ASV for UARS Help with Settings Question

[2Tired4This]

Im trying to improve my settings for my Resmed ASV VPAP Adapt (36057 model). Ive been using ASV Auto for trying to treat UARS and REM dependent sleep apnea but it typically increases the pressure too much in REM and wakes me up. So I was trying to adjust it.

And looking at the settings there are 3 options:
ASV Auto
ASV
CPAP

What is the difference between ASV auto and ASV?
And can i setup a bilevel setting on this machine to try that?

Thanks

[palerider]

What is the difference between ASV auto and ASV?
And can i setup a bilevel setting on this machine to try that?

ASV has a fixed epap, ASVauto has a variable epap.

everything (except cpap mode) is bilevel.

the only difference is that with this one, the pressure support reacts breath by breath. you can change your minps and maxps, min from zero to 6, and max from 5 to 20.

[2Tired4This]

thanks. I seem to have trouble when the ASV pressures adjust during my REM sleep and my nasal pillows mask leak.
Is there an upwards pressure limit for the nasal pillows masks?

Also I was prescribed an ASV machine to help with UARS hypersensitivity but I think the fluctuating pressures actually are disruptive too. Any advice?

[2Tired4This]

Here are 2 nights of sleepyhead for reference.
Im using a respironics pro nasal pillows mask, with OSB dental device, taping mouth with surgical tape and chin strap to prevent leaks and still showing lots of leaks.
I think surgical tape isnt working to prevent mouth leaks. Ive tried a few full face masks and have trouble with leaks too.

I have lots of trouble with obstruction in REM. I noticed that even in straight CPAP my leak rates shoot up at what looks like REM cycles. Im guessing my tongue obstruction is forcing air pressure into my mouth that is causing leaks. Just a guess.

Any advice please?



ASV Night:



CPAP Night:

[robysue]

Here are 2 nights of sleepyhead for reference.
...
I have lots of trouble with obstruction in REM.

I don't see "lots of trouble with obstruction in REM in either of these night's data. The total AHI on the CPAP night was 0.57 with about 7 hours of usage. So there was a grand total of 4 events all night long and they were well spaced. In other words, there's no clustering of events at time intervals that might be related to REM.

That said: There is some activity in the flow limitation graph in both settings and there's some (quiet) snoring on the CPAP night. The bit of flow limitation on the CPAP night may indeed be REM related given the spacing of about 90 minutes between the busiest periods of that graph.

Still, the data from the CPAP night begs the question: Why use an ASV at all when it looks like straight CPAP or APAP might give you just as good therapy (in terms of treated RDI/AHI) and be much easier to sleep with?

I seem to have trouble when the ASV pressures adjust during my REM sleep and my nasal pillows mask leak.
Is there an upwards pressure limit for the nasal pillows masks?

No, there's no upper pressure limit for pillows masks. But pillows masks may have more trouble sealing with the wide pressure jumps that ASV machines use between IPAP and EPAP. In other words, when PS = IPAP - EPAP is relatively small (say < 4 or 5 cm), the nasal pillows mask has no problem staying sealed when the pressure jumps from the EPAP to IPAP when you inhale. But when the machine starts to drastically increase the IPAP (in response to ragged breathing), and the PS gets up around 7 or 8 cm or more, that can make it harder for the nasal pillows mask to keep a good seal.

Also I was prescribed an ASV machine to help with UARS hypersensitivity but I think the fluctuating pressures actually are disruptive too. Any advice?

Some people are sensitive to changes in pressure. And if you happen to be sensitive to them, then the wildly fluctuating pressures from an ASV machine may indeed be causing as many or more problems than they are fixing.

Question: Subjectively speaking, did the sleep you got on the CPAP night feel more continuous and better quality than the night on the ASV settings?

Here's the thing: If you slept better with the constant CPAP pressure and the mild change in pressure from EPAP to IPAP triggered by EPR, then long term you might feel better with straight CPAP or a tight APAP range than you do with the ASV Auto. Certainly it would be easier to control the leaks if you were using straight CPAP instead of ASV Auto.

Im using a respironics pro nasal pillows mask, with OSB dental device, taping mouth with surgical tape and chin strap to prevent leaks and still showing lots of leaks.
I think surgical tape isnt working to prevent mouth leaks. Ive tried a few full face masks and have trouble with leaks too.

I noticed that even in straight CPAP my leak rates shoot up at what looks like REM cycles. Im guessing my tongue obstruction is forcing air pressure into my mouth that is causing leaks. Just a guess.

There's no evidence that your tongue is obstructing your upper airway in a serious way: On the ASV night, you had 0 events and on the CPAP night you had a total of 4 events in 7 hours of usage.

Now I understand that your diagnosis is UARS, which means that your diagnostic AHI was already very low (< 5) to begin with and that the events that are problems for you are RERAs---i.e. when you sleep with out PAP, your airway starts to collapse, but you wake up (arouse) before the airway has collapsed enough for the event to be scored as an apnea or a hypopnea.

