ASV Questions -

[Mask2sleep]

Good Morning,

I know there is quite the long ASV thread, and if I should just go there and look for these answers please send me that way. I don't post here much, I an more of a lurker, though I have spoken with a few of you.

To sum it up for those who don't know me, I'm a 36 year old male, 150 pounds, no complicating medical conditions. I wear a Quattro Full Face as i'm a mouth breather. After a sleep study in July 2010 I was put on BiPAP 11 / 7 on a Respronics PR System One BiPAP. My AHI ran about 14 on that machine - it is about 30 non treated. I went for another sleep study in December 2010 since the AHI was not improving, and they then tried pressures of 12 / 8 and 16 / 10, neither of which made any improvements to the AHI, and I found the level 16 nearly impossible to cope with. A year ago I switched doctors and they prescribed a Resmed S9 Auto Bi-Level set with a min of 6 and max of 16. That made the AHI even worse, and the average was now 16. They brought the pressure down to the original 11 / 7. I send my data in frequently and have met with the doctor 3 times now. They did a pulse ox over two nights and say supplemental 02 is not necessary. Over the last 6 months the AHI has been fairly steady and predictable - AHI of 12 with 8 of it being central. They say the want to put me on an ASV as that is the only option remaining for treating the remaining apneas. I typically wake up 3 - 4 times a night right now for no apparent reason, I assume from arousals.Yes, i'm still tired.

A few questions for the experienced folks -

1. Is a AHI 12 that bad? Can I just keep with the BiPAP and still receive benefit? I know the ideal is 5 and under, and i've never hit that.
2. How high does the presure go on an ASV?
3. How tight does the mask have to be on to cope with the increased pressure?
4. Does an ASV really have a set breathing pattern it thinks you should have, and if you deviate from it, force you you breath it?
5. Does it actually breath for you, that is, initiate breaths? How does having a machine breath for you feel? I read an article that said in frequent cases, non-sedated patients did not cope well with ASVs in hospital settings.
6. How loud is it? How large is the device? How expensive? Does Resmed make one?

Thank you,

Chris

[JohnBFisher]

... A few questions for the experienced folks -

1. Is a AHI 12 that bad? Can I just keep with the BiPAP and still receive benefit? I know the ideal is 5 and under, and i've never hit that. ...

Think of it this way, with an AHI of 12 you are (on average) moving from a deeper level of sleep to a lighter level of sleep once every FIVE minutes. No wonder you are TIRED! 12 is frankly unacceptable.

... 2. How high does the pressure go on an ASV? ...

They can go up to 30cm H2O. Once you are accustomed to it, you will do fine with it. Essentially it allows the ASV to act as a ventilator to help sustain your breathing even when you fail to breathe due to a central apnea.

... 3. How tight does the mask have to be on to cope with the increased pressure? ...

Not all that much tighter. But you will probably need to move to a Full Face Mask, since the higher pressure almost always causes leaks from the mouth.

... 4. Does an ASV really have a set breathing pattern it thinks you should have, and if you deviate from it, force you you breath it? ...

Yes, it helps. The Resmed device is a little more "insistent" than the Respironics unit. The Respironics unit has more "smarts" built into it. This allows it to better track your breathing. But if you fail to breathe it will start to ramp up the pressure.

... 5. Does it actually breath for you, that is, initiate breaths? How does having a machine breath for you feel? I read an article that said in frequent cases, non-sedated patients did not cope well with ASVs in hospital settings. ...

With your high central apnea values, you will probably LOVE having the ASV unit. I also have a high number of central apneas. And I used to have a horrible time getting sleep. I now sometimes notice the higher pressure .. but am assured it is there taking care of me when I fail to breathe.

... 6. How loud is it? How large is the device? How expensive? Does Resmed make one? ...

They use the same chassis as the current devices. They are no different in footprint.

They are much more expensive than CPAP or BiLevel devices.

Yes, Resmed makes one. It is their S9 based Resmed VPAP Adapt.

Hope that helps.

