ASV Titration Help Request

-SWS wrote:Ldj325, I'm wondering if you're happily working on your ASV titration via PM. I see you're posting to other threads but not this one.

ldj325 wrote: Please feel free to PM me any replies if that seems best.

Best of luck to you.

I'm back now after a little "vacation" from my problems. I appreciate each members posts. I have considered each and will respond soon. I have not been communicating via PM with others for the titration. I have learned a lot from other's posts and, as much as possible, I want to do this in a public way so that it can be a learning experience for all who are interested.

My attitude and emotions generally stay pretty positive, but I had an experience Saturday morning that sort of blew me out of the water as I considered the implications--and along with all the other things I'm dealing with. I'll post the information about this later. I just needed to step back, "catch my breath so to speak" and regain my composure. It was OK for me to look at other's posts, but I needed a break on my own.

Hello again ldj325. Good to hear from you!

Take all the break time you'd like! Great idea IMO... Talk later.

On the Resmed unit... set your EEP @ 8, min PS @ 3; Max PS @ 15 and let it roll. You cannot self titrate on an ASV as every night will be different due the Cheyene Syocks Respirations. The reason you have these CSR is a CO2 imbalance.

(This member posts from this thread have brought up a number of things. I can't address them all at once, but I have not forgotten the comments about the thyroid issue and the sleep surface or the suggestion about the ASV trial pressure.)

Upddate on my Average stats: Update Averages 5/21-9/6/2010 AHI 2.3, CA 1.6, OA 0.2, HI 0.4 Pressure Median 5.6, 95th 7.1, Max 8.2

As is evident by the OA of 0.2 my issue has predominantly been Central apneas. Then on 9/3 I had a long meditation session and the last 40 minutes it looks like I dropped off to sleep. Recently the S9 has shown that I haven't done well when in seated meditation which is why I tried on the back.

And I got this data which is what caused me to come unglued with frustration, especially since for many years meditation has been a place of renewal for me.

(Click on graphs to expand)



I have never before seen me have anything more than a smattering of OA. The few times I've slept on my back it typically looked like this:



It has taken me awhile to figure out why I would go from predominantly CA to such a run of OA. From the first week on the S9 I'd seen that I didn't do well on my back. So I have trained myself to sleep on my sides only, except in rare instances. So my average stats are largely based on sleeping on my sides. And with side sleeping I have consistently cut my autoset range down from 4-20 initially gradually to my current range of 4.4-9.

What I didn't realize this past Saturday is that I've never tried being on my back with the more narrow range. Which resulted in this:



So it looks to me like the S9 topped out in pressure but it wasn't enough to prevent the OA while on my back. At least knowing this makes it not seem so crazy to me. Does this line of reasoning seem plausible to you more experienced members?

Now that leads me to question if I'm like 2 people in terms of needed therapy. One is side sleeping where it seems like the 4.4-9 range on the S9 works pretty well. I know that the 4.4 is low, but I've looked extensively at my detailed pressure tracings at times when there are no events and I seem to be resting well. And I've seen that I spend a lot of time in the upper 4s and low 5s. This seems supported by the Median Pressure Average of 5.6. I also tried raising the lower end to 5.0 and I got aerophagia and didn't seem to do well. Similarly after my titration study I narrowed my range to 7-9 (since I was titrated for 8.0) but again I did not do well.

And with the Adapt SV even starting at 4.0 with a a minimum pressure support of 3 it provided a minimum on inspiration of 7.0--and again I seemed to be getting too much air. I am thinking that this is the case for side sleeping. And if that is the case then it doesn't seem like the Adapt SV can work for me--unless my my understanding of how the Adapt works or my reasoning is faulty. Can someone knowledgeable comment on this?

On the other hand, when sleeping on my back it seems that I need greater pressure and in that instance the Adapt SV was set too low in terms of EEP. This then brings into question the comment by the sleep tech after my titration study (which was primarily done on my back) who said they did not get me effectively titrated for the BiPAP autoSV (Respironics Omni-lab) as I kept going from the OA into CA.

Is there any ASV machine that could go low enough and not over aspirate me while on my side and still go higher for when I'm on my back?

elena88 wrote:Hi,
Im sorry I cant help you with the more complicated issues of your conditons, however I did note
that you have hip pain when sleeping on your side. My husband I both that..

Since we both had it, I knew it had to be our mattresses.. I had also suffered a sports injury to my hip years ago,
and it was aggravating that as well..

I did not want to buy new mattresses, as they can be extremely expensive..

I wanted something natural and soft, not the memory foam which gives me coughing fits and rashes..

So I bought natural latex bedtoppers for all our beds.. I spoke to the woman at the company when I bought these..
I decided on the four inch bed topper in natural latex because they are so soft, you can lie on your side all night long.
We have had them for a couple years now, and they are in as good of shape as when we bought them.
No more hip pain. These come in soft and firm.. I was sent a firm by mistake, and IT IS firm.. so if you like
a hard mattress, you might like that, if you like comfy get the soft.. I like the soft..

