SDB? Help needed with pressure settings

Wellhellothere · Post by **Wellhellothere** » Fri Aug 27, 2021 7:51 am

Hi all, it’s been a while since I last posted on the forum and with my brand spanking new Aircurve ASV I’m very curious on your views on my flow charts.
To briefly sum-up my background: 40 year old male, 170lbs, 6’3 tall with a childhood diagnosis for asthma. Here in the Netherlands, I have been treated for mild apnea for about 5 years and since I lost about 80lbs last year the sleep study recently showed an AHI<1. Hooray right? Not really. I have been struggling with daytime fatigue, muscle soreness and twitching, startle reflexes, cold fingers and other markers that make me believe I’m mostly suffering from Sleep Disordered Breathing, and not the full collapsing of my airways.
Over the years I have tried SSRI’s, my deviated septum was corrected, trying sleep therapy, and kept insisting on the apnea nurse to try a different kind machine than the good old Resmed Airsense 10 CPAP machine. I have used this machine diligently for a number of years on pressure setting 8 / EPR 3,without much significant improvement. Even though my sleep study shows a quite fragmented deep sleep, the doctor couldn’t clarify why and suggested to take medication to slightly improve my deep sleep. Tried that, and 0 result.
Last week I was able to procure a Resmed Aircurve 10-A TJ, which is an ASV-auto machine and after trying a couple of nights on different pressure settings, I’m reaching out to you guys to help me along the way with the pressure settings based on some screenshots of last night. I seem to have a constant plateau on the outbreath, just before breathing in. I would massively appreciate it if you could give me some pointers on how to set the EPAP and PSmin and PSmax for my machine. It has a ASV and ASVauto mode.

Thanks a million!

Miss Emerita · Post by **Miss Emerita** » Fri Aug 27, 2021 11:26 am

I don't have the expertise to make any suggestions about your settings, but I do have a couple of observations.

I don't see the "plateaus" in the first screenshot; in the second, are the "plateaus" the places where the flow rate line tracks the zero line for a bit? If so, that looks normal to me. You are pausing between breaths at the end of exhalations, as we often do.

You mentioned a recent sleep study; was it without a PAP machine? Was it in a sleep lab, or at home? Can you post a scan of the sleep study report?

Most of your symptoms -- muscle soreness and twitching, startle reflexes, cold fingers -- don't really sound to me as though they fit sleep-disordered breathing. I recommend that you discuss your symptoms with your doctor, who can order some tests to explore possible diagnoses.

palerider · Post by **palerider** » Fri Aug 27, 2021 6:16 pm

Wellhellothere wrote: ↑
Fri Aug 27, 2021 7:51 am
I seem to have a constant plateau on the outbreath, just before breathing in. I would massively appreciate it if you could give me some pointers on how to set the EPAP and PSmin and PSmax for my machine. It has a ASV and ASVauto mode.

At this point, I wouldn't change anything, based on what you've shown us so far.

Your second image looks like textbook sleep breathing.

Wellhellothere · Post by **Wellhellothere** » Sat Aug 28, 2021 2:33 am

Miss Emerita wrote: ↑
Fri Aug 27, 2021 11:26 am
You mentioned a recent sleep study; was it without a PAP machine? Was it in a sleep lab, or at home? Can you post a scan of the sleep study report?

I added two documents where 1 shows that something keeps pulling me out of my N3 sleep and I suspect it is the flow events. In the second picture the technician zooms in on the flow events and indicates that after the arousal my breathing slows down/stops.

palerider wrote: ↑
Fri Aug 27, 2021 6:16 pm
Your second image looks like textbook sleep breathing.

That's good to read! Always thought that the plateau meant something! My angle of improving the quality of my sleep is to keep the flow rate stable and eliminate the flow limitations by finding the right pressure settings.

Looking at last nights OSCAR readout flow limitations still show and the machine likes to hover around IPAP 13. I woke up to a bad headache halfway the night and lowered the settings to EPAP 9 /PSmin 1 / PSmax 6 and behold, no more headache. Still I'd like to eliminate the flow limitations completely and makes the spikes in the flow rate flatter and less 'choppy'. Any suggestions how to go about this is more than welcome

Appreciate it guys & galls!

palerider · Post by **palerider** » Sat Aug 28, 2021 7:11 am

Wellhellothere wrote: ↑
Sat Aug 28, 2021 2:33 am
I added two documents where 1 shows that something keeps pulling me out of my N3 sleep and I suspect it is the flow events. In the second picture the technician zooms in on the flow events and indicates that after the arousal my breathing slows down/stops.

palerider wrote: ↑
Fri Aug 27, 2021 6:16 pm
Your second image looks like textbook sleep breathing.
That's good to read! Always thought that the plateau meant something! My angle of improving the quality of my sleep is to keep the flow rate stable and eliminate the flow limitations by finding the right pressure settings.

The plateau does mean something, it means you're asleep

there's normally a pause after you exhale, before the next inhale, that's characteristic of sleep breathing, and the main way we tell (guess) when you're awake vs asleep while looking at the breathing traces.