[Mary Z]

A few questions for the experienced folks -

1. Is a AHI 12 that bad? Can I just keep with the BiPAP and still receive benefit? I know the ideal is 5 and under, and i've never hit that.
2. How high does the presure go on an ASV?
3. How tight does the mask have to be on to cope with the increased pressure?
4. Does an ASV really have a set breathing pattern it thinks you should have, and if you deviate from it, force you you breath it?
5. Does it actually breath for you, that is, initiate breaths? How does having a machine breath for you feel? I read an article that said in frequent cases, non-sedated patients did not cope well with ASVs in hospital settings.
6. How loud is it? How large is the device? How expensive? Does Resmed make one?

Thank you,

Chris

Chris, I am a new (one month) ASV user. I went on ASV to bring an AHI that averaged 28/hour with treatment down. I felt mostly ok with the AHI that high- most were hypopneas, but I slept 10- 12 hours a night and couldn't get rid of my depression. I did a trial of ASV in the lab and it worked for me.
If you feel ok and don't desat you would probably be ok with the Bilevel. I tried ASV, even though I basically felt ok to try and deal with a lingering depression (despite psych treatment) and sleeping an average of 10 hours, sometimes 12, a night. I've been on CPAP, Bilevel, or AUTO for 4 years and have never gotten my AHI under five- probably because of meds. I've been titrated up and down, from 9 CPAP, 4/8 bilevel to 24/27 bilevel, and AUTO with different ranges.
On ASV my max pressure is set for 20 with an EPAP of 8 and PS 4-12. My IPAP rarely goes above 13.5 (PS 5.5). My AHI average right now is 11.1- I have days when it's under five, but the 30 day average is 11.1. The pressure doesn't go very high and my mask copes with the pressure fine. In the sleep lab for ASV titration the pressure was all over the place and I had more mask troubles. The breath part can be set to AUTO where it only initiates a breath if you fall below your average RR. I think it calculates averages on a 3 minute rolling cycle, but I'm not sure. It can also be set to any number of breaths per minute. I never feel it breathe for me, or initiate a breath. My breath rate is set to AUTO I don't use ramp or flex. Mine is the respironics- it's 10X6X3.5 with humidifier and is very quiet. ResMed makes one. They are very expensive- average $ 5,000 give or take $1,000.
I find it very comfortable and am gradually sleeping away less of the morning. I think it will take more time to feel the full benefits. It feels very natural, I never feel the pressure changes. I've just started to use the software and haven't studied what's going on, yet. I'm renting by the month- was told it would be $109, but haven't seen a bill yet. I think at least a six month trial is in order. I see the doc soon and will see if any changes in settings need to be made.
All in all I think it's worth a try. Good luck, keep us posted.

[Grand-PAP]

Hi Chris,

You have both technical questions and some that are more personal issues. There are many out there that can and several have already given you good technical answers. I will take a crack at giving you a "little" of my perspective. From your post it does appear that you should be a candidate for ASV.

(NOTE: After writing my answers to your questions, I came back to the top and added this parenthetical comment -- PLEASE don't look at my answers as "technical" answers, but as personal experiences. Technically they may be WAY off the mark. Even personally they might be very different than other ASV users, but hopefully that provide some help.)

1. Is a AHI 12 that bad? Can I just keep with the BiPAP and still receive benefit? I know the ideal is 5 and under, and i've never hit that.

Over the last 6 months the AHI has been fairly steady and predictable - AHI of 12 with 8 of it being central.

You're correct, most feel that 5 is an acceptable threshold. Your AHI and CAI are both of concern, but your Clear Airway of 8 is a big concern to me. Another thing that is a concern to me, but is often not mentioned in the forum -- the duration of the CAs. When I was on straight CPAP, my AHI was around 10 and CAs in the 6 - 7 range. However, when I analyzed the data with SleepyHead, often the CAs were from 35 to 50 or 60 seconds in duration.

Since beginning ASV therapy I have virtually eliminated CAs -- the cumulative CAI average of .21 and cumulative OAI of .16. I have had an AHI issue with Hypopneas. I've gotten the HI down from 5.15 to a cumulative average of 3.83, with the last week in the 2.0 range.

Does an ASV really have a set breathing pattern it thinks you should have, and if you deviate from it, force you you breath it?

