ASV first SH chart - Puzzled!

[photonic]

Hi yall. Well I did my first night on my new ASV with the Quattro Air and had a really bad night so switched to the Oracle 2 for the night posted here and did much better and was much more comfortable and used the supplied nose plugs which stayed in MOST of the night. I have loaded SH software and read all of Pugsy's tutorials and had some PMs with members which have helped. But I am wondering if you could help me get the big picture about what is going on with this data.

I am surprised that my OAs and CAs are tiny but my Hypopneas are very high. Can't quite figure out why that would be with this machine. I think my nose was fairly well sealed, but did notice on one of my "breaks" that the plugs were out, but did not experience lots of air out the nose. I had two breaks, one when I was quite awake and needed to pee and the second when I was just quite awake and took a half hour's sleep hygiene break in another room. The third period I slept really well and it felt refreshing at least for those few hours.

I notice before each "break" that pressures are rising, snoring is noted (wife says I do not snore but she noticed some moaning) and then boink, I am awake and quite bothered by the machine. Can you give me some general comments as to what is going on to get me started on the road to understanding my data? Here is wishing you a good weekend.

[JDS74]

Just a wild guess. Any chance that a food reaction is going on here?
Any amount of caffeine does similar things to my stats. Same thing for spicy food, etc.
I really like the leak numbers for the last segment. That part looks great.

[photonic]

No foods or medicines. I do drink decaf coffee occasionally but my roaster says it is decafed to European standards in Germany which means leas than .000001% which is essentially none.

[robysue]

I am surprised that my OAs and CAs are tiny but my Hypopneas are very high. Can't quite figure out why that would be with this machine.

It looks to me like the ASV algorithm was kicking in well before the EPAP pressure increases and snoring was scored by the machine. The reason I say that is that there are very large increases in your IPAP pressure and in the Max IPAP pressure during the times when there are thick clusters of Hs being scored. Long chains of CAs are associated with a CO2 overshoot/undershoot cycle, and the ASV algorithm is designed to prevent this cycle from developing in the first place. In your data, it looks to me like the machine was not completely preventing the CO2 overshoot/undershoot cycle from developing. But the machine was not totally failing at its job either: At the nadir of the breathing cycle, you were still breathing, but you were breathing very, very shallowly, and hence an H got scored rather than a CA. The ASV algorithm seems to understand that these Hs are likely to be central Hs, and hence there's no large increase in the EPAP pressure being triggered by the repeated Hs.

As to what to do with this kind of pattern: That's above my pay scale. I'd say that if you are often seeing this many H's scored during periods of high IPAP and high Max IPAP values, you ought to talk to your sleep doc about it and make sure that he looks at some of the detailed data (in Encore or SleepyHead) as well. It appears that one or more of your machine's settings is not yet optimally set since way too many Hs are getting through.

[palerider]

As to what to do with this kind of pattern: That's above my pay scale. I'd say that if you are often seeing this many H's scored during periods of high IPAP and high Max IPAP values, you ought to talk to your sleep doc about it and make sure that he looks at some of the detailed data (in Encore or SleepyHead) as well. It appears that one or more of your machine's settings is not yet optimally set since way too many Hs are getting through.

my first thought, for what it's worth, is the min epap is too min.

[Pugsy]

my first thought, for what it's worth, is the min epap is too min.

As was mine but then I noticed the 3rd sleep segment...when there was significant overall improvement in the reports as well as OP says he slept well and felt better.

Not sure why the first 2 segments are so ugly unless also related to poor sleep in general...just a crappy sleep.
Makes me wonder why the difference in the 3 sleep segments. If sleep quality was poor with a lot of awakenings until that last 3rd sleep segment that starts around 4 AM then the ugliness may have been related more to awake/semi awake or SWJ stuff going on and has to be set aside.

[photonic]

Very helpful and hmmm very complicated. My MD did tell me that I had worrisome Complex apnea.

I will gather some more data with the same mask and report back.

Thanks for being here.

[palerider]

my first thought, for what it's worth, is the min epap is too min.

As was mine but then I noticed the 3rd sleep segment...when there was significant overall improvement in the reports as well as OP says he slept well and felt better.

Not sure why the first 2 segments are so ugly unless also related to poor sleep in general...just a crappy sleep.
Makes me wonder why the difference in the 3 sleep segments. If sleep quality was poor with a lot of awakenings until that last 3rd sleep segment that starts around 4 AM then the ugliness may have been related more to awake/semi awake or SWJ stuff going on and has to be set aside.

back vs side sleepin maybe?

[JDS74]

Not to pick too much on caffeine as the cause in your case but, for me, any is too much.
Three Hershey Kisses in the morning gives me stats just like your first two segments. Curry spice and other spicy foods do it for me also.

The Hershey site list 1 mg of caffeine per Kiss. With the serum half-life between 3-7 hours, that means that 12 hours later the original dose of 3 mg is now down to between .2 and .8 mg at bed time. Compare that with a 12 ounce Coke of about 30 mg of caffeine.

So, while it may not be caffeine that you are sensitive to, it could be something you ate for breakfast that only got below your threshold almost 20 hours later at 4:00 AM.