If I had to make a guess as to why your leaks are bad, I'd be guessing one of the following:

1) Once you get very sound asleep or hit REM, the muscles that keep your mouth closed relax and the mouth pops open. Once the mouth has popped open, the PAP air enters through your nose and goes out your open mouth. Hence the large and prolonged leaks. The mouth does not have to pop "wide" open for this to happen, and even though you are taping and using a chin strap, it's possible that your mouth is still open just enough for a lot of air to escape.

2) Rather than your tongue "obstructing" things and allowing the air to enter the mouth, the problem may be that the your tongue is no longer touching the roof of your mouth. When your tongue is parked up on the roof of your mouth, it effectively blocks off the oral cavity from the nasal cavity and upper airway. When the tongue is in the right position, many people can actually open their mouth and still lose little or no air through the oral cavity because the tongue is forcing the CPAP air to go down through the upper airway.

3) If the tongue is not positioned to block air from getting into the mouth (see #2), then PAP air can get into the oral cavity. If the mouth is closed, the pressure in the oral cavity can build up, and once it does, there's a tendency for the lips to "blow open" and that then allows air to escape. And enough air can escape for a large leak to be detected.

[2Tired4This]

Thank you Robysue.
Yes My AHI events are not the problem on CPAP. I usually score under 1. Its my REREs and AHI during REM that are the issue according to my sleep test numbers
My sleep test showed these numbers:
AHI - 4 non-REM, 29 REM
RERE - 39 non-REM, 41 REM
RDI - 43 Non-REM, 70 REM

I was using the ASV under the guidance of Dr Krakow who claims it is more effective for sensitive UARS patients. I disagree and am experimenting with straight CPAP now. And yes, I have felt like I get better sleep with the CPAP but am trying to control the leaks and then optimize my pressure. (good suggestion on minimizing the PS with ASV too. I will try that as well)

As for the source of the leaks, you have good guesses. I need to try and fix these issues. Not sure what else to do
Jaw Drop- I think the jaw muscle weakens and drops enough to allow mouth breathing despite my efforts to keep jaw closed with chin strap, tape, dental device and tennis ball shirt to sleep on side.
*My dental device is an OSB that unfortunately allows the jaw to drop open. Im going to try and force it closed with braces rubber bands and see if that helps.. or may have to try another device.
Tongue Position - keeping it on the roof of my mouth has been a struggle.
*I tried myofunctional therapy exercises for 9 months that wasnt helpful.
*And I got the OSB dental device because it claims to focus on optimizing tongue position.. which doesnt seem to be the case when it allows the jaw to drop open

Any other suggestions?

[Okie bipap]

I, and several other member of the forum use a soft cervical collar to keep our mouths closed while sleeping. Unfortunately, I have found I still exhale through my mouth when sleeping if I use nasal pillows, so I must use a full face mask.

[2Tired4This]

Can you send me a link to one of those collars? Thanks

[Thatgirl]

I've never heard of ASV for UARS. That's a thing?

[robysue]

I've never heard of ASV for UARS. That's a thing?

Dr Krakow, who has a sleep clinic out in NM (I think) is a strong advocate of ASV for UARS patients. His views about UARS, however, are somewhat unorthodox and are not commonly accepted in most of the sleep medicine community.

Even though he is an outlier when it comes to what he thinks should be used as treatment for UARS, Dr. Krakow is a well qualified sleep doc and he has written some very good books on insomnia that are aimed at the mass market.

[2Tired4This]

I dont recommend others with uars to see krakow. His guidance was very inneffective for me.

[robysue]

Thank you Robysue.
Yes My AHI events are not the problem on CPAP. I usually score under 1. Its my REREs and AHI during REM that are the issue according to my sleep test numbers
My sleep test showed these numbers:
AHI - 4 non-REM, 29 REM
RERE - 39 non-REM, 41 REM
RDI - 43 Non-REM, 70 REM

Unfortunately your machine does not attempt to record RERAs, which make up the bulk of your problem. But do keep in mind that your REM AHI is on the border between moderate and severe OSA. If the CPAP pressure is not sufficient to prevent OAs and Hs in REM, it should show up in your data, provided you are getting into REM sleep. Still, with the machine you have and your diagnostic AHI vs. diagnostic RERA and RDI, it's going to be tough to pinpoint whether your PAP settings are fixing the problem by looking at the data. Your main criteria for judging how well your therapy is going is going to be how well you feel during the daytime. And to feel better, you're going to have to sleep better (subjectively) with the machine as well as address some of the leak problems.

Did you have a titration study as well as the diagnostic study? If so, do you have its results? And do you know what ASV settings Krakow actually prescribed for you?

As for the source of the leaks, you have good guesses. I need to try and fix these issues. Not sure what else to do
Jaw Drop- I think the jaw muscle weakens and drops enough to allow mouth breathing despite my efforts to keep jaw closed with chin strap, tape, dental device and tennis ball shirt to sleep on side.

Are you using a full face mask that covers both your mouth and nose? That may be an easier solution to live with than all this other stuff. Remember that the point of everything is to get a decent night's sleep. And if the combination of the chin strap, tape, dental device and tennis ball shirt are making it harder to get comfortable enough to fall asleep quickly and to stay asleep for long enough to get through a full sleep cycle or two, then all of this effort to avoid a FFM may be adding to your misery rather than helping it.

