ASV - data posted and advice needed

I have been using the new ASV machine for a week and it has been somewhat problematic. The first two nights I had horrible insomnia and my AHI skyrocketed over 12. The mask I had been using for a couple of weeks was the Airfit N10 which I was pretty happy with. Unfortunately, after switching to ASV from Bipap I started to have issues. I don't quite know how to describe this but I started to grunt as I was dropping off to sleep which would, of course wake me up. It was if the back of my throat was closing up on the exhale. I also started to drool so much that the tape came off. Very strange. On Bipap the Epap was set at 10 but on this machine it is set at 8.

Since I am a mouth breather and I have been unable to find a full face mask that works for me I have ended up taping and using a chin strap. Although I prefer nasal pillows unfortunately I have had congestion issues using them so ended up switching to nasal cushions. With the problems I had on the first two nights I decided to try the Hybrid I have in my stash of masks. The next night my AHI went down to 1.8. Unfortunatley, it has come back up again - last night it was 4.3. The night before it was 5.8. I am a little concerned for several reasons. So far since using this machine my AHI has been much higher than with the Bipap. I have been having a slew of hypopneas instead of which were not my issue before. Last night my percentage of night spent with patient initiated breaths went down to 15. I am still waking up in the middle of the night. I am exhausted. Although my AHI's probably don't seem high to some I never feel very good unless it's under 1.

So here are my questions:
1. Should I be worried by my data? Especially the fact that I don't seem to be breathing on my own. I have an appointment with the Dr. in 3 weeks but I have been wondering if I need to call for a quicker appointment.
2. Is how I am transitioning from one type of therapy to another normal? The pressure changes are not bothering me very much. Will it just take time for my AHI to come down?
3. Do you think the grunting issue is because of the lowered Epap?
4. One of the reasons I have been unable to tolerate a full face mask is because of chipmunk cheeks happening periodically and suddenly. Now it is happening with the Hybrid mask as well does anyone have any ideas why?

Here's what the prescription says: Epap min 8 - max 12; PS min 6 -max 17; Max 25

With the help of the members of this forum I think I have posted last night's data below. I'd really appreciate your thoughts. Many thanks! Tuza

Chipmunk cheeks....this happens because the tongue has dropped down and is allowing the air that is going up the nose and down the airway to enter the mouth. Since the lips are closed all that air causes the cheeks to inflate. This can happen no matter what mask is used if the lips are closed (even with a full face mask if the mouth/lips are closed).
It's annoying because it can disturb sleep. There is a way to "deflate" the cheeks without opening the mouth but the most common way is to open the lips and let the excess air out. I know how to deflate the cheeks without opening my mouth but I can't put it into words what I do. It doesn't happen very often to me and when it does I am already semi awake. I don't think it has ever caused me to wake up.

To prevent the air from entering the mouth via that back door to the aireay the tongue has to keep that door closed. This is where the tongue placement at the roof of the mouth comes into play. It's easy to do while awake but not so easy to do all the time while asleep because the tongue gets lazy and drops which opens the door.
All I can suggest is make a point to keep that tongue in the roof of your mouth all the time during the day and hope the tongue will learn a new habit of staying in place even while asleep.

Your pressure triggered breaths are scary low. I don't know what it means though...this is one of the things you need to talk to your doctor about.
For the slightly elevated AHI (higher than you want but sort of sometimes within acceptable limits) talk to your doctor about it. Maybe a little more EPAP but I hesitate to suggest that people on ASV go into dialawingin things when they actually have a doctor they are seeing.
You might call and report what is happening and see if he wants to do anything any different or maybe see you sooner.
Most often they will say "give it time" and when it comes to ASV therapy this is especially true. It can take the body quite some time for it to come to trust the machine and get in tune with it.

It's possible that things will improve simply with time and often doctors prefer to give it a chance before they start changing things.

