Is my ASV therapy working . . . or a wrong diagnosis?

[wearysoul]

I'm stuck . . . and have been for some time. I'm struggling terribly and can't figure out what's wrong. Could some of the ASV experts/users out there (SWS, Muffy, and others) take a look at my data and help ? You can view a download of recent data at this link:

http://www.internetage.ws/cpaptalk/doug_harcher_1.pdf (DSM helped me w/ this link.)

Other relevant info: Age 54 years. Height 5 feet 10 inches. Weight 153 lbs. Initial sleep study 5-24-09. AHI of 20.2. Respiratory events worse in REM with REM AHI of 50.5. SpO2 nadir was 87%. RERAs present. No PLMs noted.

CPAP titration 6-4-09. CPAP titrated to 9 cm. At CPAP of 6 cm and higher, there were CPAP emergent centrals. Most events at this setting were post-arousal central apneas. No Cheyne-Stokes respiration. BiPAP of 13/9 cm and 14/10 cm did eliminate the central events. Tech noted I failed to tolerate these settings due to high pressures. At CPAP of 5 cm, residual snoring and RERAs were still present. No obvious PLMs. Poor sleep efficiency, prolonged sleep latency, normal REM latency. Abnormal sleep architecture w/ reduced REM sleep. EKG w/ normal sinus rhythm. Advised to attempt CPAP at 6 cm. In case of poor tolerance to CPAP therapy, BiPAP S/T or ASV may be attempted.

ASV titration 10-13-09. Titration performed w/ Respironics BiPAP AutoSV. Three episodes of central apnea, nine episodes of obstructive apnea, and 12 episodes of hypopnea during this titration. Overall AHI of 15.2. SpO2 nadir was 89%. RERAs were seen. IPAPmax was set at 30 cm throughout study. IPAPmin and EPAP were increased to 7 cm during titration. At these settings, residual hypopneas and RERAS were seen. AHI was 4.3 and Sp02 nadir was 91%. No PLMs. Reduced sleep efficiency, normal sleep latency, normal REM latency. Abnormal sleep architecture w/ increased stage 2 sleep and reduced REM sleep. Little slow wave sleep. EKG: normal sinus rhythm. Advised to attempt ASV w/ IPAPmax of 30 cm. IPAPmin of 8 cm. EPAP of 8 cm.

As you can see, I've been on ASV since late October 2009. Could an improper setting explain why I can't seem to resolve my chronic insomnia (early morning awakenings) and why most mornings I still feel like I've been run over by a truck? I've had insomnia for years, and when I began therapy, I hoped that it would help that issue. It hasn't. You can get a real picture of my insomnia (as well as periodic mask issues) if you scroll to the top of the file and look at "Patterns of Use." Those white spaces are intervals when I turn the machine off and/or get up for a while. A lot of fragmented sleep . . .

I wonder if my average peak flow and average tidal volume are lower than normal. If so, what does that mean? Does a setting need to be changed? Do I have some undiagnosed or underlying problem that needs to be addressed? I've noticed that I frequently invoke higher pressures during the first 1 to 1 1/2 hours of sleep. Seems the pressure is often quite variable during that period. I must have a lot of trouble getting into a deeper stage of sleep. Also, I've noticed that patient-triggered breaths frequently dip during that period. What could be causing this?

I'm following a high-dose vitamin C protocol prescribed by my primary care physician (an MD who is a practitioner of orthomolecular medicine) and taking a few other vitamins, minerals, and antioxidants. I began this regimen about three years ago when my doctor and I still thought I had chronic fatigue syndrome. Currently, I consume about 6.5 grams of buffered vitamin C per day. That's down from more than 15 grams (if I remember correctly) when I started all of this. I mention all of this because I wonder if it may be relevant to my situation. For some time I have been wondering if the amount of vitamin C I consume might possibly contribute to my insomnia. If you have never consumed this amount of vitamin C, you wouldn't know that you will get a noticeable energy lift from it after a certain point. I guess it's what has kept me going in spite of my poor sleep and relentless fatigue.

I've been looking online to see what I could find about vitamin C and insomnia. Today I ran across the following article:

http://www.hypoglycemia.asn.au/articles/insomnia.html

It isn't a documented journal article, but appears to have been written by a grad student. At the bottom of the article, under "Notes," he mentions that high doses of certain high-potency vitamins like vitamin C may cause insomnia. Well, that got my attention. I consume most of the vitamin C I take in the afternoon and early evening. Maybe it's causing some of my nighttime sleep problems? I don't know!!! Can anybody figure out this puzzle? wearysoul

[sleepmba]

During some of my xPAP titrations, I've switched the person from FF to some sort of nasal or pillow mask and the centrals and periodic breathing were eliminated. It might be time to go back to the basics. Is your mask comfortable for you?

From my experience with ASV titrations, how yours went sounds logical.

