Smargie’s Therapy Thread...in Need of ASV Advice

I am in agreement with Jas... start with something you can at least sleep with and check out the results and maybe increase EPAP minimum in slow small increments if needed.
You have more centrals than anything and the settings suggested will deal with the centrals just fine. The machine will give you the PS when it thinks it needs to be increased. Only thing is a lower minimum EPAP may not deal with the obstructive stuff well but that's really to be determined and obstructives weren't your primary issue anyway.

I am not sure I could go to 10 EPAP and 16 IPAP and sleep myself....that's a huge jump from what you have been using....it would be a huge jump for what I have been using.

We gotta be comfortable to fall asleep. Can't rely on being so bone ass tired we pass out from exhaustion.

Blerg! This is all so complicated that it seems unconscionable to me that they just set up your machine and send you out the door! I wonder how many people just give up if they don't find a site like this that gives such valuable advice from people actually using these machines. I think I would have. And the term "compliance" is really judgmental, and doesn't take into account all of the different ways a patient may struggle because of a poorly set machine.

The good news is that I slept for over 5 hours (combined) using the ASV. AHI was 4.6 and consisted of only hypops and 2 UAs. So the current settings that Pusgy has me on are preventing OAs and centrals, and is tolerable unless there is a leak. 95% of EPAP is under 8.6. All of the hypops occurred during the ramp period when I probably wasn't asleep yet. My leak rate was a little over 1% and it was all over redline (whatever that means).

When the leaks happen it make the pressure go crazy! If I know I've done my 4 hours I just stop and go back to sleep without it because sometimes I just can't win the battle when it's blowing so hard. I don't know if I've had a blast to prevent a central yet or not. Does the ASV automatically prevent all centrals?

What the ASV does is when you have a central it gives you that big rather rapid burst of PS to sort of jump start your own breathing.
Centrals happen when the carbon dioxide levels in the blood stream don't get high enough for the brain to wake up and send the "breathe" signals to the body. It's a bit of unstable breathing happening because of the blood gases are out of whack.
So the machine essentially breathes for you when you don't breathe and the act of breathing for you (that big PS burst) gets your body sort of jump started so you don't quit breathing as much or as often. So in that sense the machine breathes for you when you need it and prevents some centrals by getting you back to more stable breathing so you don't quit as often.
But mainly the machine is simply breathing for you when you don't breath on your own....that's what a central apnea is. You just don't make any effort to breathe. The machine says "whoa, my human isn't breathing so I will breathe for him and force him to inhale"...and that's what PS does.

I think that the settings they came up with during the titration study were manually figured....those probably gave optimal results.
Then they give you a machine set to those settings and didn't factor in that the machine will auto adjust and given a chance it will likely come close to those settings when you are asleep and when asleep they won't matter so much because when asleep you won't notice them as much.
While awake those settings are a bitch to get used to but you don't need them while awake. Let the machine do what it is designed to do...trust it....it will figure it out.

Smargie wrote: ↑

Sat Jun 29, 2019 11:12 am

Blerg! This is all so complicated that it seems unconscionable to me that they just set up your machine and send you out the door! I wonder how many people just give up if they don't find a site like this that gives such valuable advice from people actually using these machines. I think I would have. And the term "compliance" is really judgmental, and doesn't take into account all of the different ways a patient may struggle because of a poorly set machine.

and this from forum member dojiscalper-

dojiscalper wrote: ↑

Tue May 21, 2019 6:03 am

Your support network of doctors don't realize that this isn't like a prescription for a pill. It's like a prescription for an exercise program. It will take time and even a lot of time to get used to it and get the settings and gear right. Once you get it all working and comfortable you'll never want to sleep without it.



It took me nearly a year but I'm very sensitive to anything bugging me.

to which i say, THIS! SO. MUCH. THIS>

The AHI is only obstructive. No CA are recorded. The titration sets the max PS needed to vent the lung during a CA, in your case this was the default 15. You can't tell if the CA are effectively treated by looking at the AHI.

It was also determined that you needed min PS6 to vent your lung in the first place, instead of default ps3. They wouldn't have used the largest min ps available on the machine for no reason.

I would ask your doctor, he will explain why these pressures were chosen. Ask for a copy of your sleep study. The DME may or may not be any help in this explanation on the pressures.
Reducing pressure, because you aren't use to it yet. May not be the best course of action. With my machine I start at 12 ps5 and go up to ps18 on a bad night. You do get use to it. you really need good mask fit with ASV. It doesn't handle leaks well.

Central or CSA has a o2 drop and are serious, if there are many not treated properly. I would suggest you read about CSA. They are the reason for the asv and the titration on it.

ajack wrote: ↑

Sun Jun 30, 2019 8:10 pm

The AHI is only obstructive. No CA are recorded. The titration sets the max PS needed to vent the lung during a CA, in your case this was the default 15. You can't tell if the CA are effectively treated by looking at the AHI.

