1st Night With ASV - Fail! Advice?

[KenTheriot]

After 14 years of CPAP/AutoPap use, I had my 1st night with ASV last night. I had numerous problems I hope some folks can help me with. I was using a ResMed VPAP Adapt (S9), and a Quattro FF-mask.

1. I was swallowing air - causing discomfort and belching. After 2 hours, I tried elevating my upper body's sleeping position to no avail.
2. I was getting puffy cheeks that inflated and deflated.
3. My mouth was drying out despite my use of the H5i heated humidifier.

Here is a bit of background - I have been struggling with nasal congestion interfering with my use of a nasal mask. And for weird reasons neither my sleep doc nor I could figure out, a full-face mask would not work. I would stop breathing and choke myself awake every 20 minutes or so). Finally I was sent for an ASV sleep study, which showed I had centrals in the mix! I slept the entire night with a FF mask (Respironics Amara) and woke up with no dry mouth. It was incredible. So I was prescribed the ASV machine, and here we are.

One other piece of information that might be relevant is that I had already been using a ResMed S9 AutoSet with a SlimLine heated hose. But the tech setting up my new machine set it up for a standard hose and didn't give me access to change the hose setting. Not knowing this, I plugged my SlimLine hose into the new machine last night, but it was set on "Standard" for hose I think. Maybe that is why I felt like I had dry mouth.

Anyway, I would be so grateful for advice anyone with ASV experience and knowledge could offer.

Thanks!

Ken

ps - The initial settings on my machine are: 25/15/10/15/4/Auto/Bi-flex

[shortcake]

Hi Ken! Welcome to the ASV Club. It can be tough to get used to at first, but once you do, I think you'll find it very easy to breathe with, especially since you have the Resmed.

A couple things come to mind based on your description. The hose issue could very well be part of the problem. You'll probably need to get into the clinician menu to change the hose setting, since your tech apparently locked that feature, and it could have affected your therapy. Otherwise, you could try tonight with a standard hose (if you have one on hand).

The machine should also have an adjustable setting for mask type. Maybe the tech selected Nasal or Pillows instead of Full Face? Worth double checking.

Just to reassure you, it's very common when starting out on ASV to have the discomfort/aerophagia, and unfortunately there's no fool-proof way to get rid of it. It takes several nights, if not weeks, to get used to the "feel" of this type of machine and to learn to breathe in sync. Sometimes all it takes is time and the problem may resolve on its own. When I first used ASV, the bloating and discomfort was pretty bad, but gradually lessened. Still happens on occasion, but not nearly as bad as in the beginning. Hang in there!

[JDS74]

If your DME really locked you out, it was likely done by setting it on your SD card.
So, when you want to change something, you will need to remove the card, and on a resmed machine, format the card to erase the locking file. This works on Respironics machines and Resmed users will need to chime in and correct this assumption.

Posting your equipment in text mode rather than images is also helpful.

Have you checked that the humidifier setting is the same as during the sleep study?

[KenTheriot]

Hi Ken! Welcome to the ASV Club. It can be tough to get used to at first, but once you do, I think you'll find it very easy to breathe with, especially since you have the Resmed.

A couple things come to mind based on your description. The hose issue could very well be part of the problem. You'll probably need to get into the clinician menu to change the hose setting, since your tech apparently locked that feature, and it could have affected your therapy. Otherwise, you could try tonight with a standard hose (if you have one on hand).

The machine should also have an adjustable setting for mask type. Maybe the tech selected Nasal or Pillows instead of Full Face? Worth double checking.

Just to reassure you, it's very common when starting out on ASV to have the discomfort/aerophagia, and unfortunately there's no fool-proof way to get rid of it. It takes several nights, if not weeks, to get used to the "feel" of this type of machine and to learn to breathe in sync. Sometimes all it takes is time and the problem may resolve on its own. When I first used ASV, the bloating and discomfort was pretty bad, but gradually lessened. Still happens on occasion, but not nearly as bad as in the beginning. Hang in there!

