Smargie’s Therapy Thread...in Need of ASV Advice

[Smargie]

Pugsy, are you assuming that the UAs are obstructives because they are grouped together with the hypopneas? That would make sense. With such a sophisticated machine I'm surprised that it can't differentiate between an OA and a CA.

I suspect those UAs were probably OAs....
For obstructive stuff we would increase EPAP minimum but in your situation more EPAP causes aerophagia issues.
This is where we say that the machine has to learn what it needs to do and the only way it learns is when you have an OA or hyponea.
It learns that it needs to increase the pressure for a while...and that is mainly EPAP because EPAP does the bulk of the work for obstructive stuff.

One or two little clusters through the night like that is an acceptable compromise when the alternative is having to use a higher EPAP all night long which we know causes significant aerophagia issues.
You have a choice between 2 evils....aerophagia or maybe a couple of small clusters happening until the machine realizes it needs to go higher.

[The following are my comments. I don't know how I managed to make them appear is if it's your quote...I'll have to go over what you taught me about using quotes a few pages back, but I'm too lazy to do it now.]

Can the machine really learn over time? Like it gets to know its human better? I agree that the aerophagia is the more evil in this case. If you compare last night's data to what was showing up 2 month ago, it seems these few events would be a walk in the park as far as my body and health are concerned.

Zonker, I will stay with these settings for a few more nights. I'm guessing my brain and body are saying "Ahh...thank you!" for not putting them through that mess they had to suffer before. Finger crossed my AHI doesn't go much higher tonight.

[ajack]

Page 13. min epap4 min ps3, max ps8,
chart indication average
med epap7 PS7
95% epap 8 PS8
treatment of obstructive events, marginal
treatment of CA, unknown

are you ready to talk to your doctor yet?

[Smargie]

treatment of obstructive events, marginal
treatment of CA, unknown

are you ready to talk to your doctor yet?

Yes, I'm ready, though I doubt the doctor would even give me an appointment based on my numbers. My AHI is well under 5, which according to the medical definition of Sleep Apnea, means it is controlled. Based on everything I've read on this site and elsewhere, CAs are classified as UAs, and I've had only 3 of them. I think I'd get a pat on the back and then sent out the door.

[Smargie]

Last night was very peaceful. No battling with pressure or leaks and I only woke up once to use the bathroom.

I never thought I'd see a chart like this:

ASV snip 7.9.PNG (76.43 KiB) Viewed 1562 times

I'm starting to think this isn't a fluke.

[Pugsy]

I don't think it's a fluke either.

Just don't get upset if you have a night occasionally where a few events slip past the defenses. We all have those nights from time to time anyway....and you are skirting on the bare minimums (both for obstructive prevention and central treatment when the centrals happen) of everything in an effort to battle the aerophagia issues so you can sleep.
So every now and then you might see a little random cluster of something...shrug your shoulders and move on. The machine will learn from that first cluster anyway and do it's darnedest to not let it happen again...and even if it did...it's not the end of the world.
It's still a lot better than you were doing on the apap.

I still am scratching my head over how or why the sleep lab came up with the settings suggested and the only thing I can think of is maybe they were needed when using a fixed machine with a back up rate or something.
Maybe they didn't use the ASV machine or something....or maybe your sleep in the lab was so crappy they really couldn't get a good handle on things.

You are seeing good results and more importantly....feeling those good results. If the doctor isn't happy with that then he's not much of a doc. You have to be able to actually sleep before any of this stuff matters.

[Smargie]

OK, Pugsy, I won't expect scores this low every night. And if they become significantly worse I still have some room to play around, since the last changes we made were so big. The minimum EPAP was lowered by 3 and the max PS by 7, so I may be able to adjust up a tad without horrible aerophagia.

In regards to the sleep settings prescription made based on lab results.... The first part of the night was CPAP and I got an AHI of 65.5 on a pressure of 8, and then 9.7 on pressure of 10. The drop in centrals went from 31 to 2. During the ASV portion with EPAP 8 - 20 and PS 0 - 16 the AHI was 9.2, and with EPAP 10 - 20 and PS 0 - 15, the AHI was 4.8. I hardly slept the entire night and during the ASV portion 97% of TST was spent in N 2. I'd say you're right that my sleep was so crappy they couldn't get a handle on things. The pressure during the ASV was intolerable and the aerophagia was awful.