It was also determined that you needed min PS6 to vent your lung in the first place, instead of default ps3. They wouldn't have used the largest min ps available on the machine for no reason.

I would ask your doctor, he will explain why these pressures were chosen. Ask for a copy of your sleep study.

Do you mean that the AHI is only obstructive in general, or that on ASV centrals are not included in the AHI reading? I'm confused about this. On both of my sleep studies the centrals were included to determine the AHI, and when I downloaded the data from my previous Auto CPAP onto SleepyHead the centrals were included there, too. With my new ASV the events that show up on OSCAR haven't shown any centrals yet at all, and in the flagged event box the only categories are LL, UA OA, and H. I don't know how to interpret this.

I do have the copies of my last sleep study that the DME deemed pertinent. During the CPAP portion of the night the lowest number of centrals and hypops did occur when I was at a 10, but it was only measured for 24 minutes. Sleep onset was 82 minutes, and I was awake and watching a show on my iPad while they tested level 6 and most of level 8. I felt like I was awake the entire night. When they switched to ASV I spent most of the time feeling very uncomfortable and like I was being blown up like a balloon. I fidgeted with the mask constantly and the tech came in to adjust it twice. My readings were:

EPAP min, EPAP max, PS min, PS max, Max Pres, Min Sp02, Sleep Du,r AHI, OAs, MAs, CAs, Hypops

8, 20, 0, 16, 25, 86%, 142.9, 9.2, 0, 0, 0, 22

10, 20, 0, 15, 25, 92%, 25.1, 4.8, 0, 0, 0, 2

[I made a nice chart for this, but when I previewed it everything got squished together. Hope it's not too hard to read.]


I know I was wide awake during those last 25 minutes because I was so miserable and I had a terrible stomach ache.


So, this is what my settings were based on. When I got there the DME had set it for:

Min EPAP 4.0 Max IPAP 25.0 PS 0.0-15.0 (cmH2O)

Then she got a fax from the doc who wanted it changed (which she felt was odd) to:

Min EPAP 10.0 Max IPAP 30.0 PS 6.0-15.0 (cmH2O)



Last night I upped my setting to EPAP 8.4 and PS 3.4. I definitely noticed a difference and did not sleep as well. The aerophagia was worse than before and my AHI was 4.66, which is the highest it's been so far and more than 3 points higher than the last 2 nights.


Thoughts and/or advice anyone?

Ajack, I also wanted to mention that it's very hard to get an appointment with your sleep physician here. I've only had 2 so far: the intake, and then the follow up to see how the therapy was working. During that second appointment I provided data from SleepyHead to show how bad things had become and only then did she order a more detailed and specific report from my machine. in the interim I'd called her office to say that something strange was going on, and I'm not sure who I spoke to, but he downloaded a report and spoke briefly with the doc. When he called back he said she'd said I had treated related central apnea, which was very common, and that it would clear up on its own in 2 or 3 weeks. I was advised to stop using the CPAP by members of this site as it seemed to be doing more harm than good. Anyway, during that second appointment she acted as though she had no idea of how bad my readings were. I won't be able to see her again until I've been on the ASV for at least 30 days. Also, she said she'd be on vacation during my second study and would have a colleague read my results and call me. After no one did I called the office and the staff pleaded ignorance, but did agree to have another doc read my results and write the prescription.

Maybe the sleep physicians are more accessible in Australia? I hope so for your sake, though you seem to be very knowlegable about sleep apnea and its treatment. It's been a steep and ongoing learning curve for me and I'm astounded at how little patient education is offered in this particular field of medicine.

Smargie wrote: ↑

Tue Jul 02, 2019 11:08 am

ajack wrote: ↑

Sun Jun 30, 2019 8:10 pm

nosie

Best to just not engage with ajack.. he spews confusion, doesn't read the threads, and doesn't bother to correct his typos.

Smargie wrote: ↑

Tue Jul 02, 2019 11:08 am

Do you mean that the AHI is only obstructive in general, or that on ASV centrals are not included in the AHI reading? I'm confused about this. On both of my sleep studies the centrals were included to determine the AHI, and when I downloaded the data from my previous Auto CPAP onto SleepyHead the centrals were included there, too. With my new ASV the events that show up on OSCAR haven't shown any centrals yet at all, and in the flagged event box the only categories are LL, UA OA, and H. I don't know how to interpret this.

Resmed ASV's don't record centrals, because when your breathing effort starts to drop off, they *immediately* increase PS to force air into you. The only way that they could record a central is to leave you not breathing for 10+ seconds, and run the FOT to see if your throat is open before they start trying to make you breathe.

Resmed apparently decided that keeping you breathing was more important than counting how many centrals you were having that the machine should have been preventing.

And, technically, since the machine is breathing for you, you can't have a central apnea, since apnea means 'not breathing'.

Thanks palerider. I don't know what FOT is but everything else makes good sense to me.

