ASV users: the everything ASV thread.

[ameriken]

07/11/2011 Edit: I originally started this thread to ask about some specific issues I was having, and have learned that it seems that other ASV users are experiencing similar issues. It seems that these problems are quite unique to the ASV and may differ from the experiences of CPAP/BiPAP.

Since at this point we don't have our own forum, I thought I'd change this thread so all ASV users (there are only a few) can chime in and perhaps we can get this thing figured out. Please feel welcome to voice your problems, successes, thoughts, etc

AmerikenI

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So, after a few weeks on the ASV, I finally got my software and reader set up and got to take a look at whats been happening. My DME did download my info from 6/9 to 6/30 which is my first 3 weeks.

I don't have my original #'s from my sleep studies, but I can say that I was diagnosed with severe apnea with OSA, CSA, and periodic breathing, which is why the ASV was recommended.

Here are the averages from my first 22 days, June 9 through June 30:

Avg AHI: 8.59
Avg Hypopnea: 8.2
% of night in periodic breathing: 3.8%
Avg breath rate: 15.4
Avg % patient triggered breaths: 89.7%
Avg Pressure support: 6.5
90% EPAP: 7.2
% large leak: .1%

Machine settings:

Min EPAP 7.0
Max EPAP 18.0
Min PS 5.0
Max PS 18.0
Max Pressure 30.0
Rate= Auto

Obviously, my goal is to improve my numbers and an API of 8.5 puts me into the mild SA category, however there are nights when it was as high as 18 or 19. I am definitely feeling better than before I started therapy, but not as good as I expected.

Is there any way I can better these #s or is it just a matter of time? Or perhaps this is the best I can expect? Are there adjustments that can be made to bring this down? My compliance is excellent...I don’t have a problem with taking the mask off, rarely any leaks, and I sleep the entire night, every night, with the mask and machine on.

Can someone point me in the right direction?

Thank you! Ken

[Pugsy]

Could you post a single recent night detailed data report? It helps to see the individual graphs.

How to insert image/report


Open the image to full size so it is easily read.
I use Vista snipping tool to create a screen shot and crop the image at the same time.
Prt/scr key will also take a screen shot if using XP. If laptop is used sometimes the Fn key has to be pushed at the same time as the prt/scr key
I think windows 7 has the snipping tool.
Once the screen shot is created save it in jpg format.
Upload the image to a host site. I use Photobucket it is free, there are others.
Once the image is uploaded then copy the ENTIRE IMG address. Be sure to include the opening and closing IMG in brackets. Paste that copied address into a post here.
Use the preview button. If you can't see the image try again because if you can't see it we can't.

[ameriken]

Sure, I'll try and get that done soon. I should be able to post last nights report.

[HoseCrusher]

My suggestion is to accept where you are for now. Take some time to get used to everything, and watch your trends.

Many times an improvement is revealed by simply stepping back to review the whole picture.

[ameriken]

Well, I hope this works, not the cleanest copy. This is last nites report.

[ameriken]

[Pugsy]

Posting a clearer image per Ameriken request.
I would suggest adding ASV user or something like that to subject line to get the attention of other ASV users

[ameriken]

I would suggest adding ASV user or something like that to subject line to get the attention of other ASV users

Good idea, done

[mebeingme]

You are mainly having hypopneas. Take your flew off. Looks like it is currently set @ 3.

[ameriken]

You are mainly having hypopneas. Take your flew off. Looks like it is currently set @ 3.

Thanks, I think I know how I can shut if off...how does that affect breathing?

[StillAnotherGuess]

Thanks, I think I know how I can shut if off...how does that affect breathing?

Set Min EPAP 9. Leave everything else the same.