I know it can be important to sleep on your side if you have sleep apnea, so I thought I would pass this on to you.

here where I bought mine:

http://www.absolutecomfortonsale.com/latexfoam.htm

Elena, Thanks you for the link. The only reason I'm interested in back sleeping is that I'm getting a lot of sleep fragmentation due to pressure point pain awakening me. I have tried many sleep surfaces, from my top of the line Sealy mattress to sheep skins, to memory foam and I think a latex mattress. I've had various issues with each.

The latex I tried didn't seem to provide enough back support. The best, and it still isn't great is the alternating pressure medical mattress I am currently using. The true memory foam seemed promising as a sleep surface, but the out-gassing of chemicals almost drugged me. The topper I tried was not a true Tempurpedic. Does anyone know if Tempurpedics out gas any less than most of the other brands?

OC Sleeper and SWS. I have noted your mention of the thyroid issue. I am doing some reading and will get back about this.

OCSleeper and SWS,

I have done a bit of reading about hypothyroid and sleep apnea. I figured there could be a connection with OA and hypothyroid due to the issue of weight retention, but I was not aware of a possible connection with central apnea. And the reading I did seemed that sometimes there was and sometimes not. But is certainly something for me to check out.

I haven't done anything with the hypothyroid yet for the following reasons: 1. My primary hypothyroid is very mild. Since starting out with the chin strap and even more so since the S9 my daytime fatigue has very significantly improved and I never really had a lot of true daytime sleepiness. I think the hypothyroid is contributing to my weight retention but that is the primary symptom I can identify.

2. With my heart rate being so high and erratic, I have been cautious about anything like thyroid meds that could elevate the HR further. I have even held off on using more natural supplemental products like iodine supplementation that might help. (I did a 24 hr urine lab test which established iodine deficiency.)

3. I have a scientific background and recognize the wisdom in limiting my variables as much as possible. And I thought it would be best to hold off with the thyroid until after getting more settled with my sleep therapy.

OK, so those are my reasons, but I'm not attached with being right about this. Given the above do both/either of you feel I would be wise to start addressing the thyroid now for the SA?

Ldj325, I think if it were me I would first stay on top of the cardiac issues, including optimizing and trialing ASV treatment. However, IMO that should not be mutually exclusive with correctly treating hypothyroidism either. So my next objective, would be to hop right on that issue as well...

More later about your previous post with those evenly-distributed obstructive apneas...

-SWS wrote:Ldj325, I think if it were me I would first stay on top of the cardiac issues, including optimizing and trialing ASV treatment. However, IMO that should not be mutually exclusive with correctly treating hypothyroidism either. So my next objective, would be to hop right on that issue as well...

More later about your previous post with those evenly-distributed obstructive apneas...

Further cardiac treatment in in a holding pattern for right now with the next step being cardiac ablation (estimated that 2 would be needed), which at $50,000 a pop is not currently economically feasible.

ldj325 wrote:

-SWS wrote:Ldj325, I think if it were me I would first stay on top of the cardiac issues, including optimizing and trialing ASV treatment. However, IMO that should not be mutually exclusive with correctly treating hypothyroidism either. So my next objective, would be to hop right on that issue as well...

More later about your previous post with those evenly-distributed obstructive apneas...

Further cardiac treatment in in a holding pattern for right now with the next step being cardiac ablation (estimated that 2 would be needed), which at $50,000 a pop is not currently economically feasible.

Here's a controversial thread you might find interesting if not relevant:
viewtopic.php?f=1&t=40490&p=354195&hilit=india#p354195

-SWS wrote:

ldj325 wrote:

-SWS wrote:Ldj325, I think if it were me I would first stay on top of the cardiac issues, including optimizing and trialing ASV treatment. However, IMO that should not be mutually exclusive with correctly treating hypothyroidism either. So my next objective, would be to hop right on that issue as well...

More later about your previous post with those evenly-distributed obstructive apneas...

Further cardiac treatment in in a holding pattern for right now with the next step being cardiac ablation (estimated that 2 would be needed), which at $50,000 a pop is not currently economically feasible.

Here's a controversial thread you might find interesting if not relevant:
viewtopic.php?f=1&t=40490&p=354195&hilit=india#p354195

Thanks I have considered this as an alternative. And this may be the only way it could happen.

ldj325, I think one thing I can offer is to help you understand how an ASV unit (either Respironics or Resmed) differs from a CPAP or BiPAP unit.

In a nutshell, the ASV units can function during normal breathing as either a CPAP unit or BiPAP unit. So, they would be no different than your S9 unit. The BiPAP mode, of course, means you would have a slightly elevated inhalation pressure. The newer Respironics ASV unit also includes the ability to auto adjust the BiPAP pressure within a range.