Shortcake - I want to thank you!!! I have spent most of the day trying to learn what the numbers mean from my sleep study and how they translate to his machine. And I found your reply here: viewtopic/p887842/ASVwhat-does-my-rx-mean.html that absolutely answered every question I had. Knowledge is good:).

When I found the clinician's access and got into the settings, I see - interestingly - that having plugged the ClimateLine hose in last night (presumably), the machine selected it like a Plug-and-Play feature. So that wasn't causing any problems. The machine did have the mask type set to user control, and was already set for FF. I did switch to my nasal mask at one point and was able to change that setting.

I spoke on the phone to a CPAP tech at the hospital where I had my titration, and the tech at the medical supply place who set me up yesterday. Both of them kept saying "man, those are high pressures." And though that is exactly how it felt to me too, I didn't know how the prescribed initial settings corresponded to the pressures. Thanks to you, I now know that my minimum pressure (after ramp) is 15, because my min. PS is 5 and my min EPAP is 10. My max. My maximum pressure is 25 because my max. PS is 10 with a max. EPAP of 15. This is massive, compared to the range on my AutoSet, which I have been using for many years, which was 7.5 to 12. My max wasn't even as high as my new minimum is! the long-term data from my AutoSet showed that on average, I required a pressure of about 8. So this high pressure is unsettling, to say the least.

During my ASV sleep study, I experienced no bloating or air-swallowing at all. So it seems to me that this particular symptom, at least, may not be something I should need to get used to.

My instinct is to lower the minimum at least a little by decreasing my min EPAP. Since I teach and advise about the dangers of "tampering" with processes (mainly in the context of business), I am keenly aware of how it can make things worse. But I do have to get my optimal pressures dialed in initially to establish stable, on-target performance. My measure of success will be to sleep through the night with a FF mask, as I did during the sleep study. Perhaps I'll just start by increasing my max ramp from 20 to 45 and see how well that works for me.

Thanks again for your help!

Ken

[KenTheriot]

JD,

I found the clinician's access, so no worries there. Thanks for the tip about the SD card though:). They didn't use the same kind of machine or humidifier during the study. So I don't know if it will correspond. The report does not say what the settings were. Sigh. One thing I did notice while learning about the machine today, is that the humidifier is set to Auto mode, which combines the control into one number (a temperature). I had been using a manual setting on my AutoSet, which is why I had one control for humidity level and one for temperature. I changed it to manual. So we'll see how that works.

Thanks again.

Ken

[shortcake]

ps - The initial settings on my machine are: 25/15/10/15/4/Auto/Bi-flex

Hi again. Glad my post answered some of your questions! Just wanted to give a quick reply and can respond more tomorrow, but based on the pressure settings you mentioned, I think they mean the following. Since the numbers aren't labeled, this is a best guess:

Max pressure (max possible IPAP) = 25
EPAP range = 10 - 15
PS range = 4 - 15
BPM = Auto
Biflex = ? (Looks like there wasn't a recommended setting, so you can just use what's comfortable)

So after ramping, your min EPAP is 10 and IPAP min is 14 (bc PS min is 4). You'll always have at least 4 cm pressure difference between exhale (EPAP) and inhale (IPAP), but the difference can be up to 15, as long as the max IPAP of 25 isn't exceeded. In other words, comparing to your old BiPAP settings, you're basically starting the night at 10/14 with both pressures adjusting through the night, staying at least 4 cm apart.

It's interesting that your settings are so much higher on the ASV vs BiPAP... Usually the EPAP min is set to the lowest to resolve obstructive events, which is potentially lower if Bi-level modality is used. For example, my original CPAP pressure was 11. When retitrated for ASV, twice, min EPAP was set to 6.

What was your diagnosis to switch to ASV? CompSA?

In that other thread I mentioned how ramp can impact your therapy. If your EPAP min was truly supposed to be 10, I wouldn't blame you for using ramp! Just be careful and check Sleepyhead to see if you have tons of events during that time. If you tend to fall asleep quickly, a lower ramp period and starting around 6 (I think default starts at 4) might help.

Anyways, keep us posted how tonight goes!