[BrianinTN]

Congratulations -- you've joined the ranks of another half dozen of us on the forums who are battling the exact same issue (residual hypopneas) with the exact same machine (Respironics BiPAP AutoSV Advanced). My first suggestion would be to enter "residual hypopneas" into the search field above and read the threads from the past few months having to do with me, Paper_Nanny, Bons, and JIMCHI, off the top of my head. I've seen you comment in Paper_Nanny's thread, so I know you're at least somewhat familiar with the goings-ons around here!

Warning: long post ahead. Before I begin, let me note four things:

1) Your average AHI isn't something you should consider to be too big of an issue. I have two sleep doctors, one with a pulmonary focus and one with a neurology focus. My average AHI is around yours, and like you, it consists almost entirely of hypopneas. Neither of my doctors is especially worried about it. Their primary concern has to do with the quality of sleep that I'm getting. For me, I feel less rested when using my ASV than not, so that's the bigger question that we are trying to unravel.
2) If you experiment with different settings, I would urge you to change only one thing at a time, and give things a bit of time so you can collect ample data. Looking back and forming a complete picture will be more complicated than you think. I've spent most of my adult life in the field of data analysis, and even I made elementary mistakes in my experimentation. Don't let impatience take you off the course.
3) I would also encourage you to write down each day in a journal the quality of your sleep from the previous night and how rested you felt after waking up. The numbers your machine spits out are important so long as you are feeling good. It is possible to find settings that achieve a low AHI while making you feel awful. Be sure to have a way to synch up what you write down with your nightly reports. Because the clock on your unit and your computer may have some disagreement, I've found it difficult to go back and figure out exactly which night is which.
4) If you are going to tinker, please keep your doctor in the loop. Only your doctor knows your complete medical history and situation. It's easy for people to suggest things here that are not good ideas given your medical background. It's also easy for people to suggest things that are simply silly or wrong. Running things by your doctor is quick, mostly painless, and a good check against bad advice.

Many of us have played whack-a-mole with this problem of residual hypopneas by adjusting our min EPAP and our min PS settings, our Flex settings, our BPM, our masks, and even our medications. Unfortunately, hypopneas can have multiple possible causes, and the various underlying causes have different "correct" courses of action. There is, simply put, not sufficient data in nightly reports for anyone here to tell you with certainty what is going on with your hypopneas. What we can suggest, though, is a framework by which you can evaluate the efficacy of different settings to determine what works best for you. I would focus your historical reading on JIMCHI's thread, especially starting with -SWS's comments beginning here: viewtopic.php?f=1&t=60687&st=0&sk=t&sd= ... 90#p572497. He does an excellent job of explaining some of the if-then scenarios in this post: viewtopic.php?f=1&t=60687&st=0&sk=t&sd= ... 05#p574405

Someone threw out the idea of starting with Flex. I'm skeptical this will ameliorate your problem, but because it is one of the few settings only our machine that is user-changeable without accessing the clinician's menu, it is not unreasonable to begin here. You asked how to change it. Hit the right arrow key on your machine, and the first thing it will bring up is your Flex setting. Hitting the up or down arrow will change the options. Hit the silence key when you're done to lock it in.

Turning off Flex entirely does require entering the clinician's menu. To do that, hold down the right arrow key and the silence key together for about four seconds. Your machine will beep twice, and you'll be in that mode -- where using the right arrow button takes you through the various parameters that can be set on your machine. One of those options is Flex, and here you can turn it to off. If you want to read about what Respironics is trying to do with Flex, check out the options here: http://flexfamily.respironics.com/

Let me turn last to EPAP and save any discussion of PS (pressure support) for another day. As you'll find in reading some of the old threads, hypopneas can be either obstructive or central in nature. If you experimentally increase EPAP and it reduces your hypopneas, it is suggestive to us that your hypopneas were obstructive. However, it is possible your current EPAP is even too high, and that your hypopneas are central in nature. Note how your minimum EPAP is set at 7, which means that no matter what, the ASV will never take your EPAP below 7. It can, however, raise your EPAP as needed in response to your breathing. However, note that your machine very rarely has increased your EPAP. What dies this tell us? There are three possibilities:
1) 7 may be the "right" minimum EPAP for you.
2) Your "right" minimum EPAP should be even lower, but we can't observe that because the ASV is unable to dip below 7.
3) Your "right" minimum EPAP ought to be even higher, but the ASV isn't quite figuring this out for a number of reasons.