Looking at your leak rate, it seems to be a little much. If I saw that during a titration, I would address that before I would do anything else.

Sorry my responses are a little scattered. I'm just trying to throw some ideas out there. Good Luck to you!

[timbalionguy]

Very interesting. Upon looking at your data, your therapy results are kind of like my therapy results-- they vary all over the place.

I'm no expert at interpreting these graphs, but here's my thoughts FWIW.

It looks like most of your issues are in the early hours of the night-- the time when you would be expected to be having the most stage 3 sleep. This is consistent with your description that you have trouble with the deeper sleep stages. This is kind of opposite of what most people experience, which is that their biggest issues are during REM sleep. In your case, I don't think your pressure is too low. Your nearly zero AI component suggests your base pressure is fine, and you have plenty of upward range for the ASV feature to do its thing. Your leak line, as far as I can tell, looks OK, especially considering how high the pressure has sometimes gone. But the gentleman that posted while I was composing this undoubtedly has more experience with reading graphs from this machine.

I would first look for mechanical impediments to good sleep-- poor pillows, poor sound/light shielding, sleeping on your back (do you ever do this?). Alcohol? Stress? (No alcohol here, but lots of stress.)

Overall though, an average AHI of 2 is good, especially considering that a single event will give you an overall score of1 with this machine. Its a software bug that has been discussed here in other threads.

Here's an experiment you can try if you would like. Decrease your vitamin C dosage down to 1 gram/day in a series of steps, while monitoring your therapy. Cut your dose by say, half each day until down to 1 gram/day. Maintain this dosage for at least 3 days, while watching your therapy. Since vitamin C is water soluble, any excess should leech out of your system in a short timeframe. If no change/improvements are noted, increase your vitamin C back up to where you would like it over several days.

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[dsm]

Doug

My 1st reaction is that Peak Flow looks very low all night. But I am really only going by what I am used to from my own data which is very much higher that that.
Your RR seems fine. But I see you gave up using the machine on many of the nights !. I would also wonder about the tidal volume as that too seems lowish.

Hopefully you will get more explanatory answers than mine but I am too wondering about that Vitamin C intake.

Good luck

DSM

[JohnBFisher]

wearysoul, I agree with sleepmba. your leak rate appears to be a bit high. the quattro ffm can be very difficult to get a good seal. Trust me, I know. I have problems with mine all the time. as you note, i feel as if a truck ran me over when i awaken on those mornings when i have a high leak rate.

i would definitely work on that first. have you replaced the mask cushion? you need to on a periodic basis. also, the mask seems to work well if it is cleaned occasionally, but not every day.

i did note that during high leak periods, you also had a higher AHI score (more apneas and hypopneas and periodic breathing). that is why i think you should focus on that.

but let me be very clear you are complaint ... even apparently during naps. good for you.

[wearysoul]

I've switched the person from FF to some sort of nasal or pillow mask and the centrals and periodic breathing were eliminated. It might be time to go back to the basics. Is your mask comfortable for you?

Yes, my Quattro is pretty comfortable. I just bought an Ultra Mirage and have experimented with that. I like it also. I used a Comfort Fusion nasal mask during my first titration (for CPAP) and still had the emergent centrals, so it seems that's not the solution for me. I think I breathe through my mouth enough (during certain stages) to render my therapy impotent. I recently tried using a chin strap with my Quattro. I got the idea from Dr. Krakow on his YouTube video: https://www.youtube.com/watch?v=LB6jeLhpXgk

If nothing else, the addition of the chin strap makes my Quattro feel more stable. I haven't compared leaks on nights w/ and w/out the chin strap. Will do that. When I go to bed, I work with my mask until I cannot feel any leaks. But somehow, they still occur.

I would first look for mechanical impediments to good sleep-- poor pillows, poor sound/light shielding, sleeping on your back (do you ever do this?). Alcohol? Stress? (No alcohol here, but lots of stress.)

Yes, I'm a back sleeper. I'd like to sleep on my side, but I get aerophagia. (Don't most people get aerophagia on their backs?) And my back aches when I sleep on my side. Some nights, I'm lucky and I can sleep a while on one side or the other. But switching becomes difficult because of the pillow issue. I need a thin pillow for back sleeping and a thicker pillow for side sleeping. So I mostly sleep on my back.

I've tried a variety of pillows (including a pillow from my chiropractor) but I keep going back to a very thin, soft pillow that doesn't raise my head too much. In other words, my head is elevated very little so I can avoid creating an angle in my neck.

No alcohol here, either. But plenty of stress: family, financial, and of course, the stress from not sleeping.

Here's an experiment you can try if you would like. Decrease your vitamin C dosage down to 1 gram/day in a series of steps, while monitoring your therapy. Cut your dose by say, half each day until down to 1 gram/day. Maintain this dosage for at least 3 days, while watching your therapy. Since vitamin C is water soluble, any excess should leech out of your system in a short timeframe. If no change/improvements are noted, increase your vitamin C back up to where you would like it over several days.

