Daytime sleepiness one year into ASV

[petemsw]

I'm not having any more obstructive events, just some minor central apneas and hypopneas, typically 0-2 events per hour, most often 0 and very occasional excursions to 4 or 5. Yet I'm as sleepy during the day for the past year as I was using BiPap for the previous 5 years.

I've been taking opioid pain medication for the soft tissue pain of Fibromyalgia for 20 years, and in the past year have reduced the amount by more than half, from an MME of 490 down to 235. I also take Klonopin 1.0mg at bedtime for generalized anxiety disorder, been taking it since 1987. It lasts 24 hours and gave me a normal life. But I was taking twice the amount of opioids during the 5 years I was on BiPap and daytime sleepiness has not improved. No other medication changes. This is beyond the knowledge of my pulmanologist - I had to suggest ASV to him when BiPap wasn't doing the job. A typical recent day from OSCAR is attached. Any of the wonderful CPAP experts here have any ideas?

[SarcasticDave94]

According to the stats, the ASV is taking care of all things Apnea. In this screenshot anyway.

Is this a decent representative of your typical stats?

Does the ASV therapy feel fine to you?

I have to think the sleepiness/fatigue is caused by something else. Blood work and such been done? Anything found in that or other similar testing?

[sheepless]

that's an awesome looking chart & I agree your problem probably isn't related to apnea or asv. the only thing I can think of machine-wise is some of us (like me) are sensitive to asv pressure support changes. to test this you might try reducing max pressure support to 12. if ua (ca) increases enough to make you feel worse, go back to 15. if not, experiment with further reductions depending on how you feel. meanwhile, look for causes other than pap.

[staceyburke]

I know little about asv but on my bipap I find flow limitations cause me sleep problems. Your flow limits could be better. Maybe raising the lower ps would help that - I know it would help on my VAUTO.

[SarcasticDave94]

Changing PS Min is an option, but generally the ASV has one area it doesn't treat as well as others like the VAuto. That area is flow limits.

If you want to try a PS edit and if you want to see if the FL is the fatigue issue, consider the edit of PS Min to 4 and try it a night. Alternative is anything between 3-4 PS min. (These are what I call fractional pressure edits .2 .4 .6 .8) Only the one change if done. That way we know how much the change actually affected this.

[sheepless]

it only looks like a lot of flow limitations because of the 1.0's, a byproduct of asv's response to central apnea. petemsw had zero in the 95%tile - and 0.61 in the 99%tile - columns. while some people are sensitive to them, you don't often see better stats than that. that said, scroll through your flow rate at a 3 minute view scale looking for unflagged flow limitations. if you see a lot, raise min ps. nothing wrong with experimenting but imo this chart doesn't call for it. if you want more detail re setting the view scale and what flow limitations look like in the flow rate, just ask.

[petemsw]

Thank you sheepless, SarcasticDave94, and staceyburke. This was a typical night, representative of most nights. The only thing that changes is a tiny increase in centrals to 3 up to once every 10 days or so, and as high as 5 every 2 to 3 weeks. ASV is doing an amazing job compared to BiPap. 

I will try the two small adjustments you have suggested, one at a time for a week each, to see if I feel more well rested. Thank you!

[SarcasticDave94]

You're welcome. There should be some pattern reveal itself after a few days with an adjustment. If you see or feel changes, post the OSCAR and ask a question or state what's current.

[petemsw]

I was wrong - the occasional excursions in AHI appear to be hypopneas, not centrals. I've posted screen shots from two August nights where this happened. I don't know if this is relevant, but I did want to correct my earlier statement.

[SarcasticDave94]

OK copy. Sometimes Hypopnea can be a Central based, not always an Obstructive based event. If you wish to try, you could edit EPAP range slightly and see if things improve or not.

If you want, edit EPAP from 4-8 to 6-10 sliding the whole range up 2 clicks. Or if that doesn't work, add onto PS Min at plus 1.