[shortcake]

Oops, misread about the Auto CPAP and figured those were BiPAP pressures of 7.5 - 12.

Either way, if your average CPAP pressure was 8, and you began experiencing centrals, it doesn't make much sense to me to start you even higher than that. You might want to ask your doc why those settings were supposedly the best... or get a copy of your sleep study to see for yourself how the each titration pressure level affected you and any scoring comments, etc.

[KenTheriot]

Oops, misread about the Auto CPAP and figured those were BiPAP pressures of 7.5 - 12.

Either way, if your average CPAP pressure was 8, and you began experiencing centrals, it doesn't make much sense to me to start you even higher than that. You might want to ask your doc why those settings were supposedly the best... or get a copy of your sleep study to see for yourself how the each titration pressure level affected you and any scoring comments, etc.

shortcake,

The reason for the ASV study was that I could not reliably use the nasal mask due to chronic sinus and nasal blockage I could not solve over a period of years working with multiple docs and my allergist. I had 2 septoplasty/turbinate-reduction surgeries between 2005 and 2010. I have no allergies, according to a complete blood allergy test. So the dx is "non-allergic rhinitis" - specifically vasomotor rhinitis. All the preventive medications available (Flonase and it's ilk, Astelin, etc.) have failed. So the obvious solution for most is to use a full-face mask. But whenever I have tried to do that, I could never fall completely asleep for all the obstruction events (so I thought). The same pressures that worked perfectly well when using a nasal mask seemed not to work with a FF mask. After describing this multiple times to my sleep doc, she finally decided to have me tested with ASV, and it worked! I slept through the night with a full-face mask. And the results did show centrals. At the end of the report it said: "IMPRESSION: Complex Sleep Apnea, severe." So that's the story of why.

I do have a copy of the report.

The "Combined Pressure Summary" shows results under 6 pressures: 25/5, 25/6, 25/7, 25/8, 25/9, and 25/10. I assume the 25 in these combos represents a wide-open ability for the machine to react up to a max pressure of 25. The lower number, then, would mean what? Since they seem to have settled on 25/10, I assume it means "MIN EPAP." But that doesn't mean a minimum pressure of 10 cm for the final combo, right? With a MIN PS of 5 (which is what my machine was set to), that means at 25/10, I have a minimum IPAP of 15, right? So if 25/10 was supposed to mean a minimum IPAP of 10, then I'm 5 cm too high. Do you think that is likely that 25/10 was supposed to mean a minimum IPAP of 10?

If you are correct and the 4 is supposed to mean a PS range of 4, then the med supply company must've set something wrong, I think, because my initial settings said MIN PS = 5 and MAX PS = !0. So that would be a range of 5 and not 4, right?

Anyway, I'll report back tomorrow with how (if) things changed tonight.

Thanks again!

Ken

Either way, I've increased the ramp for tonight, as well as knocked the MIN PS from 5 to 4, which is where I believe it was supposed to be.

[JDS74]

It sounds as if your sleep study was done using Respironics equipment. Any chance you could get the DME so swap out so you could be set up exactly the same way as the sleep study.

Respironics has a different and more detailed set of parameters than the ResMed machines and that might make a difference.

Just a thought.

[KenTheriot]

JD,

It's a thought to keep in mind. I've gotten quite used to the S9 (and S8 before that from the AutoSet), and I think I can make it work. I had my 2nd night on ASV last night and will report on it in a separate post.

Thanks again.

Ken

[JeffH]

A good chinstrap helped me with the change from cpap to asv. Like you I was a long time cpap user that started having problems and got on asv. Man, I LOVE it. Best sleep of my life, except when I was a little kid. I use the Respronics premium chinstrap and usually only wake up once a night and get to sleep pretty easily. My AHI is always under one and usually under .5. I "worked" my way up to my prescribed EPAP. That seemed to help, but once I got to that pressure my sleep improved alot.

