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[Diagnosis] Experimenting with CPAP titration for my wife
#1
Experimenting with CPAP titration for my wife
Hi Sleepyheads,

I was diagnosed with OSA in July of this year and started treatment shortly after with a AirCurve 10 ASV. The machine was given to me by a former DME provider who set it to CPAP only mode and a fixed pressure to bypass the unnecessary ASV features. I've had a rough few months with it and finally decided to get a AutoSet 10 For Her. The EPR/Flex feature makes breathing feel much better already. I just need to find a way to get passed the insomnia issues I'm having. Running on 3-5 hours of sleep is rough. 

That's not why I'm looking for your help today, however. I'm seeking your experience and guidance to help my wife get her life back on track. My wife is always tired, regardless of getting >12 hours of sleep every night and taking naps throughout the week so I'm starting to suspect that she could have sleep apnea. I'm still tired too but we're in our mid 20s and shouldn't have such little energy to do things.

Our budget is tight right now because of my sleep studies and having to buy the equipment out of pocket so I thought I could at least experiment with CPAP titration on her before trading in the ASV machine. I had her take a nice, long nap with my AutoSet 10 to see how she responds with it set in auto mode (min. 6 max. 20) and to find a starting pressure. She said it was comfortable and felt that it helped her breathing. Oscar had her pressure between 7-8 so I had her sleep last night with my original machine set at a fixed 7.4 and it was good enough for her to sleep 14 hours!

Would you kind folks be willing to review the attached chart and provide feedback/suggestions? We'd greatly appreciate it!

Thank you!


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#2
RE: Experimenting with CPAP titration for my wife
Part of the problem with the Aircurve 10 ASV is that it does not determine apnea type, but is designed to primarily treat any apnea with pressure support to cause a breath. So we have a lot of UA.  The respiratory statistics all look normal and AHI is in a good range at 1.6 events per hour.  Leaks are minimal.  

I think you might try using some EPR and see if she finds that comfortable, or if it increases or decreases events.  If we assume the UA events are obstructive, then that suggests a need for higher pressure. At a minimum, be sure to offset any use of EPR with an equal pressure increase.  It appears that she will benefit from using CPAP and it would make sense to try to leverage the purchase of an Airsense 10 Autoset or even Aircurve 10 Vauto.  If your ASV is low-hours, Supplier #2 will often do an exchange, and may throw in some money.  There is a lot of demand for ASV from individuals that really need it, so they are always looking. Note you may not use your Apnea Board account to facilitate a sale on the forum.  

I'd like to see if these good results continue or improve with a setting of 8.0 with EPR 1, and perhaps move to 9.0 with EPR 2.  For fixed CPAP, you would want to use the 95% pressure form the Autoset, not the average.

Edit to add: The ASV does not have EPR in its CPAP mode. Please disregard all suggestions referring to that feature.  It would be great if you could let her try it on your machine, but AFAIK the ASV won't do this.
Sleeprider
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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#3
RE: Experimenting with CPAP titration for my wife
just out of curiosity, until they get an autoset, can they use the asv at epap 7 and ps 1? where necessary, make min and max equal to achieve this setting?
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#4
RE: Experimenting with CPAP titration for my wife
I think in order to activate PS, mode ASV or ASV Auto would need to be active. When JesseLee tried an ASV while not needing it, he stated it wasn't giving him good results. It may be best to try the trade like Sleeprider had suggested. I do see your point, but I'm not sure the results would be really good.
Dave

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INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#5
RE: Experimenting with CPAP titration for my wife
(10-17-2019, 01:33 PM)walkingdead Wrote: Hi Sleepyheads,

That's not why I'm looking for your help today, however. I'm seeking your experience and guidance to help my wife get her life back on track. My wife is always tired, regardless of getting >12 hours of sleep every night and taking naps throughout the week so I'm starting to suspect that she could have sleep apnea. I'm still tired too but we're in our mid 20s and shouldn't have such little energy to do things.

Would you kind folks be willing to review the attached chart and provide feedback/suggestions? We'd greatly appreciate it!

Hello Walking Dead, 
 
We are of course just participants and not medical staff so of course must strongly encourage your wife to connect with a Doctor as her primary path forward to sort things out and nothing else should take place until she starts that engagement with her Doc.   
 
