Can ASV cause fatigue? Need BiPAP instead?

[Todzo]

A recent study comparing ASV with CPAP for the treatment of CompSAS demonstrated that ASV yields better carbon dioxide maintenance but does not reduce arousals, reduce daytime sleepiness, or improve quality of life better that CPAP[1].

So while the better carbon dioxide maintenance may help preserve your brain your quality of life will likely remain the same.

ASV is a mechanical attempt to deal with the ventilatory gain issues often associated with OSA and exacerbated by the pressure of CPAP. But more is in play here[2]. Arousal threshold is likely to be breached by all the pressure changes (and apparently is). As well if tongue muscle issues are involved the pressure of CPAP is unlikely to move that sufficiently.

I use CPAP by choice. I long ago noted that the least arousals occur with CPAP. Post Traumatic Stress (PTS) forced me to deal with ventilatory gain and arousal issues. I have found many things that help but will focus on the ventilatory gain issues here in my response here. A little list:

1. EERS[3]
2. The addition of a bit of compressible air space to deal with expiratory pressure intolerance[4]. Note that this also reduced the noise and vibration “in the tube” and made life so much quieter at sleep time.
3. Recently (I am about two weeks into the experiment) I have found that chrono therapy[5] (blue blockers on at 8p (to 8a) – bright light at 10a) has resulted in much more consistent breathing level at night (consistent thickness of the airway breathing waveform as well as minimal difference between the average and 95% minute volumes). No waking up breathing hard. Much more rested. And much more consistent bed times (about 10p). This is particularly amazing to me as I am days away from the anniversary of the assault and robbery which brought the PTS into my life. It is more normal for me to be having problems with breathing levels and slip of my “sleep phase” (DSPD to non-24).

While I hope that Dr. Krakow soon tires of the inadequacies of ASV I very much do respect him and his work. He seems to understand the issues much better than most. I think that industry pressures simply make it hard for him to move on.

But in general the industry needs to become much more interdisciplinary. Perhaps at least the circadian and CPAP gangs can strike a truce??


[1] http://www.journalsleep.org/ViewAbstract.aspx?pid=29458

[2] Danny J. Eckert, David P. White, Amy S. Jordan, Atul Malhotra, and Andrew Wellman “Defining Phenotypic Causes of Obstructive Sleep Apnea. Identification of Novel Therapeutic Targets”, American Journal of Respiratory and Critical Care Medicine, Vol. 188, No. 8 (2013), pp. 996-1004.
doi: 10.1164/rccm.201303-0448OC link: http://www.atsjournals.org/doi/abs/10.1 ... _06LdZx0xB

[3]: Gilmartin G, McGeehan B, Vigneault K, Daly RW, Manento M, Weiss JW, Thomas RJ.
Treatment of positive airway pressure treatment-associated respiratory instability with enhanced expiratory rebreathing space (EERS).
Source: J Clin Sleep Med. 2010 Dec 15;6(6):529-38. Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Link: http://www.ncbi.nlm.nih.gov/pubmed/21206741

[4] http://www.sleepreviewmag.com/2014/01/a ... a-and-sdb/

[5] http://www.amazon.com/Chronotherapy-Res ... B007P7HZUE

[cnaumann]

Interesting stuff, Todzo, I am responding because I want to read those links in depth at a later time.

I have really ratty breathing at night. Actually, I did a little experiment yesterday and turned the pressures on my machine all the way down and breathed through it while awake and watching TV for a couple of hours. Turns out I have pretty ratty breathing while I am awake as well. I don't have any apneas while awake (I don't go over 10 seconds without breathing), but my awake breathing does not seem to fit any regular pattern. I will go for 15 minutes breathing slow and deep (RR around 8 ), then go for a while breathing faster and shallower (RR around 14). My breaths don't really seem to be regularly spaced. I have no idea if this is normal or very unusual.

I believe that the current thinking is that centrals don't cause the arousal that obstructives do, and therefore they do not interfere with sleep as much. You don't actually have to 'wake up' to deal with a central, as you do with an obstructive. So in spite of low O2 levels and decreased blood pH, they may not be as damaging, or at least they are not damaging in the same way.