I thinks that many doctors just look at the AHI and don't take quality of sleep and comfort in mind at all. I called the DME when I had an AHI of 63 and all they had to say was "Looks like there's a full mask in your future. Try a chin strap." When I called the doctor, as I'm sure you recall, I was told to give it another week or 2 and it should get much better. And the doc was shocked when she saw my data. I think she's about to retire and her head isn't in the game anymore if it ever really was.

Anyway, I'm happy now and feeling optimistic so I won't dwell on that anymore. Thank God for this site!

[zonker]

Last night was very peaceful. No battling with pressure or leaks and I only woke up once to use the bathroom.

I never thought I'd see a chart like this:



ASV snip 7.9.PNG


I'm starting to think this isn't a fluke.

tapdancing.gif

and to the newbies: no, we don't chase zero!

but it doesn't mean we don't celebrate it.

[Smargie]

[idlewire]

I'm glad that your results continue to look great! With regards to the previous night, we knew that setting a low Min EPAP would probably let an initial Obstructive through. That's totally okay. Look at it like this: the machine had to raise EPAP as high as 9.5 to deal with that obstructive. You would not want to try to start your sleep with that high of an EPAP, just to prevent an obstructive that might or might not happen a few hours later!

You also said (for the previous night):

I had a very hard time falling asleep and getting in sync with the pressure.

There's no harm in using a little ramp! An ASV is like the Breath Police - "every breath you take, every move you make, they'll be watching you". So you settle in, you put on your mask and start the machine, and then chances are you move around a little and change position. Now the ASV thinks your breathing is irregular and tries to stabilize it. Pressure increases, annoyance increases, and now you're farther away from sleep than when you laid down.

What I do is set a 5-minute ramp. I know I'm going to twist and turn a bit and I don't want it over-reacting. The great thing about a 5-minute ramp is that you can use it over again if you remain awake. So let's say I haven't fallen asleep right away (most nights) and I twist and turn again after the ramp period, and the pressure starts to kick in again. I turn the machine off and then on again, and now I get another little 5-minute grace period to settle in again. I do this as often as I need (usually ends up about 3 times) until I'm more fully settled and can transition into sleep.

[ajack]

treatment of obstructive events, marginal
treatment of CA, unknown

are you ready to talk to your doctor yet?

Yes, I'm ready, though I doubt the doctor would even give me an appointment based on my numbers. My AHI is well under 5, which according to the medical definition of Sleep Apnea, means it is controlled. Based on everything I've read on this site and elsewhere, CAs are classified as UAs, and I've had only 3 of them. I think I'd get a pat on the back and then sent out the door.

That is simply wrong with an ASV. Your doctor will explain it to you. UA are obstructive on your script. There is no flag for a CSA on ASV. Eventually you will have an appointment. I hope you will take notice. If you look at other ASV users on apneaboard, you will see that AHI well under 1 is common enough, when the machine is set up. It is a measure of the obstructive treatment and not of any of the other things an ASV does. You have your machine changed from your script and is set up wrong.

[idlewire]

treatment of obstructive events, marginal
treatment of CA, unknown

I'm not sure why you're sowing the seeds of doubt here but "marginal" and "unknown" is a bit disingenuous considering that we've seen 3 charts with almost no apnea. It is certainly reasonable to value comfort at sleep more than a small cluster of obstructives - that's why our machines are "auto" to begin with, or else we'd all just try to go to sleep at the highest necessary EPAP all the time, which you're welcome to do, but many others would choose not to.

Smargie, to clear up the "Unclassified Apnea" (UA) confusion: the machine does not detect if the apnea is obstructive or central. The algorithm that determines the pressure assumes that the apnea is obstructive and responds by increasing EPAP. The reason it assumes that it's obstructive is that ResMed presumes that their breath-triggering would effectively "abort" a central apnea in progress. Is this 100% true in all cases? Probably not. If, say, you had PS Max at a low of 5, it might not be enough to trigger a breath. Rest assured, though, that in the case of a true central apnea, this would be flagged in the UA column. By saying "unknown" ajack seems to be implying that you could be having central apneas that the machine does not know about. This is patently untrue, the machine flags all apneas, regardless of cause.