Keep in mind here, I am a novice myself. But to answer this question, let me share my perspective on both machines. (YOU EXPERTS feel free to jump and correct any of my perceptions!) With the ResMed S9 Adapt you can only set three pressures: EPAP, Minimum Pressure Support and Maximum Pressure Support. The breathing support is "Automatic." The S9 then begins to analyze your breathing and develops a "pattern." After the pattern is developed and you begin to deviate from that pattern and/or "not" breathe, it begins pulsing pressures. With the PR, you can set: Min EPAP, Max EPAP, Min PS, Max PS, BPM Rate (breaths per minute), Timed Insp (number of seconds), Rise Time and Ramp Time. If you set all those values, the PR will attempt to "force" your breathing to conform to that pattern. (I'm not sure if it would calculate a different pattern or continue to use those settings all night.) You can set the Rate to AUTO. By doing so, it would operate more like the ResMed. However, even with setting the Rate to AUTO, you still would need to set the Max Pressure, Max EPAP, Min EPAP, Min PS and Max PS.

My personal experience. My Rx was for the PR and with ALL the pressures set. Literally after ONE night I had to change it to AUTO. The reason was that my breathing rate is EXTREMELY consistent. Over the four months of treatment, I have breathed almost 100% of the time at 13.8 - 14.2 breaths per minutes. With the Rx settings on the PR, beginning with my first breath, it was attempting to force me to breathe much faster, probably 16 -17 breaths per minute. I felt I was fighting it and I had great difficulty going to sleep. From night two through last night (night 20) with it on AUTO, I have had no problem. My experience with the S9 Adapt has been more comfortable. It seemed to much more effectively "adapt" to my breathing pattern. Both machines work well, but I feel a little more comfortable with the ResMed.

5. Does it actually breath for you, that is, initiate breaths? How does having a machine breath for you feel? I read an article that said in frequent cases, non-sedated patients did not cope well with ASVs in hospital settings.

Chris, if you lucky, you won't even know the machine is doing anything. Referring back to my prior answer and my first night with the PR, I was "breathing too slowly," so the machine would "pulse" higher pressure. If you are awake (as I was) you just feel an intermittent increase in the pressure, like a PUFF of air. If you don't begin to inhale the intermittent PUFFS will continue and increase in pressure (I assume to your Maximum Pressure.) With the ResMed, I have never felt that. I "assume" it is because the machine is calculating what my breathing pattern is and won't begin to try and manage the breathing until that is accomplished. I've read it does the calculation for 4 or 5 minutes. FORTUNATELY, I fall asleep rapidly and apparently beat the machine's calculations and/or don't have "irregular breathing" prior to going to sleep. After being asleep with BOTH machines, I don't recall ever having been awakened by the pulsing - the machines just do their jobs!

6. How loud is it?

Both machines are very quiet. Personally, I feel the ResMed is quieter. In a previous thread someone was questioning the "noise" that the PR S1 made on inhalation. There were a lot of mixed responses to the question. My personal experience is that, whether it is conductive noise or whatever, the PR seems to have more "breathing" noise than the S9, but neither is loud enough to create a problem for me or my wife.

How expensive?

From what I understand, ResMed does not allow their machines to be sold on the internet. As a matter of fact, it is difficult to even get a price. With a LOT of internet research and phone calls, I got quotes, literally from $5,000ish to $8,000!!! The PR S1 is available from internet sites - most seem to have prices in the mid-$5,000 range. I checked a few days ago and our host, cpap.com, had the PR S1 for $5,500 discounted to $3,900 without a humidifier and $4,000 with a humidifier. I saw one instance of a PR for $2,300, but it was on a medical supply site and I'm not sure if the general public could purchase from them. I think both machines can be purchased for less, but it would take a lot of investigation!

Chris, I hope this will be of some benefit to you. Best of luck with your therapy!

[SneakerPumpernicle]

I have the S9 adapt, I do feel a lot better on this machine then others, i've only been on it a few days so I hoping that it will get better and better, the tech steeing it up said to give the machine a week to learn my breathing pattern. when it breaths for you it doesnt feel weird at all, try not breathing.... it will just force more air almost instantaniously and you'll feel it. only adjustment shock was when I tried to speak to my wife in the middle of the night, I guess it conciders that a moment of stopped breathing and really kicked in with preassure while i was talking.

P.s. Machine also gives me a wicked case of the loud burps when I first wake up. I'm hoping i'll adjust