I have been doing ASV for only two nights now. It is definitely keeping my spO2 levels up (I can measure that) and I have not had a headache or ringing in my ears either morning as I typically do (might be due to the therapy, but could be anything). The pressure changes are waking me up, I am hoping that I will 'settle in' after a while. The idea of just CPAP to keep my airway open and re-breathing some CO2 to keep my brain from stopping respiration is interesting. I may have to get some soda pop bottles and duct tape and try it.

As far as ASV fatigue and needing simple BiPAP, my own experience is that my breathing is quite stable during part of the night even without therapy, and all over the place at other times even with the ASV therapy. For me, I don't believe there is a magic BiPAP pressure setting that just works. A fixed pressure will work for a while, then things always go bonkers. Your mileage may vary.

[palerider]

just be aware that todzo is on the 'best ignored' list. and if you read what was linked, you'll find very little to substantiate his 'interpretations' in most cases.

[cnaumann]

PHhht. A full face mask, some duct tape, a few soda bottles and maybe a plastic bag.... what could possibly go wrong?

[buran]

justinjustin,
Look at the following presentation, starting from page 41 (pages 1-40 cover the modern implementation of EERS, see Todzo post above):
http://www.northeastsleep.org/speaker-s ... ations.pdf
If you have similar “pressure cycling” as shown at p.44 you may need to try different ASV (Respironics), but not BiBAP. See the table (p.45) Resmed ASV vs. Respironics ASV.
Also, see Fig.1 and Fig. 2 in this paper: “The chemoreflex and sleep disordered breathing: man and machine vs. the beast”
http://www.sleep-journal.com/article/S1 ... 9/abstract
(but to me these figures look less convincing)

[palerider]

PHhht. A full face mask, some duct tape, a few soda bottles and maybe a plastic bag.... what could possibly go wrong?

don't forget the superglue and the bailing wire, you gotta have bailing wire.

might need a paperclip too.

[cnaumann]

don't forget the superglue and the bailing wire, you gotta have bailing wire.

You and your fancy-pants bailing wire. All things can be fixed with JB Weld and WD40. If it moves and it is not supposed to, apply JB Weld. If it is supposed to move and doesn't, apply WD40.

[palerider]

don't forget the superglue and the bailing wire, you gotta have bailing wire.

You and your fancy-pants bailing wire. All things can be fixed with JB Weld and WD40. If it moves and it is not supposed to, apply JB Weld. If it is supposed to move and doesn't, apply WD40.

waaaaaait a minute.... I'm pretty sure bailing ware (pronounced correctly) predates both of them newcommers o yours!

though I admit, your preferred methods do have advantages.

[Wulfman...]

For all you "city slickers" it's actually spelled "baling" wire......."B A L I N G"

I think by now, most of it has been replaced with twine......but the wire is still available.


Den

.

[palerider]

For all you "city slickers" it's actually spelled "baling" wire......."B A L I N G"

I think by now, most of it has been replaced with twine......but the wire is still available.

not to be argumentative (oh, who am I kidding) but...

google and the internet would tend to disagree with you: (yeah, I know, all them city slickers)

Bailing wire: About 764,000 results
Baling wire: About 264,000 results

though, fair enough, wikipedia agrees with you: http://en.wikipedia.org/wiki/Baling_wire

(see? I'm happy to admit when I'm wrong )

[Wulfman...]

For all you "city slickers" it's actually spelled "baling" wire......."B A L I N G"

I think by now, most of it has been replaced with twine......but the wire is still available.

not to be argumentative (oh, who am I kidding) but...

google and the internet would tend to disagree with you: (yeah, I know, all them city slickers)

Bailing wire: About 764,000 results
Baling wire: About 264,000 results

though, fair enough, wikipedia agrees with you: http://en.wikipedia.org/wiki/Baling_wire

(see? I'm happy to admit when I'm wrong )

You just can't trust the Internet.......those 764,000 results were probably due to spelling by "city slickers"......

I did think this part of the Wiki was kind of funny.......the "haywire" part. Hadn't really thought of that connection before.