I have no idea what the grunting is or might be related to. If it happens right when you seem to be going into first sleep stage then maybe it is a sleep onset central popping up. If it is...then it has nothing at all to do with EPAP.
Now if it is maybe the airway trying to collapse then EPAP might be a factor...just a little too low to keep the airway held open and prevent further collapse and those flagged events you see.
So again...might be worth investigating a little more EPAP. Probably wouldn't take much ....assuming that is what it is related to.

You are concerned...call your doctor and convey your concerns. That's what they get paid for and then he can decide if you should be seen sooner or not. I don't think it is life or death critical to be seen earlier but it may ease your mind to at least talk to him and see what he wants to do.

I have no idea what is going on with the Patient Triggered Breathing....except don't ever sleep without the machine.
Talk to your doctor about this for sure. He can explain why and what's maybe going on and what to expect.

I think you are right, Pugsy, I'll just give the office a call tomorrow and tell them what's going on. When I saw that 15% I was quite shocked and a little scared - I'll see what they have to say. I don't want to change anything myself on the machine; I'm definitely not qualified to fiddle with it. Look at how long it took me to figure out how to post the charts! The tongue thing I thought I had mastered but you know when I used the Hybrid last year my mouth was opened most of the time. The past couple of nights it has been closed. I have to tell you I am so-o-o tired of being tired.

tuzacat,

Welcome to the world of ASV. Things here are very different from CPAP or BiPap.
I notice your breathing rate is 11 bpm which reflects the very low percent patient breathing. Could you post one page from the wave data? The third page would be nice. That one has the higher percent and so might show more detail of what is going on with breathing rate.

When you speak to your doctor, you might ask about getting an overnight oximeter to see if you are having desats related to the low breathing rate.

Your leak line looks quite good. Aside from the scary looking percent line, the rest looks fine. It may be that's what your proper ASV data looks like.

Hang in there.

Well, JDS74, I sure can see that things are very different and I don't really understand what some of this stuff means or what's going on. I looked for wave data in Encore Basic but I don't see it. Will I have to use Sleepyhead to show you that? How many bpm is normal?

Thursday night I had another miserable night but the patient triggered breaths went way up. At about 12 I took a bunch of sleep herbs and a Zaleplon but it still took a couple of hours to get to sleep. Still had the issues with grunting and chipmunk cheeks.





Yesterday, I was so fed up I consulted a nutritionist and asked for suggestions. Last night about an hour before I turned in I took magnesium supplements, calcium supplements, and 2 Valerian capsules. I passed out for almost 13 hours! AHI was 1! The patient initated breaths were down though. Since Valerian is a sedative I'm going to try taking just one tonight and see if it goes back up. I also did not have the grunting or the chipmunk cheeks! Very strange. I kept in mind what Pugsy said about the tongue thing and the second I started to have an incident I clamped my tongue up there. I also noticed my mouth was slightly open when I woke up.





I am hoping I can repeat getting to sleep again tonight. Tried to wear myself out today. Thanks so much for your help and your comments!

Best, Tuza

Wave form graphs are a separate report in Encore Basic.
When you are looking on the therapy tab where you click on "detailed" therapy for your reports...look to the left of that area just a little for a little blue paper clip looking thing...that's wave form report and you have to click on it separately from the other detailed graphs. Let me know if you can't find it and I will get you a screen shot of it.

Basic limits you to the most recent wave form night though. If you want to be able to review old wave form graphs just generate the report and save it to pdf in a folder on your computer....means you have to download daily and save the report daily if you want those old reports.
Encore Pro let's you select old dates and for some people they won't those old wave form reports and it's worth the Pro hassle to have them. Most doctors and DMEs aren't going to look at wave form graphs though and if they do they just will want the most recent. It's a 6 or 7 page document for 7 or 8 hours of sleep.

OK, thanks, Pugsy, I'll see if I can find last night.

EncoreGuide link this will show you examples of what you will see.
http://www.healthcare.philips.com/pwc_h ... _Guide.pdf

I think the wave form blue thing and an example of what you see is included in the above link.