It's pretty normal for you to have anomalies in breathing after an arousal, you often will take larger breaths during it, and that messes up the CO2 levels, often causing a pause in breathing until the loop cycle gets going again and you go back to normal breathing.

Here's a short video with a bit showing the plateau in breathing that you were concerned about:

https://www.youtube.com/watch?v=8mPHMHRh-_o

(I don't have time right now to dig up anything else.)

Miss Emerita · Post by **Miss Emerita** » Sat Aug 28, 2021 12:44 pm

I want to reiterate my advice to talk with your doctor about your symptoms.

I also want to caution that completely eliminating flow limitations is not a realistic goal. Everybody has some, and your FL graph looks good. You can also check on FLs by zooming in here and there to see whether the inhalation trace is curved or exhibits flattening or a dent. (The machine's algorithms don't pick up each and every FL.) For some people, even heavy FL doesn't interfere with a good night's sleep; other people may find that moderate or heavy FL is a problem.

The spikiness may indicate frequent arousals or just sighs, so you want to look for arousals, again by zooming. The traces for arousal breathing will have greater amplitude than asleep breathing, will be mostly missing those pauses between breaths, and often will show other ragged-looking features. Some arousals don't involve a full awakening. Those that do will be followed by awake breathing, often with a lower-than-usual amplitude, and they may show shorter (or absent) pauses between breaths.

Here's an example from last night:

Arousal and short awakening.png

I appeared to have been asleep at the beginning of the segment and back asleep toward the end. The arousal was (I think) a full though quite short wake-up. The breathing after the arousal shows lower amplitude (though not an absence of pauses between breaths.) That's what makes me think I was briefly awake then. (Note: Instead of a flat line between breaths, I have a little squiggle around the zero line. That's just my heartbeat telegraphing itself to my airway.)

palerider · Post by **palerider** » Sat Aug 28, 2021 2:24 pm

Miss Emerita wrote: ↑
Sat Aug 28, 2021 12:44 pm
I want to reiterate my advice to talk with your doctor about your symptoms.

I also want to caution that completely eliminating flow limitations is not a realistic goal. Everybody has some, and your FL graph looks good.

The ASV machines have been known to report FL's ... misleadingly. ie "OMG THAT LOOKS TERRIBLE" when it's really not, I think there may be a different multiplier used on the ASVs, not sure.

PS, I agree with your interpretation of your graph.

Pugsy · Post by **Pugsy** » Sat Aug 28, 2021 3:52 pm

palerider wrote: ↑
Sat Aug 28, 2021 2:24 pm

Miss Emerita wrote: ↑
Sat Aug 28, 2021 12:44 pm
I want to reiterate my advice to talk with your doctor about your symptoms.

I also want to caution that completely eliminating flow limitations is not a realistic goal. Everybody has some, and your FL graph looks good.
The ASV machines have been known to report FL's ... misleadingly. ie "OMG THAT LOOKS TERRIBLE" when it's really not, I think there may be a different multiplier used on the ASVs, not sure.

PS, I agree with your interpretation of your graph.

totally agree with PR. ResMed ASV flow limitation graphs well known to make huge mountains out tiny molehills when it comes to FL graphs. Never could figure out why. I have reports from Adapt and AutoSet to prove it from my own use of both machines. Don't feel like digging them up at this time but remind me later if interested.

I don't recommend trying to kill FLs on an ASV report. It will drive a person crazy because what we see that looks horrible isn't really horrible at all.

Miss Emerita · Post by **Miss Emerita** » Sat Aug 28, 2021 10:54 pm

Important to note: the OP’s FL graph isn’t horrible at all; it looks fine.

Pugsy · Post by **Pugsy** » Sun Aug 29, 2021 7:28 am

Miss Emerita wrote: ↑
Sat Aug 28, 2021 10:54 pm
Important to note: the OP’s FL graph isn’t horrible at all; it looks fine.

True if we compare it to some others but it has several points where it maxes out the scale.
This in turn gives the impression that the FL at 1.0 on the graph was really bad and something needs to be done to make that 1.0 spike go away. Potentially sending someone on a wild goose chase when there aren't any real geese to hunt. Trying to "fix" every little slightly weird looking breath with some sort of setting tweak.

Miss Emerita · Post by **Miss Emerita** » Sun Aug 29, 2021 9:30 am

Got it. And to the OP: a few maxed-out FLs over the course of 9 hours is absolutely nothing to worry about.

Wellhellothere · Post by **Wellhellothere** » Sun Aug 29, 2021 11:59 am

Thanks for all the feedback all! In all you've definetely helped me get a better perspective on what my flow graph is actually telling. I seem to have found a pressure setting that shows a very stable flow graph, you could almost hold a ruler on top of it! No need to tweak much further then and I'll give these setting a go and notice how I'll feel.

Heel veel bedankt uit Nederland!
(many thanks from The Netherlands)

SDB? Help needed with pressure settings

SDB? Help needed with pressure settings

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