*My dental device is an OSB that unfortunately allows the jaw to drop open. Im going to try and force it closed with braces rubber bands and see if that helps.. or may have to try another device.

Again, this idea sounds really uncomfortable. And you've got to be comfortable enough to both get to sleep and stay asleep. The idea of sleeping in a cervical collar (which is relatively soft and comfortable) that's been suggested by somebody else may be a more reasonable "next thing" to try.

Tongue Position - keeping it on the roof of my mouth has been a struggle.

The thing to do here is to try to focus on where you keep your tongue in the daytime. If you usually breathe through your nose during the daytime, then you may simply need to get into the habit of keeping the tongue in the right spot during the day. Once it's trained to stay there without you making a conscious effort to keep it there, you may find that it will start staying put most of the night on its own.

If, however, you regularly breathe through your mouth when awake, then you probably need a full face mask. A full face mask would allow you to open your mouth without losing any CPAP pressure.

*I tried myofunctional therapy exercises for 9 months that wasnt helpful.

I have not heard of myfunctional therapy before and a google search only turned up sites that were promoting/selling it rather than sites discussing its efficacy in a more objective fashion. So I can't say anything about this.

*And I got the OSB dental device because it claims to focus on optimizing tongue position.. which doesnt seem to be the case when it allows the jaw to drop open

I have to admit that I'm not familiar with OSB dental devices. A quick google search shows that they're custom fit devices designed to improve both daytime and night time breathing, along with managing some kinds of tmj and/or facial pain. What were the symptoms that you and your dentist were trying to treat when you had the OSB dental device made?

Any other suggestions?

My first suggestion is a full face mask if you have not tried on.

But my main suggestion is patience. I know it's not what you want to hear 'cause I sure didn't want to hear it for the first six months I was PAPing. But it takes time to learn how to sleep with one of these machines. And until you are sleeping reasonably well with the machine, you might not feel much better, and in fact you might feel worse in the short run if you have a really steep learning curve like I did. Here's the thing you have to remember: The machine does not fix bad sleep; it fixes one potential source of bad sleep, namely it fixes sleep disordered breathing. Once the sleep disordered breathing is managed by the machine, there's still the issue of addressing all the other potential causes for bad sleep. Until they're addressed and solved, the sleep can remain bad enough to continue to cause the daytime fatigue and sleepiness that caused you to get the sleep test in the first place.

Here are some questions for you to think about:

1) Does the process of getting ready for bed, including inserting the oral device, putting on the chinstrap, taping your mouth, and then masking up cause you to get uncomfortable or stressed out even before you lie down and try to go to sleep?

2) How often are you waking up in the night uncomfortable with all that stuff in and around your head? What goes through your head when you first wake up in the middle of the night?

3) How often are you waking up fighting leaks and rearranging the mask, the chinstrap, or retaping in an effort to fix the leaks?

4) How much sleep are you trying to get each night? How much sleep are you actually getting each night? How much do you worry about how much sleep you manage to get each night?

The answers to these questions may point to what you need to do in addition to PAP in order to finally start sleeping well at night.

[palerider]

I dont recommend others witb uars to see krakow. His guidance was very inneffective for me.

you're not the only one who's come back here and said that, after spending THOUSANDS of dollars.

[2Tired4This]

The titration settings suggested were ASV Auto Max PS 14, Min PS 6, Max EPAP 15, Min EPAP 6
Ive struggled with the ASV with mask leaks and waking.

Tried multiple full face masks but would get leaks.. Im guessing due to shifting mask on pillow, ASV pressure changes and jaw drop.. and unfortunately threw them away. May need to give it another try.
Tried a few nasal masks and had leak problems and skin problems.
Im now trying a few nasal pillows but cant solve the leak.
And dentist recommended OSB because he said it was helpful for many patients with sleep apnea so I decided to try it.

As far as comfort, nasal pillows are much more comfortable than a full face mask and all the other stuff like dental device and chin straps, etc are not uncomfortable and dont cause me any sleep anxiety or anything. I just want something to work consistently with minimal leak so I can determine best pressure.


Last night I adjusted dental device to prevent jaw drop and had a horrible leak night. I have no idea what happened. May have rolled on back as I did not wear tennis ball shirt

[robysue]

I'll write more later, but I have to comment on this:

Last night I adjusted dental device to prevent jaw drop and had a horrible leak night. I have no idea what happened. May have rolled on back as I did not wear tennis ball shirt

I don't see how back sleeping by itself would lead to the kind of large leak problems that are shown in the data. Either the pillows are slipping out of place or, much more likely, your lips are opening enough for large quantities of air to flow from your nasal cavity into your oral cavity and out through the open lips.

In other words, it may not be enough to keep your jaw from dropping. You have to find a way to keep your lips closed as well. Since your tongue is unwilling or unable to stay parked on the roof of your mouth to effectively keep most of the PAP air from entering the oral cavity, the lips may start fluttering open when enough pressure builds up in your mouth. And once that happens, your lips open up further and the leak gets larger and larger.