Good luck

JeffH

[KenTheriot]

A good chinstrap helped me with the change from cpap to asv. Like you I was a long time cpap user that started having problems and got on asv. Man, I LOVE it. Best sleep of my life, except when I was a little kid. I use the Respronics premium chinstrap and usually only wake up once a night and get to sleep pretty easily. My AHI is always under one and usually under .5. I "worked" my way up to my prescribed EPAP. That seemed to help, but once I got to that pressure my sleep improved alot.

Good luck

JeffH

Thanks Jeff! I like the idea of working up to your prescribed EPAP.

Ken

[KenTheriot]

I spent my 2nd night with the ASV and full-face mask. It was much better. I put the details in a separate post here: viewtopic/t95978/2nd-Night-With-ASV--Better.html

Cheers!

Ken

[shortcake]

The "Combined Pressure Summary" shows results under 6 pressures: 25/5, 25/6, 25/7, 25/8, 25/9, and 25/10. I assume the 25 in these combos represents a wide-open ability for the machine to react up to a max pressure of 25. The lower number, then, would mean what? Since they seem to have settled on 25/10, I assume it means "MIN EPAP." But that doesn't mean a minimum pressure of 10 cm for the final combo, right? With a MIN PS of 5 (which is what my machine was set to), that means at 25/10, I have a minimum IPAP of 15, right? So if 25/10 was supposed to mean a minimum IPAP of 10, then I'm 5 cm too high. Do you think that is likely that 25/10 was supposed to mean a minimum IPAP of 10?

If you are correct and the 4 is supposed to mean a PS range of 4, then the med supply company must've set something wrong, I think, because my initial settings said MIN PS = 5 and MAX PS = !0. So that would be a range of 5 and not 4, right?

The "Combined Pressure Summary" seems to be referring to Max pressure/Min EPAP. Since the EPAP is the most important part of keeping obstructive events under control, EPAP is the minimum that needs to be titrated, then they'd start adjusting your PS as needed to correct for additional hypopneas, etc and to stabilize your breathing. So the bottom number shouldn't be an IPAP min. Unfortunately it doesn't mention the PS ranges, from which you could calculate the IPAP min & max that was possible during each titration level. For example, my studies would include a chart with each line listing the ranges for EPAP and PS tried. So something like:

(Starting titration settings)
Max Pressure 25 EPAP 4 - 14 PS 0 - 10 # obstructive apnea, centrals, hypopnea, RERA, AHI, RDI, # spontaneous arousals that occurred at the level
(next setting)
Max Pressure 25 EPAP 5 - 15 PS 0 - 10 # obstructive apnea, etc...
...
(last setting)
Max Pressure 25 EPAP 8 - 19 PS 4 - 10 # obstructive apnea, etc...

So from the info you have, it sounds like you don't have the EPAP range or PS range used at each level, just the Max and the EPAP min.

On your most recent post, you said your machine was set to min PS = 5 and max PS = 10? The prescription, if I read that correctly, should be: min PS = 4 and max PS = 15. So both actually might have been set incorrectly. Yes, this would mean your minimum gap between EPAP and IPAP is 5... you're inhaling with a pressure of 15 and exhaling against a pressure of 10. Also, with max PS set to 10: when your EPAP is 10, your IPAP max (EPAP + PS max) would be limited to 20.

Dropping your PS min to 4 may also help lessen the feeling of swallowing air. If the Rx was 4 but machine set to 5, that may actually cause your lungs to hyperinflate unnecessarily and thus impact CO2 exchange. Another good point to mention is that some people find they need a higher EPAP min when changing to a FF mask in order to receive the same level of therapy. That could be a reason why during your titration, the EPAP min was set higher than when you were using the AutoPAP with an average of 8.

As a disclaimer for others who may stumble upon this thread later, I'm not advocating changing your settings after one bad night! Just making sure Ken's ASV is set to the correct prescription pressures

If you'd like, you can PM me with a scan of your sleep study (omit your name, etc if that'd make you more comfortable about doing so) and I'll let you know what I see, and if I can figure out if your Rx settings are what I think they are.

[KenTheriot]

Thanks again shortcake! I'll pm you with what I have.

Cheers!

Ken