Spelling note: "Baling wire" is sometimes misspelled as "bailing" wire, but "bailing" usually refers to a leak or flood, as in "bailing" out a leaky rowboat with a pail, or bailing out a bank with funds to keep it afloat.

It is also known as "haywire," from which the term "go haywire" arose, referring to crazy or mixed up from the wire's use to fix anything in an ad hoc manner.[1]

Lots of both of them....wire and twine-wrapped hay bales went through my (gloved) hands in my youth.


Den

.

[justinjustin]

justinjustin,
Look at the following presentation, starting from page 41 (pages 1-40 cover the modern implementation of EERS, see Todzo post above):
http://www.northeastsleep.org/speaker-s ... ations.pdf
If you have similar “pressure cycling” as shown at p.44 you may need to try different ASV (Respironics), but not BiBAP. See the table (p.45) Resmed ASV vs. Respironics ASV.
Also, see Fig.1 and Fig. 2 in this paper: “The chemoreflex and sleep disordered breathing: man and machine vs. the beast”
http://www.sleep-journal.com/article/S1 ... 9/abstract
(but to me these figures look less convincing)

This stuff is way over my head. I don't get it.

But I have a question: Does Respironics BiPAP autoSV allow you to set PSmin and PSmax to the same value? That would create a BiPAP-like setting.

[Wulfman...]

justinjustin,
Look at the following presentation, starting from page 41 (pages 1-40 cover the modern implementation of EERS, see Todzo post above):
http://www.northeastsleep.org/speaker-s ... ations.pdf
If you have similar “pressure cycling” as shown at p.44 you may need to try different ASV (Respironics), but not BiBAP. See the table (p.45) Resmed ASV vs. Respironics ASV.
Also, see Fig.1 and Fig. 2 in this paper: “The chemoreflex and sleep disordered breathing: man and machine vs. the beast”
http://www.sleep-journal.com/article/S1 ... 9/abstract
(but to me these figures look less convincing)

This stuff is way over my head. I don't get it.

But I have a question: Does Respironics BiPAP autoSV allow you to set PSmin and PSmax to the same value? That would create a BiPAP-like setting.

Try it and see what happens. But, I think you'd need to set the "PSmax" before you set the "PSmin".


Den

.

[cnaumann]

But I have a question: Does Respironics BiPAP autoSV allow you to set PSmin and PSmax to the same value? That would create a BiPAP-like setting.

Yes. It is possible to emulate a BiPAP with the DS960. To do so, you also have to set the EPAPmin and EPAPmax to the same value.

You cannot really emulate an auto-BiPAP, ASV is a very different algorithm than auto-BiPAP and setting PSmin and PSmax to the same (fixed) value will make ASV near useless will not create a useful auto-BiPAP.

And you can also emulate a CPAP by setting EPAPmin and EPAPmax to the same value and both PSmin and PSmax to near zero. Again however, you cannot really emulate an auto-CPAP.

[justinjustin]

But I have a question: Does Respironics BiPAP autoSV allow you to set PSmin and PSmax to the same value? That would create a BiPAP-like setting.

Yes. It is possible to emulate a BiPAP with the DS960. To do so, you also have to set the EPAPmin and EPAPmax to the same value.

You cannot really emulate an auto-BiPAP, ASV is a very different algorithm than auto-BiPAP and setting PSmin and PSmax to the same (fixed) value will make ASV near useless will not create a useful auto-BiPAP.

And you can also emulate a CPAP by setting EPAPmin and EPAPmax to the same value and both PSmin and PSmax to near zero. Again however, you cannot really emulate an auto-CPAP.

My issue is that Resmed S9 ASV won't let me set PSmin and PSmax to the same value.

I see in my data that whenever I'm at IPAP of 18cm, my waveforms are stable, but then the ASV changes the pressure.

I want to try using an ASV like a BiPAP (non auto) to test a constant 18cm IPAP + 8cm EPAP and see how I feel.

But, I don't have a prescription for BiPAP, only ASV. So I'm trying to find an ASV I can test out like a non-auto BiPAP.