Good suggestion. In fact, I've already begun reducing my vitamin C intake to see if that helps matters any. The vitamin C I take is a buffered powder. One teaspoon contains 3200 mg ascorbic acid, 80 mg calcium carbonate, 32 mg magnesium carbonate, 1.6 mg zinc ascorbate, and 198 mg potassium bicarbonate. The minerals are supposed to be a good thing, but I'm wondering if they could be the culprit rather than the ascorbic acid. In other words, maybe too much potassium could unbalance my pH enough to affect my breathing and sleep. I'll monitor this and let you know the results.

My 1st reaction is that Peak Flow looks very low all night. But I am really only going by what I am used to from my own data which is very much higher that that.
Your RR seems fine. But I see you gave up using the machine on many of the nights !. I would also wonder about the tidal volume as that too seems lowish.

Maybe someone who knows more about peak flow and tidal volume could comment on these issues. What do these variables measure (in plain language)? What is considered normal? Is normal based on body size/weight or something else? At first glance, it may appear I gave up using the machine on many of the nights. But if you will look closely at the dates and the times posted at the top of each chart, you will see that what appears to be non-compliance is actually a fragment that occurred because I turned the machine off for a period and then turned it back on. The software posted the resulting fragment on a separate page. There were at least two nights without data. I forgot to put the card back into the machine those two nights. (No card=no data.)

i would definitely work on that first. have you replaced the mask cushion? you need to on a periodic basis. also, the mask seems to work well if it is cleaned occasionally, but not every day.

i did note that during high leak periods, you also had a higher AHI score (more apneas and hypopneas and periodic breathing). that is why i think you should focus on that.

.

I replaced the mask cushion a couple of months ago. And I'm fastidious about cleaning it every day. Maybe I need not be so fastidious about it. Seems I remember reading here or elsewhere that someone found a little facial oil (on the face or on the cushion) to be beneficial in creating a seal. I'll give it a try.

Thanks everyone for the comments!

[sleepmba]

I'll chime in a little about tidal volume. Most of the people that I do titrations on have a tidal volume of 300 to 500 in general. I would consider that the normal range. When someone has a tidal volume less than 300, sometimes I have to go to ASV.

Tidal volume is the volume of air taken in when you inhale. So for you, you breathe in 391 milliliters of air on average when you inhale.

I think things would be better for you if you could control that leak. The masks you have may be comfortable, but you may need to continue your quest for a mask that holds its seal all night. Let us know how it goes.

[desmondwl]

John, I to wear a Quattro. I started out with a standard medium but found my leak was hard to get it to stabilized. I switched to a standard small and now my mask leak is better controlled and much more stable. Of course as we sleep we have no control over how our mask may leak because it gets bumped and the seal breaks as we move or change positions. All-in-all I feel the smaller mask helped solve a lot of my problems. I also wash my face before I put on the mask. This helps to eliminate body oils that may cause mask leaks.

desmondwl

[dsm]

I'll chime in a little about tidal volume. Most of the people that I do titrations on have a tidal volume of 300 to 500 in general. I would consider that the normal range. When someone has a tidal volume less than 300, sometimes I have to go to ASV.

Tidal volume is the volume of air taken in when you inhale. So for you, you breathe in 391 milliliters of air on average when you inhale.

I think things would be better for you if you could control that leak. The masks you have may be comfortable, but you may need to continue your quest for a mask that holds its seal all night. Let us know how it goes.

Sleepmba,

Do the Respironics folk ever talk about the peak flow & its significance. Reason I ask is Weary-soul seems to have a very low level in his charts for the Peak Flow graph. Mine was always quite a bit higher than that. But I am 202 lbs & 6ft vs Weary-soul's lighter weight & smaller height.

Just curious

Tka

DSM

[sleepmba]

DSM,
In the literature I recieve, they don't mention peak flow. When it comes to ASV titrations, we can control the following:
BPM (Auto or specific number)
Rise Time
Inspiratory Time
EPAP
IPAP(min)
IPAP(max)

Hope this helps.

[dsm]

DSM,
In the literature I recieve, they don't mention peak flow. When it comes to ASV titrations, we can control the following:
BPM (Auto or specific number)
Rise Time
Inspiratory Time
EPAP
IPAP(min)
IPAP(max)

Hope this helps.

Sleepmba

It does thanks.

The Average Peak Flow is what the ASV servo ventilation algorithm tracks in a 4-min window & IIRC tries to keep the user to within 90% of the current Av peak flow from that moving (rolling) window. The Av Peak Flow data is displayed in the report.

By contrast the Vpap Adapt SV targets volume in a 3-min window & IIRC also seeks to keep the user to 90% of tracked volume.

An interesting contrast in the way the two work.

Cheers

DSM