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18 mths of apap: need help optimizing settings to feel better [ASV]
RE: 18 mths of apap: need help optimizing settings to feel better
thanks jaswilliams. still wondering about that ps 12cmw said to be necessary to trigger a breath.

average ipap is around 13.xx, max last night was 19.54. ipap max is 21 (12 + 9) so there's still room to move.

pressure support does not stay high very long, never has, I assumed by design. pressure support swings wildly as I think it's supposed to. often, I believe, in response to periodic leg movements. often, I assume, in response to ca and pb. when I had epap and ps set to allow the machine free rein to 25cmw it went up close to 25 for short periods and I had more ua and h at those high pressures than at current lower settings.

fragmentation is ongoing but improving slowly. still wake up guessing 25 times a night to roll over. 5 - 9 times a night wake enough to remove mask and shut machine down but working on keeping the awake time in the gaps to a minimum. nudging my sleep efficiency a hair over 85%. session times graph in overview tab: clearly visible consolidation and densification of sessions with asv vs apap. still believe perodic leg movements are the problem but haven't sought treatment for it yet beyond trying and quitting gabapentin for restless legs.
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RE: 18 mths of apap: need help optimizing settings to feel better
should not move in response to PLM, at least not directly. If your PLM is causing changes to your Minute Ventilation, then yes.

ASV Therapy "ResMed's ASV therapy targets the patient’s own recent Minute Ventilation (MV). It treats central sleep apnea and/or mixed apnea and periodic breathing by automatically adjusting the pressure support (PS) in a defined pressure range to maintain Minute Ventilation at the target."

 in ASVAuto mode "EPAP is automatically adjusted depending on three parameters: inspiratory flow limitation, snore, and obstructive apnea."
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RE: 18 mths of apap: need help optimizing settings to feel better
thanks for the response bonjour. sorry if I'm a bit thick. I do not understand what your 2nd 2 paragraphs are telling me. is this an answer to my question about Sleeprider's statement about 12cmw to trigger a breath?

regarding plm, of course it's not leg movement I see, it's my respiratory response. the movement triggers a sharp inhale, frequently preceded or succeeded by what looks like a snore but is actually a moan or groan of complaint about the movement and arousal. there are a fairly uniform number of breaths between these inhale spikes. it repeats for fairly long periods through the night.

this has been confirmed by my wife's observations and audio recordings correlated with the time of these patterns. I've posted screenshots of this in several threads on this forum.

edit: maybe the 2 paragraphs are about how the machine uses minute ventilation to vary pressure and you mention in relation to plm? if so, it's my sharp inhale in response to a leg movement that causes the spike in the waveform, not the machine. pressure support then catches up.
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RE: 18 mths of apap: need help optimizing settings to feel better
It's not the sharp inhale, it's the change in minute volume that changes PS.  Only if your PLM is altering Minute Volume will it impact your pressure support.

The ASV algorithm monitors your recent Minute Volume, and alters PS to keep you Minute Volume the same.  More PS increases the Minute Volume.  That is how it detects centrals and eliminates them.  The goal is to maintain constant breathing via a constant volume of air being exchanged.  This is determined on every breath.

"ASV Therapy "ResMed's ASV therapy targets the patient’s own recent Minute Ventilation (MV). It treats central sleep apnea and/or mixed apnea and periodic breathing by automatically adjusting the pressure support (PS) in a defined pressure range to maintain Minute Ventilation at the target."

The rule of thumb with ASV is to set the Max PS to as high a value as possible.  ResMed recommends a min of 15 for max PS.
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RE: 18 mths of apap: need help optimizing settings to feel better
Sheepless, the need for at least 12 cm PS is a "rule of thumb" I use when setting up a new user. The default PS suggested by Resmed and Respironics is 15 cm. I have found most people can get by with less than 15 cm and some people can indeed get therapeutic results with PS max as low a 8.0. So 12.0 is mostly a middle of the road number. The thread where that suggestion was posted was specific to Broomstick, who is making random, ill-advised changes to settings that in my opinion will compromise the effectiveness of his ASV. There is certainly room for fine-tuning his needs once he actually uses the machine and shows some data, but the short term goal in his case is to improve comfort enough to get him to actually use the machine. I think you know that a negative attitude is something the forum can't change, and that is the biggest obstacle to therapy for some.
Sleeprider
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RE: 18 mths of apap: need help optimizing settings to feel better
thanks for your informative replies.

bonjour, I'm going to have to study on your response to be sure I understand it. I'm not sure yet but we might be saying the same thing. my initial thoughts / questions are these:

doesn't a sharp inhale increase that minute's minute ventilation?

breaths may be affected by pressure but how do we account for the breath itself, i.e., as initiated by us, considered independently of the pressure? the flow rate tells us volume rather than pressure and it seems to me an increase in volume may be entirely a result of our respiratory effort and not necessarily a result of pressure support. that's consistent with my theory anyway, that the flow rate spike is a result of human triggered respiratory effort triggered by involuntary spontaneous leg movements. it certainly matches my wife's observations and the audio recordings. don't know if it'll work but I might try to replicate the pattern while awake to see how the machine and SH/Oscar render a sharp inhale.