Pugsy wrote:Wave form graphs are a separate report in Encore Basic. ...
Encore Pro let's you select old dates and for some people they won't those old wave form reports and it's worth the Pro hassle to have them. Most doctors and DMEs aren't going to look at wave form graphs though and if they do they just will want the most recent. It's a 6 or 7 page document for 7 or 8 hours of sleep.

For all the machines that collect the data that are not ASV machines, the waveform reports show one hour of data for each page. For ASV machines, the waveform report is 30 minutes per page. So for a 760 machine, 8 hours of sleep time gets you 8 pages of wave reports. For a 960 (or 950) machine, you get 16 pages of wave reports. Both come with a single page of summary information in the front.

Since you are using Encore Basic, you won't have access to the older wave data. What I wanted to see was a single page in which the % patient breaths were quite high so I could take a close look at the breath-to-breath variability. On mine, there Is significant variability that I think accounts for a large part of the machine deciding it needs to help. Taking a sleep aid can depress the respiration rate. If it does that enough, then the ASV machine will kick in and help.

This may be related to sleep hygiene issues. That's a different discussion though.

I saw that there were multiple pages from last night. It started after 2 when I got up one time. I'm sending pages 3 and 4. Not really sure if that is quite what's going to be the right info.

If you look at the first two minutes starting at 3:06 AM, you'll see some variability in the breathing rate. Just after 3:07, it gets long enough for your machine to kick in and do one breath. There are a couple just before that are not long enough to trigger. You'd have to set your backup rate to a lower fixed rate for one night to see if this sort of pattern is common. In the two samples you show rates of 12.4 and 13.8 so I'd guess that setting it to 10 would be safe for one night. Then you could look at the waveforms to see how much variability there is. In auto mode, much of that is masked.

Do you keep a meds log so you can see if there is a connection between your % PTB and any meds or supplements you are taking? Your more recent numbers look good. I occasionally get a night down down in the 50% range so a few of them shouldn't be cause to worry. Plot the data, keep records and you should be able to find what is going on.

It took me a long time to find out how sensitive I am to even minute amounts of caffeine so you may find something similar.
Take care.

Keeping a log is a good idea; I've been thinking about keeping a food diary for a while to see how what I'm eating is affecting how I feel. Thanks for the info!
Best, Tuza

In regards to the waveform graphs, the each block labeled with a time contains two lines of data.
The first line is the actual breaths being taken. I don't remember if down is breathing in and up is breathing out but each up and down is a single breath. The distance between the peaks is the duration of the breath.

The second row labeled CmH2O is the pressure curve. The bottom of that curve is the actual EPAP value at that moment. The top is the actual IPAP at the same moment offset by the time difference between breathing in and out.

If you see a small reddish dot above the pressure curve, that is a machine triggered breath.

It is easier to see variations in breath durations by looking at the pressure curves. Notice the length when there is a machine trigger. Now compare that duration to others in the same minute on the graph. As you get more familiar with what your breathing looks like you will begin to see patterns.

For example, in my data, the breath curve goes along for a while and then jumps up to the maximum on the graph. That is either an arousal or I am awake. Frequently, just after you see one of those, you see one or two machine triggers. That is what pugsy refers to as SWJ (sleep-wake junk) and those are almost always meaningless. Looking further down the graph, you can see when the breathing returns to a more regular form. That's when you are back asleep again. Measuring the distance, you get an estimate of your sleep latency. If the graph goes really squirrelly in the middle, that may indicate that you are rolling over or doing some large movement. That is what mine shows. You'll have to get used to your own data to be sure.

Do you have a copy of your sleep study. That will be very helpful in interpreting you wave data. Somewhere in the report it mentions arousals and wakenings. You can see those in your data.

Thanks for the explanantion. I don't have a copy of the sleep study - my appointment is not for a few more weeks. I'll ask for it then. Hopefully, by then I will have the kinks worked out.

I took one less Valerian last night and woke up in the middle of the night. I decided it was more important for me to sleep than it was to worry about whether the machine was breathing for me so I took the second pill. AHI 1.8.

I will keep tweaking it. It's good to know that I can actually sleep without taking major drugs.