So, what's the Adaptive Servo Ventilation (ASV) all about? Well, it's important to understand what happens when a central apnea occurs - or periodic breathing. In that event your body is not properly handling the CO2 in your body. Essentially, your body builds up too much CO2. It blows it off by increasing your respiration (frequency and volume). You essentially blow off so much CO2 (overshoot) that your body no longer sees the need to breathe and you cease breathing (undershoot). The CO2 builds up and away the cycle goes again. This is the overshoot / undershoot condition. Rather than having a happy medium, your body no longer can properly regulate breathing.

To break this cycle, the ASV unit detects the apnea event and increases pressure. This increase in pressure is WAY beyond the normal CPAP / BiPAP pressure. Why the increase? Essentially it attempts to sustain 90% of the normal air intake during the apnea. This helps oxygenate the blood and blow off SOME of the CO2. Though it is not a full ventilator, it does enough to help break the cycle. In fact, on my good nights I have no apneas (ZERO). On my bad nights it is still an issue, but it is no where near as bad as it was. And I'm certain without the ASV unit, I would not be around to tell you about this. It was a life saver for me.

And it's that high burst of pressure that seems to throw you for a loop. It took me several months to acclimate to it. But I had such severe problems with central sleep apnea that I can not sleep without it. So, I learned to trust the ASV unit. I learned that when it ramps up the pressure, I can just relax and continue to drift to sleep. But it's not an easy adjustment. You have to be determined to want to make it work.

To help provide more information, the following set of links might be helpful.

Rested Gal's Links on Central Apnea:
viewtopic.php?p=22702

The best documents for you would be:

Efficacy of Adaptive Servoventilation in Treatment of Complex and Central Sleep Apnea Syndromes
http://chestjournal.chestpubs.org/conte ... l.pdf+html

A Randomised Controlled Trial of Adaptive Ventilation for Cheyne-Stokes Breathing in Heart Failure
http://ajrccm.atsjournals.org/cgi/repri ... 2-1476OCv1

Adaptive Servo-Ventilation in Patients With Idiopathic Cheyne-Stokes Breathing
http://www.aasmnet.org/JCSM/Articles/020212.pdf

I hope all of this helps. Due to a previous engagement, I will be away for a bit. Know that I will be thinking about you and hoping that you are able to find something that works.

John,

Thank you for this. The articles were informative, especially the second one, but the best of it all was your concise explanation of the ASV. It sounds like you are busy and I appreciate you taking the time to answer.

Especially in my first trial of the Adapt SV where the pressure was lower I did fine with the use of the Adapt as it lulled me off to sleep better than anything else. So I wasn't aware of fighting the unit. But the next day (and progressively) something was not working well and I was going downhill.

In a post I am finishing up I'll update on my current trial of increasing the pressure as per GuestASV's suggestion.

After my recent trial I've pretty much given up the idea of sleeping on my back for the time being. That leads me to the next reason for my interest in the ASV units, and that is the increased left ventricular ejection fraction (LVEF) improvement reported for the ASV units. The one paper (I can't recall if it was #1 or #2) mentions this improvement, but also mentions that CPAP has also improved LVEF.

Do you (and I know you may not see this for awhile) or anyone know if the AHI is kept low, as I believe I can achieve with the S9, if this is responsible for the LVEF improvement? And/or does anyone know of any studies comparing LVEF improvement in CPAP vs ASV?

I wish you well and hopefully you will be having an enjoyable time with you engagement.

If you have primary Central Apnea...the S9 is not treating the Central's. The s9 cannot treat Central's. The only unit that can control centrals is the ASV units for reasons explained very well by John above. Not to be harsh, but forget about the s9 altogether and use the treatment that is correct for your condition. Yes your AHI is going to be low on the s9 because you have primary central apneas.

ldj325 wrote:... Do you (and I know you may not see this for awhile) or anyone know if the AHI is kept low, as I believe I can achieve with the S9, if this is responsible for the LVEF improvement? And/or does anyone know of any studies comparing LVEF improvement in CPAP vs ASV? ...

Unfortunately as ASV pointed out, the S9 will NOT address your periodic breathing or central apneas. Even the BiPAP S/T units do not do as well at either of those problems. The reason is that without the support during the central apnea, you will find yourself in the overshoot, undershoot cycle. This causes the periodic breathing and (from my limited reading) appears to lead to symptoms such as uncontrolled high blood pressure. It stresses your body and that is NOT what you need.

Though I understand the Resmed VPAP Adapt SV unit did not work well during your short test you need to give an ASV unit a longer try. As you note, you may need to tinker for a while to get the pressure settings correct. You can set the BiPAP portion of the ASV to emulate the S9. Then you set the upper level to 25 or 20. See how that does for a few days.

Here's hoping you get a handle on this. I understand the limitations of your situation. But you may need to find a sleep center that will do an ASV titration for gratis. Some do, when the patient can not afford it. In fact, that is something I actually look for when I choose a sleep center. Check around.