Ajacks concern was my fiddling with and turning down the EPAP and PS. My AHI was nice and low after I made those adjustments so that I could tolerate the pressure and be able to sleep. After going back up a little my AHI went up 3+ points. Aren't these machines supposed to be auto adjusting, based on breathing pattern? Now he's got me worried that I may be having centrals and not know it. Would the machine let that happen? If not, I may not even bother adjusting the settings back to the prescription.

Smargie wrote: ↑

Tue Jul 02, 2019 12:21 pm

Thanks palerider. I don't know what FOT is but everything else makes good sense to me.

Ajacks concern was my fiddling with and turning down the EPAP and PS. My AHI was nice and low after I made those adjustments so that I could tolerate the pressure and be able to sleep. After going back up a little my AHI went up 3+ points. Aren't these machines supposed to be auto adjusting, based on breathing pattern? Now he's got me worried that I may be having centrals and not know it. Would the machine let that happen? If not, I may not even bother adjusting the settings back to the prescription.

FOT is explained in this video: https://www.youtube.com/watch?v=4GW97Xk06N8

Hi Smargie,

Good to see you got a new machine and are trying. I'm confident you'll adjust and it will work for you.

I'm not an ASV expert, but I understand the ASV does not report centrals because technically, as PR implies, you can't have them while using the machine. If you don't initiate a breath (a central) then the machine does.

Have you been able to load your results into Oscar? Somewhere in the results, it will tell the percentage of triggered breaths, which will give you an idea how hard the machine is working for you. You may also be able to see this result on the machine's LCD report. If you are able to use Oscar, let us see a night using the new ASV so some of the members more familiar with ASV can interpret your results.

I suggest you go back to, or stay with the settings that are comfortable so that you can become accustomed to breathing with the machine. My understanding is that it does take a little getting used to.

j

I do not believe Resmed records triggered breaths on an ASV

Jay Aitchsee wrote: ↑

Tue Jul 02, 2019 12:54 pm

Somewhere in the results, it will tell the percentage of triggered breaths, which will give you an idea how hard the machine is working for you. You may also be able to see this result on the machine's LCD report

Jas_williams wrote: ↑

Tue Jul 02, 2019 1:45 pm

I do not believe Resmed records triggered breaths on an ASV

You could be right, Jas. I don't have the Clinician's Manual to check. Sorry if my statement was in error.

Jay, the LCD report on the ResMed ASV is oddly lacking. It gives you the total time you used the machine for the night, a face that smiles or frowns depending on how well your mask fit, and another face to report whether the HumidAir worked. Apparently a clinician can set it so that it gives you your AHI, but mine decided not to. I'll change that mode tonight and see what other info it might supply.

There are some concepts I'm still trying to understand. On OSCAR, which pressure are they referring to in the table and graph? Can't be EPAP since that has its own info. Is it the IPAP or the PS? What does mask pressure mean, and time at pressure? Why is it that the machine has no setting options for IPAP?

The good news is that my numbers are excellent. My AHI has been 1.09-1.50, except for one night when I had a lot of larges leaks (2.33) and the night I turned my settings up (4.66). I think that these numbers should actually be lower because almost every event (all hypops...can you have an OA with an ASV?) occurs during the 10 minute ramp period when I'm not asleep yet.

The problem is that I'm getting really bad aerophagia. It's so painful that I start to be unable to sleep anymore at around the 4 hour mark, so I take the mask off and go back to sleep without the machine. At that point I'm also fighting with the pressure--I don't want to breathe very deeply because it hurts and the machine responds by blowing harder. Now I'm wondering if I should turn the settings down even lower than I already have.

My prescription for PS is 6 and I've turned it down to 3 per Pugsy's suggestion. The min. EPAP was set for 10 and we have it at 8. These setting are clearly treating the obstructive stuff. Palerider says that the ASV won't let you have a central by definition. But I'm only using the machine for as little as I can get away with because of the aerophagia and battles with the pressure, so I'm not being treated during 30% to 50% of the time I sleep.

Anyone care to weigh in?

Smargie wrote: ↑

Tue Jul 02, 2019 12:21 pm

Thanks palerider. I don't know what FOT is but everything else makes good sense to me.

Ajacks concern was my fiddling with and turning down the EPAP and PS. My AHI was nice and low after I made those adjustments so that I could tolerate the pressure and be able to sleep. After going back up a little my AHI went up 3+ points. Aren't these machines supposed to be auto adjusting, based on breathing pattern? Now he's got me worried that I may be having centrals and not know it. Would the machine let that happen? If not, I may not even bother adjusting the settings back to the prescription.

I really would defer to your doctor, The advice you have been given is suspect. Unlike normal apap, the ASV doesn't record CA, it only records obstructive events. By reducing PS you have choked the machine to effectively treat yourself. Again, please refer back to your doctor. These people really are out of their depth.
The epap min is for obstructive and you raise that 1cm at a time to resolve UA/H.