.65 (OA 6.18 H 2.56 CA 0.90)
Sept 12 AHI: 18.02(OA 7.09 H 3.85 CA 7.09)
New setting
Sept13 AHI: 6.65 (OA 0.91 H 4.87 CA 0.76)
Sept 14 AHI: 14.53(OA 1.82 H 5.90 CA 6.81)
Sept 15 AHI: 10.89(OA 2.80 H 4.36 CA 3.73)
Sept 16 AHI: 16.84 (OA 7.19 H 5.97 CA 3.67)

(Are hypopneas considered obstructive or central or neither?)

Here goes:
Out of 15 available nights' data:
OA>CA 12 nights
OA=CA 1 nights
CA>OA 2 nights

If hypopneas are addressed:
H>OA 9 nights H>CA 15 nights H> both CA and OA 8 nights
H= OA 1 nights
OA>H 5 nights

OA + H >CA 15 nights

Soooo, it looks like hypopneas + OA predominate. More than half of the 15 nights hypopneas predominate. If counting only OAs then OA > CA 12/15 nights

Conclusions if any?
Thanks for all the help!

[Pugsy]

The hyponeas could be central in nature but they are more commonly obstructive in nature and since you seem to have predominately OAs being in the greater number I would suspect the hyponeas are obstructive.

We already found out from your apap machine time that you need a substantial pressure to deal with the obstructives.
So it doesn't surprise me that you have too many OAs and hyponeas (assuming they are obstructive in nature). If I remember right you needed in the mid teens and not only did those pressures cause the centrals it caused a lot of gastric distress. So those pressure needs are unlikely to change and it's going to create a problem if you use those higher pressures all the time with the gastric issues.
I was hoping that adding the bilevel pressures into the mix that the gastric issues would stay away but you need the burst of IPAP to breathe for you when the centrals pop up.

I am wondering if adding something besides minimum PS of 0 would help hold the airway open in conjunction with the minimum EPAP and do a better job preventing the obstructive stuff.
Right now with PS minimum of 0 the machine is starting out the night pretty much like an APAP machine with a minimum of 8 which we know is not enough and PS of 6 is for centrals which really probably isn't enough.
There's no IPAP until PS changes from 0 to whatever it wants to go to.
Having IPAP available with EPAP could maybe hold the airway open better....maybe.

They titrated you to pressures that would deal with both the centrals and the obstructive but unfortunately those needed pressures create significant gastric pain.
I am wondering how good of a job having minimum PS of say 3 would do along with maybe increasing max IPAP to 20.
Sort of compromise on the IPAP max and hope that it won't cause so much gastric issues.

I hesitate to recommend changes yourself since you are actively working with someone but perhaps run these settings by your medical team

Keep minimum EPAP at 8.0 for right now
Change Minimum PS to 3
That would give you 8.0 exhale and 11 inhale and might help hold the airway open a little better to start with than the plain 8.0.
PS max needs to be at least 10 to deal with the centrals.
Change IPAP max to 20 (up from the 15 you are using now but down from the 25 that was initially used).
Keep EPAP max at 15 though. When EPAP is up there IPAP is going to be restricted somewhat but maybe it won't be restricted too much and let too many centrals happen.

You may have to make a compromise and allow a few centrals and OAs happen in an effort to keep the pressures low enough not to create the gastric issues. Obviously AHI in the teens is more than a "few" of either but if you could get it down to around 5 to 7 without causing the gastric problems it might be an acceptable compromise.

It's painfully obvious that these current settings aren't working very well. The machine's hands are tied in such a way that it can't really go to where it needs to go to do a good job. The challenge will be to find some settings that will do a decent job and at the same time not cause the gastric problems to worsen.

[rosevader]

Thanks for all the help! This has been a very discouraging journey since I started it in May. This forum has been so helpful and supportive though (especially Pugsy!). I don't know how I could have managed without you guys.

The last comment I have about the data is that I don't understand what happened after September 12, when my AHI went from sort of okay to horrible. My health and circumstances didn't change at all. I find the change completely mystifying.

I have an appointment with the sleep doc on Tuesday (not a tech this time). We'll see if he is less clueless than the first doc!