If you are going to start playing with EPAP, I personally think starting with a lower setting has some merit. I'm biased here -- in my own experimentation, I initially went up, but a min EPAP of 4 is exactly where I should be. Putting my bias aside, though, it's entirely possible that you only need a higher EPAP during parts of the night. The point of an in-lab titration is to find optimal settings, and once you "stabilize" on them, they try to leave you there, and that becomes your prescription. Just because they stabilized you at 7 later in the night doesn't mean that, say an EPAP of 5 wasn't the right pressure for you earlier in the night. Two common reasons why people have different pressure requirements throughout the night are positional apnea (i.e., apneas that are more severe supine than when the patient is on his or her side) and REM sleep (which usually has more apneas). So if your min EPAP is set too high, you've tied one hand behind your back, so to speak. But again, let me emphasize that it's impossible for me (or anyone) here to tell you whether that's the case with the currently available data. This is merely one possibility.

OK, that's enough for one night.

[ameriken]

Brian, thanks for chiming in. Last night I actually was reading one of your other threads viewtopic.php?f=1&t=63954&st=0&sk=t&sd= ... me#p596599

I did notice there are just a few ASV users. Reading through some of these threads now explains why I feel somewhat better, but not great. I wish I could have had straight OSA, but as the VA tech told me "you have the whole shebang of breathing issues going on at one time". So I guess if the machine has me down to an average of 7 or 8, I guess that's quite an improvement, and I am grateful, but obviously I'd like to make it better. Last night both my AHI and hypopnea indexes were 3.0, which is great, but I don't feel like it.

I changed the flex to 0 (thank you), and the DME suggested the rise time to 6, which I did. I'll give this sometime before I do anything else, but as I said, my hypop index was 3 after those changes.

My sleep doctor is extremely difficult to reach so it will be next to impossible to run ideas by him. He in fact told me once "Don't ever leave me phone messages, I never check them" and whenever we talk it sounds like his goal is to say goodbye. He's just difficult to talk with. A very nice guy, but he's a VA doc and I think he is way overworked with far too many of us to deal with. I may have better luck trying to run ideas by the techs there.

I wonder if it's possible to get one pinned thread or a forum for ASV's? My guess is there will be many more users posting the same issue and I think it would be great if we could consolidate them all into one area.

Thanks again, it appears I've got some reading to do and if you have an other ideas, I'd love to hear them. I appreciate you (and everyone else as well) for sharing your ideas, knowledge and experience.

[BrianinTN]

That stinks about your doctor, but it sadly seems all too common. It's good that you have techs you can bounce stuff off of, though.

IMO, you should feel free to post data in your thread for as many nights as you like. The more you do, the more folks here will have sufficient data to spot trends or red flags.

I'm glad last night's numbers looked better, but I wish the subjective side of the equation improved along with it. I found some crazy settings (20/13) on my old BiPAP S/T that got my AHI consistently below 3, but I felt awful. Most nights I'm around 9/4 or 10/5 on my ASV, and while my numbers bounce around a little bit, they're OK and I don't feel totally wiped out. Long story short, AHI is a helpful tool, but not the be-all end-all.

In general you seem like you're on the right track and "doing it" better than I did when I started. Fingers crossed we get you feeling better soon!

[ameriken]

Thanks Brian, I really appreciate your help. And you're right, I look at the numbers and wonder why I don't feel as good as I might look on paper. I do notice 'patient triggered breaths having a lower %, could that be a problem in how I feel, or is that handled by the ASV responding with higher pressures?

Here are the last 3 nights, I hope these are readable:

July 5 - 6:



July 6 - 7:



July 7 - 8: