First night with new ASV (AirCurve 10 ASV)

ozij wrote: ↑

Wed Dec 27, 2023 12:39 am

...
It looks to me as if your machine is at default, or almost default setting. Min EPAP 4, max IPAP 30 max PS15?

Those are indeed the settings; I don't know if they are default or not; they are supposedly what the sleep study technician recommended.

I just re-read the sleep study report. The technician ended the study with the following settings:
Max EPAP: 15
Min EPAP: 4
Max PS: 9
Min PS: 4
(no mention of IPAP settings).

The reviewing doctor stated he would order a machine with settings:
Max EPAP: 15
Min EPAP: 4
Max PS: 15
Min PS: 0
(also no mention of IPAP settings).

So it's not clear why the Max PS is 15 when the study tech ended the study with it at 9, and it's not clear why the the Min PS is 0 when the study tech ended the study with it at 4. I have no idea what to make of the IPAP numbers. Should I leave the EPAP numbers as is, and set min/max PS at 4 / 9 ?

ozij wrote: ↑

Wed Dec 27, 2023 12:39 am

I'm looking at that roller coaster of flow limitations and thinking: That doesn't make sense. The whole point of ASV for TECSA is solving the problem of CA's that appear for some people when the pressure is high enough to eliminate the obstructive events. And its very clear that your flow limitations and hypopneas appear when the pressure is lower.

If I zoom in on a couple of specific Hypopneas, I see the following:

This looks like there's no flow limitation and the pressure is moderate?

Here's another three hypopneas; they seem to be happening with no flow rate issues and with pressure high, medium, low?


and another threesome; this time, pressure seems high for all three, and no flow limitation?

ozij wrote: ↑

Wed Dec 27, 2023 12:39 am

If you have obstructive sleep apnea, with TECSA, wouldn't it make sense to have the machine's minimum set closer to a level when flow limitations/hypopneas don't happen, preventing them, and then adding the higher PS that ensures your breathing doesn't stall when the airway is open?

It seems to me they sent you out with a wide open ASV - with a minimum EPAP that does nothing to treat your obstructions.

"The machine's minimum" - would that be PS, EPAP or IPAP? Sorry, this is all new to me!

ozij wrote: ↑

Wed Dec 27, 2023 12:39 am

I remember you were getting those periodic breathing period on non-ASV therapy, but please check, and remind us, what pressure eliminated your obstructive events.

Here's my record of my previous CPAP adventure, approx 5 weeks worth. I ended up with Min pressure at 9, Max Pressure at 14 (though the results were so messed up overall due to the high CA numbers, it's hard to say if that was the best)

ozij wrote: ↑

Wed Dec 27, 2023 12:39 am

If it were me, this is what I'd say to myself:
Letting my EPAP revert to pressure that is low enough for those tremendous flow limitations doesn't make sense. I want to see how my obstructions (FL's, H's OA's whatever) behaved on non-ASV, and I'd like to try raising my EPAP to a level that doesn't drop to where I get flow limitations.

What would 'non-ASV' translate to - changing the mode of the machine? And you are suggesting raising the minimum EPAP?

I'm new to ASV and only had a month of CPAP experience, so this is a bit overwhelming but I really appreciate your input!

Steerpike58 wrote: ↑

Wed Dec 27, 2023 8:40 pm

What would 'non-ASV' translate to - changing the mode of the machine? And you are suggesting raising the minimum EPAP?

I would go with the technician's settings, not the doc's. I would do that because it's the technician who saw my responses to various pressure, and the doctor's script totally ignores it.

When I searched for info on the ASV's default settings, I found only one that has IPAP up to 30, it's a machine for COPD patients - but my search may not have been good enough
Do you have COPD?

Your doctor's script reminds of a story from my brother, a physician in a hospital. They have a template for reporting the status of a person brought into the ER.
The template has a line for "pulse found in both legs". My brother said he'll often see that checkmarked, when a patient comes in who has only one leg...
I am guessing your doctor has a default script template and didn't take the trouble to check the details.
Though of course he can blame whoever filled the data before he signed it....

Steerpike58 wrote: ↑

Wed Dec 27, 2023 8:40 pm

I just re-read the sleep study report. The technician ended the study with the following settings:
Max EPAP: 15
Min EPAP: 4
Max PS: 9
Min PS: 4
(no mention of IPAP settings).

IPAP is not mentioned in the tech's recommended settings, because that' how ASV's work: the breath by breath analysis of the machine decides how much higher to push the pressure from the defined EPAP -- The automatic Pressure Support is what defines the next Inhalation Pressure. On a ResMed ASV, PS can vary. Look at the images too.