We can tell that the apnea in your 2nd chart was obstructive because a) raising EPAP resolved them, and b) we know from your history of centrals (your old charts) that if the PS Max of 8 weren't handling them, you would not just have a small isolated cluster of them - they would be going on all night long.

This isn't to say that all your charts are going to be as good as these, but there's no reason at this point to change your settings.

[ajack]

again, people are saying what they think it is and not what they know it is. The resmed ASV doesn't tag CSA, resmed themselves say they don't. The max ps has been reduced to 8, from memory the prescription was max ps 15. As such. no one can say whether the CSA are being effectively treated, without detailed examination and a spo2 meter. Yet still can't duplicate what they did in the lab. The chart on the last page did have the obstructive AHI as marginal with AHI of 4 H. There has since been better ones.
Again AHI on an ASV is just cpap and not CSA PB CSR or any other thing that an ASV is used for. To use this as a measure of success is a folly.

[Jas_williams]

Last night was very peaceful. No battling with pressure or leaks and I only woke up once to use the bathroom.

I never thought I'd see a chart like this:



I'm starting to think this isn't a fluke.

Well done just ignore ajacks ramblings labs make mistakes all the time. It seems to me they tried Apap in the lab and you had a lot of centrals, so they moved you to asv using the starting pressures as those setup on the APAP rather than a fresh titration on the ASV, that was wrong and the cause of your aerophagia and discomfort.

[Pugsy]

ResMed will flag all apneas....central and obstructive but they just don't differentiate because they don't use the FOT on ASV.
Everything gets dumped in the UA basket....both central and obstructive.

Idlewire is correct....ajack is not correct.

8 PS can do a decent job breathing for a person sometimes...it doesn't always have to be 15 PS. It's probably the bare minimum that will work but it looks like it's working well enough here and that's all that matters.
And I got that information from a sleep lab tech....I think I trust him over ajack who has proven over and over again that he doesn't know nearly as much as he thinks he knows.

If a bucket load of centrals were happening and the machine wasn't dealing with them...they would indeed show up as a bucket load of of UAs. I have actually seen it happen when someone with central apnea had the PS limited to 3. They all went away once the PS max was raised to just 10....no other changes were made to account for the improvement.

More importantly though....OP is sleeping well and feeling well....imagine that. None of this means squat when someone can't even sleep with whatever settings were prior to changing. If we can't sleep...the settings aren't working anyway.
Gotta get to sleep and stay asleep first and foremost.
Ajack's attitude that "we eventually get used to it" is probably why so many machines end up in the closet because people can't get used to his ideas which usually seem to involved using much higher pressures than are needed. Sometimes people simply can't use higher pressures and they don't "get used to it" despite his saying that "he got used to it".
He means well I suppose but he tends to think that doctors walk on water alongside himself....and that's simply not the case.
Doctor's don't walk on water and they aren't above making mistakes or not understanding what happens when people can't tolerate some of these settings.
And lab titration studies don't always get it right either....especially when people don't sleep much.
I know mine didn't.

[Pugsy]

Last night was very peaceful. No battling with pressure or leaks and I only woke up once to use the bathroom.

I never thought I'd see a chart like this:



I'm starting to think this isn't a fluke.

Well done just ignore ajacks ramblings labs make mistakes all the time. It seems to me they tried Apap in the lab and you had a lot of centrals, so they moved you to asv using the starting pressures as those setup on the APAP rather than a fresh titration on the ASV, that was wrong and the cause of your aerophagia and discomfort.

They really didn't have time to do a proper ASV titration since they did a good chunk of the night on the cpap.
They first tried cpap/apap with some high settings and the aerophagia monster showed up right on cue and then they tried ASV at some settings but by then time was limited and the aerophagia monster was really messing with her sleep....so not a good test.