Sleeprider, thanks for letting me know 12cmw to trigger a breath is a rule of thumb. if there's anything I've learned it's that every case can be different. meanwhile, I was curious how my ca and pb were being managed at ps max 9 if 12 was instead more like a machine spec than a generalization.

I learn something(s) with every visit to the AB!
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RE: 18 mths of apap: need help optimizing settings to feel better
rereading my post #121, I see that I said I thought pressure support was moving in response to plm as well as assumed ca and pb. ps does swing around what I believe are plm's but I think I should have said I see the sharp intake of breath in the flow rate not ps. I'm actually not clear on the relationship of ps to plm if any. as you say, bonjour, it's not a direct relationship. sorry if I confused things.
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RE: 18 mths of apap: need help optimizing settings to feel better
this is one of many examples from last night of the pattern I associate with periodic limb movements, corroborated by my wife's observations and audio recordings (not this one but many others like it).  I guess one could argue pressure support is pushing up flow rate spikes but I don't see a clear correlation there. plus, it's so uniform and more repetitive and long lasting than I'd expect from my ca and pb.  moreover, this pattern was evident during more than 1.5 years with apap which doesn't have pressure support.
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RE: 18 mths of apap: need help optimizing settings to feel better
copied from idlewire's how does asv deliver a breath thread.

ajack wrote:

Sleepless, I just noticed your pressure in you avatar.
EPAP: 7.6 - 12 PS: 3.2 - 9

This tech explains ASV adjustment and pressure well, You might consider raising your max ps, at the moment your machine is restricted.
pick it up at the 12 minute mark.
youtube Bilevel and ASV Titrations: Pressure Changes for Technologists and Patients.


ajack, thanks for noticing my settings and mentioning the video. I appreciate it. I had stumbled across the video before and I watched the asv part again when you mentioned in another thread not too long ago.

I think having open settings might work for some and I also think it's useful in the initial stages of titration. however, through a lot of trial and error I find my current settings better than an open max ps/ipap. I got more events when reaching 21 - 24+ cmw than I do with my current max of 21, which the machine hasn't reached at these settings. I'm not sure I can do much better than the last 48 days at my 'choked' settings with 0.23 ahi. also, when it did range up there I had more leaks and aerophagia, as one might expect.

in fact, lip leaks (with p10 nasal pillows and c-collar) seem to be on the rise even at these 'choked' settings. my 'baseline' leak used to be around 4, a bit higher at higher max pressures; now it's more like 10. I'm not aware of any mask leaks other than through the vents. everything I tried before cpap for snoring and apnea seemed to work for a bit and as my wife says my body / mind always seem to find a way to circumvent it and return to bad snoring and apnea behavior. I hope that's not what's happening now as the c-collar is the only thing I've found to help my lip leaks. I assume my 3 collars are just wearing / softening. in addition, I'd like to think there are times that I sleep more deeply than I used to as my fragmented sessions get longer, which unfortunately leads to supine lip leaks caused at times by palatal collapse. I try to sleep on either side most of the time.

we know what works for some may not work for others and for now I don't think opening up max will benefit me. but many thanks for pointing it out and please feel free to comment on / critique my case any time. as with so many things, the more I learn, the more I realize I still have so much more to learn.
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RE: 18 mths of apap: need help optimizing settings to feel better
Hard to say if it's PLMD, it looks like PB and the machine trying to fix it with what PS is available. If the chart also has minute vent, tidal volume and respiration will help. You don't need snore, FL, leaks etc now. Have you got more of the current charts. to look at good and bad.

If you are getting aerophagia with your current settings. I'd assume you wouldn't want higher anyway. PLMD can trigger stuff, and can lead to an arousal. If you really think it's plmd you will need it done in a lab. It really might be time to go back to the doctor, get checked out properly and then have a sleep study, if the copay is Ok.
mask fit http://www.apneaboard.com/wiki/index.php...ask_Primer
For auto-cpap, from machine data or software. You can set the min pressure 1 or 2cm below 95%. Or clinicians commonly use the maximum or 95% pressure for fixed pressure CPAP, this can also be used for min pressure.
https://aasm.org/resources/practiceparam...rating.pdf
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