I don't know if this -- AirCurve™ 10 CS PaceWave™--- is your exact, machine but here's the description of how it works.

ASVAuto mode
ASVAuto mode adapts to a patient’s ventilatory and upper airway stability needs on a breath-by-breath basis. By treating central breathing disorders with auto-adjusting pressure support and upper airway obstruction with auto-adjusting EPAP, it rapidly stabilises respiration.

"Look mom, no hands!" OOPs, I meant "Look Doc, no IPAP"
Here too:
https://www.resmed.com/en-us/healthcare ... v/#support
Your doctors "script" by letting the machine drop PS to less than 4 is keeping the basic inhalation pressure too low waiting for an obstruction to respond to, thereby letting you have too many obstructive event, and the automatic PS too high, blowing you up.

By keeping the minimum PS at 4, the technician decided your minimal pressure for each inhaled breath would be 8.Which turns out to be pretty close to your APAP median. But now you're working with a machine that doesn't let your breathing destabilize into CA's, and analyses breath by breath, and with more flexibility in varying the inhalation pressure as needed.

ozij wrote: ↑

Wed Dec 27, 2023 11:18 pm

Steerpike58 wrote: ↑

Wed Dec 27, 2023 8:40 pm

What would 'non-ASV' translate to - changing the mode of the machine? And you are suggesting raising the minimum EPAP?

I would go with the technician's settings, not the doc's. I would do that because it's the technician who saw my responses to various pressure, and the doctor's script totally ignores it.

When I searched for info on the ASV's default settings, I found only one that has IPAP up to 30, it's a machine for COPD patients - but my search may not have been good enough
Do you have COPD?

I don't have COPD. I'm 5'11", 150 lbs, I hike 4+ miles every day and aced the last 'stress test' at my cardiologist's office.

ozij wrote: ↑

Wed Dec 27, 2023 11:18 pm

...

Steerpike58 wrote: ↑

Wed Dec 27, 2023 8:40 pm

I just re-read the sleep study report. The technician ended the study with the following settings:
Max EPAP: 15
Min EPAP: 4
Max PS: 9
Min PS: 4
(no mention of IPAP settings).

IPAP is not mentioned in the tech's recommended settings, because that' how ASV's work: the breath by breath analysis of the machine decides how much higher to push the pressure from the defined EPAP -- The automatic Pressure Support is what defines the next Inhalation Pressure. On a ResMed ASV, PS can vary. Look at the images too.

I don't know if this -- AirCurve™ 10 CS PaceWave™--- is your exact, machine but here's the description of how it works.

ASVAuto mode
ASVAuto mode adapts to a patient’s ventilatory and upper airway stability needs on a breath-by-breath basis. By treating central breathing disorders with auto-adjusting pressure support and upper airway obstruction with auto-adjusting EPAP, it rapidly stabilises respiration.

"Look mom, no hands!" OOPs, I meant "Look Doc, no IPAP"
Here too:
https://www.resmed.com/en-us/healthcare ... v/#support

These are the RESMED AirCurve 10 models I'm aware of (this is from RESMED's site):

I have the third model - the ASV model. That 'AirCurve 10 CS PaceWave' is obviously yest another variant, but certainly not mine!

In the clinician menu on my machine, I can set PS (min Max) and EPAP (min Max). No IPAP - I could have sworn I saw that but it's not there. Maybe it was seeing it in the OSCAR report that threw me off.

ozij wrote: ↑

Wed Dec 27, 2023 11:18 pm

Your doctors "script" by letting the machine drop PS to less than 4 is keeping the basic inhalation pressure too low waiting for an obstruction to respond to, thereby letting you have too many obstructive event, and the automatic PS too high, blowing you up.

By keeping the minimum PS at 4, the technician decided your minimal pressure for each inhaled breath would be 8.Which turns out to be pretty close to your APAP median. But now you're working with a machine that doesn't let your breathing destabilize into CA's, and analyses breath by breath, and with more flexibility in varying the inhalation pressure as needed.

are the two pressures additive; that is - if max EPAP is 15, and max PS is 15, does that mean I could be experiencing a max total pressure of 30? As you say, the current machine is 'blowing me up' (literally - I had really bad stomach cramps yesterday and was gassing out all day!) so with max PS at the sleep technicians setting of 9, that would still be (15+9) max - 24. with my previous CPAP, I had a max of 14. But at least 24 is less than 30!

Thanks again for your help!

Your ASV machine won't do 30 cm....25 is as high as it will go....and just because it can do 15 PS doesn't mean it will do 15 PS.

Steerpike58 wrote: ↑

Fri Dec 29, 2023 2:03 pm

are the two pressures additive; that is - if max EPAP is 15, and max PS is 15, does that mean I could be experiencing a max total pressure of 30?
As you say, the current machine is '[blowing me up' (literally - I had really bad stomach cramps yesterday and was gassing out all day!) so with max PS at the sleep technicians setting of 9, that would still be (15+9) max - 24. with my previous CPAP, I had a max of 14. But at least 24 is less than 30!

Thanks again for your help!

Yes, the two pressures are additive. IPAP (inhalation positive air pressure, aka "Pressure" in the OSCAR report) Is the result of EPAP (exhalation positive air pressure) + Pressure Support.

Info about the highest pressure you are really hitting can be see in the charts, and on the charts.
The sleep technician settings mean the following:
When you're using the machine, the pressure never goes lower than 8 when you're inhaling. That's the minimum pressure needed to keep your airway from collapsing - fully or partly - and you have no business being below that.

On the present settings (the doctor's settings) in which there's no minimum pressure support you're spending half the night at a pressure of 7.75 or lower -- half the night at pressure lower than the minimum recommended at your titration - and we don't know how much lower. At those lower pressures, you're getting obstructions -- be they hypopneas or flow limitations.
But the aim of ASV therapy it to keep you breathing smoothly - EPAP should be set to relieve the obstruction and it doesn't look like the wide open machine is doing that.

ozij wrote: ↑

Fri Dec 29, 2023 10:56 pm

Steerpike58 wrote: ↑

Fri Dec 29, 2023 2:03 pm

are the two pressures additive; that is - if max EPAP is 15, and max PS is 15, does that mean I could be experiencing a max total pressure of 30?
...

Yes, the two pressures are additive. IPAP (inhalation positive air pressure, aka "Pressure" in the OSCAR report) Is the result of EPAP (exhalation positive air pressure) + Pressure Support.

That makes sense - thanks. So IPAP = EPAP + PS. And the 'Pressure' chart in OSCAR is showing that IPAP.

ozij wrote: ↑

Fri Dec 29, 2023 10:56 pm

...
On the present settings (the doctor's settings) in which there's no minimum pressure support you're spending half the night at a pressure of 7.75 or lower -- half the night at pressure lower than the minimum recommended at your titration - and we don't know how much lower. At those lower pressures, you're getting obstructions -- be they hypopneas or flow limitations.
...

I'm sure you are correct, but could you elaborate on exactly where you are getting the value of 7.75 from?

I have a call scheduled tomorrow with a sleep tech about making changes to the settings so I want to be as conversant with the numbers as possible.

Thanks again!

Steerpike58 wrote: ↑

Fri Jan 05, 2024 11:40 am

ozij wrote: ↑

Fri Dec 29, 2023 10:56 pm

Steerpike58 wrote: ↑

Fri Dec 29, 2023 2:03 pm

are the two pressures additive; that is - if max EPAP is 15, and max PS is 15, does that mean I could be experiencing a max total pressure of 30?
...

Yes, the two pressures are additive. IPAP (inhalation positive air pressure, aka "Pressure" in the OSCAR report) Is the result of EPAP (exhalation positive air pressure) + Pressure Support.

That makes sense - thanks. So IPAP = EPAP + PS. And the 'Pressure' chart in OSCAR is showing that IPAP.

ozij wrote: ↑

Fri Dec 29, 2023 10:56 pm

...
On the present settings (the doctor's settings) in which there's no minimum pressure support you're spending half the night at a pressure of 7.75 or lower -- half the night at pressure lower than the minimum recommended at your titration - and we don't know how much lower. At those lower pressures, you're getting obstructions -- be they hypopneas or flow limitations.
...

I'm sure you are correct, but could you elaborate on exactly where you are getting the value of 7.75 from?

I have a call scheduled tomorrow with a sleep tech about making changes to the settings so I want to be as conversant with the numbers as possible.

Thanks again!

7.75 was a slip, I meant 7.70.
I took it from the settings side of your first image, where reports the Median pressure. Median means you're spending half the time at or below the reported pressure.

ozij wrote: ↑

Fri Jan 05, 2024 9:44 pm

Steerpike58 wrote: ↑

Fri Jan 05, 2024 11:40 am

ozij wrote: ↑

Fri Dec 29, 2023 10:56 pm

Steerpike58 wrote: ↑

Fri Dec 29, 2023 2:03 pm

are the two pressures additive; that is - if max EPAP is 15, and max PS is 15, does that mean I could be experiencing a max total pressure of 30?
...