Your EPAP MIN number is quite low as is your pressure support number. It might be useful to ask your doc if those numbers should be adjusted. I am absolutely not suggesting that you start fiddling with these numbers without you doc's guidance. ASV machines are complicated beasts and fiddling is a way to get in trouble.

I forget, but did you get a copy of your sleep study and titration? There should be data in them that might lead to a different set of pressures.

[Pugsy]

back vs side sleepin maybe?

Maybe.
I would have thought more maybe if he had said he slept well the first 2 segments. Then we could blame the ugliness on maybe sleep position. When someone says they slept poorly I can't help but wonder if the ugliness caused the poor sleep or the poor sleep in general caused the ugliness. Which came first sort of thing. If EPAP itself was insufficient and caused the poor sleep in first 2 segments...then why was EPAP apparently sufficient during the 3rd segment.

Also I don't remember just how long he has been using ASV...is ASV totally new therapy or is this just a new ASV machine replacing old therapy. If new to ASV therapy...how many nights has it been used? We all know that it can take a little longer for the body to adjust to ASV therapy (at least for a good many people) Plus multiple (as in a different mask) masks were used...adding another unknown variable into the mix.

If it is supine sleeping making the ugliness worse we need to know OP's usual sleeping position to be able to factor that into the mix. So need to have an idea of sleeping position for sure.

Reports like this always make me ask more questions at first that so I can get a better handle on things before I start wanting to zero in a therapy setting as maybe something which could be looked at to fix it.
First I want to see several reports and also have noted any variables...like different masks and/or sleeping positions and the variable of sleep quality itself. It's fairly easy to come up with ideas when the entire night's report sucks...harder to come up with concrete ideas when we see part of the night sucking and part of the night with a report we would all be happy with.
Like what changed at 4 AM.
Heck, look at that pressure line on that 3 rd segment....boring pressure line. Didn't move around much at all...makes me wonder why it didn't want to move around.
Makes me wonder if all the pressure moving around with the first 2 sleep segments caused the poor sleep. and if so....why was it moving around so much. Why didn't it move around after 4 AM?

Or was this just a weirdo one off fluke that we can't ever come up with a reasonable explanation. Lord knows I have had a few ugly flukes myself that I never could figure out some sort of explanation. Like when I had 17 centrals in 17 minutes that looked very suspicious for CSR and I don't know why. Ugly 17 minutes and I am 99.9 % sure I was totally asleep. I never could figure that out and it never happened again for me to try to isolate potential variables.
If I am awake enough to comment that sleep quality was horrible and I had a lot of awakenings...I totally discount the graphs because it's too difficult for me to isolate awake time and SWJ time. And in all honesty...that's a lot of work and I am not inclined to expend a lot of work energy on a fluke that I can't reproduce the fluke.

In Photonic's situation here. I would want to see a lot more detailed reports to have a remote chance of coming up with any ideas backed by common sense reasoning. Instead of an idea that came out of a magic 8 ball response. I would also need more history.

[photonic]

Great reply. I vote for really poor sleep as I am new to this. Your comments have been really helpful getting me grounded and starting to appreciate the graphs ad stats. Now is time to put in some good time on the ASV with the same mask and be sure I have acclimatized to the alien and then see what the trends are. Thanks for getting me started. I will report back when I can find out if this was a fluke or not.

[palerider]

back vs side sleepin maybe?

Also I don't remember just how long he has been using ASV...is ASV totally new therapy or is this just a new ASV machine replacing old therapy. If new to ASV therapy...how many nights has it been used? We all know that it can take a little longer for the body to adjust to ASV therapy (at least for a good many people) Plus multiple (as in a different mask) masks were used...adding another unknown variable into the mix.

iirc, this is new territory, he had lots of questions indicating he'd never touched one of these beasties before and i think that's his first night chart.

[Pugsy]

Now is time to put in some good time on the ASV with the same mask and be sure I have acclimatized to the alien and then see what the trends are. Thanks for getting me started. I will report back when I can find out if this was a fluke or not.

Please do report back after a week or two or three.
I am curious as to how things go after the overall adjustment process has had a chance to get entrenched and affects both sleep quality and the reports. The brain and the body needs to get acclimated to this new way of sleeping/breathing.

[photonic]

Will do.....

[igdoc]

All good advice. It is very early days and you do need to see if things settle down. I too have Complex sleep apnea and use this machine.

I note that the ASV has been left wide open which is as suggested by Philips Respironics (except they recommend increasing the EPAP if high CPAP pressures have been needed previously). In my own experience with a very small amount of data, it seems that having a PS Max of 10 or more produces a higher AHI and more frequent central hypopneas than when it is reduced. Whether the effect of lowering the PS is due to preventing more frequent arousals or, by reducing instability in a feedback mechanism where the response is too large, I cannot be sure. A PS Max of 7 seems to works best for me and produces my lowest AHI's. Studies suggest that a PS of between 8 and 12 should be enough to induce a full breath from the machine if a central apnea occurs when the lungs are normal. Therefore a PS of higher than this may, in some individuals, be more than is necessary.

Anyway I am not suggesting lowering your PS Max based on just one night of data. However if your numbers do not improve and your PS Max keeps persistently going up to 20 (with a good flow response), then this might be the first thing I would suggest.
Ian