Yes, the two pressures are additive. IPAP (inhalation positive air pressure, aka "Pressure" in the OSCAR report) Is the result of EPAP (exhalation positive air pressure) + Pressure Support.

That makes sense - thanks. So IPAP = EPAP + PS. And the 'Pressure' chart in OSCAR is showing that IPAP.

ozij wrote: ↑

Fri Dec 29, 2023 10:56 pm

...
On the present settings (the doctor's settings) in which there's no minimum pressure support you're spending half the night at a pressure of 7.75 or lower -- half the night at pressure lower than the minimum recommended at your titration - and we don't know how much lower. At those lower pressures, you're getting obstructions -- be they hypopneas or flow limitations.
...

I'm sure you are correct, but could you elaborate on exactly where you are getting the value of 7.75 from?

I have a call scheduled tomorrow with a sleep tech about making changes to the settings so I want to be as conversant with the numbers as possible.

Thanks again!

7.75 was a slip, I meant 7.70.
I took it from the settings side of your first image, where reports the Median pressure. Median means you're spending half the time at or below the reported pressure.

Got it! Thanks.

The sleep technician couldn't explain what the doctor had done, and agreed to adjust the settings a bit. She raised Min EPAP from 4 to 6, and lowered max EPAP from 15 to 9. She also increased min PS from 0 to 2, and lowered max PS from 15 to 10. Note - I'm being cooperative / respectful of the sleep center's involvement for now, since I need to go back there for a followup shortly. I don't want to be blatantly adjusting the machine myself without consulting them.

Last night, I had a 'tolerable' night's sleep, with one long session from 2am to 7:15am (at which point I took off the mask).

Steerpike58 wrote: ↑

Sun Jan 07, 2024 1:41 pm

The sleep technician couldn't explain what the doctor had done, and agreed to adjust the settings a bit.

That's good. I mean it's good she agreed to change.
I'm curious: Did you sense any surprise on her side? Do you think she will go back to him to ask why? Did she record the changes she made (and your complaints)? Did you ask why not set the machine to the sleep study results? (in a "wanting to learn" way, not argumentative of course). Is this a question you could bring up with your doctor at the follow-up?

And She raised Min EPAP from 4 to 6, and lowered max EPAP from 15 to 9. She also increased min PS from 0 to 2, and lowered max PS from 15 to 10.

Now I know why your previous setting showed "Max IPAP = 30" on the chart. It's OSCAR simply adding max PS and max EPAP and reporting this sum as though it were another setting regardless of the machine's actual capabilities or of what you could really set it to.

Note - I'm being cooperative / respectful of the sleep center's involvement for now, since I need to go back there for a followup shortly. I don't want to be blatantly adjusting the machine myself without consulting them.

Makes sense.

Last night, I had a 'tolerable' night's sleep, with one long session from 2am to 7:15am (at which point I took off the mask).

How was you're aerophagia? When's the follow up - does it include the doctor?
Please keep us posted.

ozij wrote: ↑

Sun Jan 07, 2024 10:42 pm

Steerpike58 wrote: ↑

Sun Jan 07, 2024 1:41 pm

The sleep technician couldn't explain what the doctor had done, and agreed to adjust the settings a bit.

That's good. I mean it's good she agreed to change.
I'm curious: Did you sense any surprise on her side? Do you think she will go back to him to ask why? Did she record the changes she made (and your complaints)? Did you ask why not set the machine to the sleep study results? (in a "wanting to learn" way, not argumentative of course). Is this a question you could bring up with your doctor at the follow-up?

She sounded hurried, as they always do, but she was very impressed by the fact I was quoting 'Oscar' charts, and told me I can make changes if I want, and I said I'd keep her informed about changes. She recorded the changes she made as a 'progress report' posted to my chart. I can't really explain why she wouldn't go straight to the 'sleep study results', she did make a comment about how it was only 2 hours which isn't really long enough. The follow up will not be with a doctor, but one of the technicians, probably the lady I spoke to.

ozij wrote: ↑

Sun Jan 07, 2024 10:42 pm

And She raised Min EPAP from 4 to 6, and lowered max EPAP from 15 to 9. She also increased min PS from 0 to 2, and lowered max PS from 15 to 10.

...
How was you're aerophagia? When's the follow up - does it include the doctor?
Please keep us posted.

We ended up having a few followup calls, and she's quite 'engaged' in the process. After hearing me continue to complain about aerophagia and mask 'trumpets', she said she wanted to focus on getting me comfortable with the mask first, and then we'll worry about the AHI later. So her idea was to set the machine into basic CPAP mode (constant pressure) and just run it for a few nights at a steady pressure of 8, to see how I go with the mask, with breathing, and with aerophagia. She said once we establish my 'baseline pressure', we can start worrying about all the rest. This seemed pretty reasonable, so we did that. I'm currently on night 5 of running this way, and the aerophagia and mask noise is minimal, so hopefully we'll be working on next steps next week. The main thing is, she seems somewhat intrigued by what's going on and is therefore 'engaged'. I doubt there'll be any followups with the doctor though! Oh, and she's arranging for me to get a different size mask to see if that helps with the 'trumpeting' - this will be mask #6 or 7, I think. My AHI has gone way up to around 20 in this 'basic CPAP mode', but that's to be expected.

Biggest problem I'm running into now is that my nose is itching like crazy in the middle of the night - this is a new phenomenon! I'm having to remove the mask just to scratch my nose, which is very disruptive. The itching is right on the tip of the nose, and I've never experienced anything quite like it.

Where do you get those charts? On a laptop-program? I have only MyAir.

Namdalingen wrote: ↑

Sun Jan 14, 2024 6:03 pm

Where do you get those charts? On a laptop-program? I have only MyAir.

oscar. see here-
viewtopic/t88983/Pugsys-PointersSleepyH ... Hints.html

and welcome to the zoo!

For annoying reasons, I am broadly in the same CA boat as you, but I have learned a lot about ASV in the last month. (I am a "no, I will just stop breathing or underbreathe periodically and not wake up" person). I watched a youtube video in which the tech suggested starting with the ASV settings opened wide, but I do know from cpap that if my minimum pressure is under 8 i feel like I cant breathe, and I do in fact have low pulse ox. So I used that as a minimum. Anyway, I did well, except I had one night where the machine seemed to be surging oddly, and I was hiccuping air, and yet after that my pulse ox was still dropping in scary ways (I have a commercial wellue pulse ox alarm ring). So I did just take the max PS down by just 3 points, and I think it's likely to be better. I wont explain the ad hoc way I came up with this, but it has to do with using the OSCAR software to look at what the min and max actual pressures were that were used on the "good" nights with good oxygen levels, which has been most nights.

BTW, if you have a commercial oxygen monitor (amazon or ebay), you can show that in oscar too. It is relevant in setting my pressures, but no worries if you don't have nighttime oxygen problems.

Commercial: It is so dumb that the only medical pulse ox that integrates with the airsense machine costs $1000 so of course they don't include it, even with CA or complex apnea. Maybe I qualify now?

Too long, dont read:
Still waiting for the consulting appointment for my lab sleep test (my 2nd apnea test) to come back so I can hear if they are prescribing ASV - but the PA has already fiddled with every setting available on a new CPAP AS 11 machine, and we can see it doesn't support my oxygen (slept with sleep lab's o2 monitors at home while using CPAP), thus the second and real in-lab test with multiple types of machine support... A scary place to be waiting for any official response, and so I don't feel bad about rolling my own until the official channel comes through. But it is dumb to have to wait so long.

About the weird night, I actually have 2 wellue devices which I have checked against the sleep doc's, and they performed similarly on the bad night, so I feel the ox "dips" were real. I also thought that during the surges the ox looked highish for me (I seldom get above 92 at night with CPAP/ASV and can drop below 80 on cpap at any setting, unassisted and unalarmed I happily drop below 70), so I wondered if that or the burping suggested that some physiological issue. I sure will be glad when my sleep study consultation comes back, although the conversation with the sleep doc may be... awkward... But boy, ASVs can be much cheaper used than they are new, and in the long run I will have a spare...

I should add that I am a relatively healthy-looking 140 lb 5'2" 64-year-old female with an active lifestyle and a keto-mediterranean diet with limited carbs and sugar for at least last 10 years, I fast from 6PM until 9AM every day, I ebike and walk every day. Ortho issues are getting more intrusive, but still manageable. I do have exercise-induced asthma and live at 5200 feet, I have had every lung and heart test that could possibly be relevant. Have not explored neurologist yet. I can tell that doctors are surprised at my sleep maladies when they look at me and talk to me, but I like having enough oxygen for my organs, and they do agree with that!