I saw you both in your mid 20s.  You did not mention if have not been diagnosed with any medical conditions.    Note: ASV therapy is contraindicated in patients with chronic, symptomatic heart failure (NYHA 2-4) with reduced left ventricular ejection fraction (LVEF ≤ 45%) and moderate to severe predominant central sleep apnea. And her Doctor might have other reasons for wanted to avoid this approach. 
 
After that is all cleared ..   Of course we have to recommend following the vendor recommended path to titration and posting the results here for coaching along the way.  ResMed's titration plan starts with Titrating for Basic CPAP, then if needed BiLevel and then if needed ASV or other more specialized machine.    With the ASV machine in hand one can methodically just follow the ResMed Titration process for CPAP, but if CPAP fails you would need to skip the second "BiPAP" phase and go directly to the ResMed ASV Titration process, links below.       
 
Just as in a sleep lab, to improve home use safety a little bit I personally encourage all users to wear all night a pulse-oximeter with an Alarm set to notify and awaken the user if SpO2 drops below 90%.  I believe this is even more strongly needed when assessing new settings.
 
I recommend both you and your wife read the full WIKI page titled Optimizing Therapy before you begin.  Links to some of the areas you might want to return to frequently are listed below.   
 
If you do not yet have the ResMed ASV Clinical Guide  - Get the Clinician Setup Manual for your CPAP here
 
 
From the ApneaBoard WIKI Optimizing Therapy Table of Contents
       
 
CPAP titration
CPAP is an effective treatment for moderate to severe obstructive sleep apnea with fixed pressure.
  1. Set your initial pressure, protocols call for values from 4 to 6 or 2-3 cmH2O below your current settings then
  2. Increase CPAP ≥1 cm H2O every ≥5 mins for obstructive apneas, hypopneas, RERAs and at least 3 min of loud or unambiguous snoring
  3. Is the patient having obstructive events? If yes, repeat step 2
Obviously we cannot make an evaluation every 5 minutes while we are sleeping so we perform our evaluations in nightly cycles.
Note: By protocol, Titration of 15 cmH2O or greater is justification to go to a BiPAP / BiLevel machine.
   
 
ASV bilevel device for central breathing disorders such as Cheyne-Stokes respiration, central sleep apnea, or obstructive events.
The Typical Path to ASV
  1. Try CPAP and Fail
  2. Try BiPAP/BiLevel and Fail
  3. Assess if you should be considered for ASV
  4. Titrate for ASV
 
"The ASV titration protocol ... starts new users on ASVauto mode at 4.0 min to 15 max EPAP, and PS 3.0 minimum to 15 maximum.    
 That is a good starting place, but many users find the pressure can become too much. Most find a PS max of 12 is sufficient to cause breathing during centrals and hypopnea, and can fine-tune EPAP based on the first few days of experience. Many new users start with EPAP min 5.0 if they know they need the airway support against obstructive apnea."
   
 
 
-----------------------------------------------------------------  

 
Last Thought:  You seem to have already covered some titration ground with her and the ASV does not have EPR to adjust so the ASV does not make for the most capable CPAP to titrate with or use.   Not sure I would recommend the ASV in that mode to anyone. 

Given the weakness of the ASV in CPAP mode and that you have already seen how she responds to pressure adjustments using the Autoset is there a reason you prefer to start a titration with the ASV in CPAP mode rather than titrate her with the ASV set to ASVAuto mode, maybe following the protocol above with the addition of starting by not limiting the MAX of EPAP and limiting PS to only 3-4 cmH2O above each current PS Min setting so the ASV behaves a "~little" more like a VAuto?     

Maybe something like a starting tritation setting of:
Min EPAP 4cm H2O
Max EPAP 15cm H2O
Min PS  3cm H2O
Max PS 4cm H20    

I would expect this configuration to technically start at a total pressure (IPAP) 7cm H20 just like in the ResMed ASV Titration guide but most likely very quickly PS would rise to 4 and be effectively 8cm H2O total pressure (IPAP) with an PS 4 so might behave from that point close to Autoset with EPR set to 4 (if that was possible) and might behave like a BiPAP with the starting titration configuration recommended in the ResMed Titration guide of IPAP=8, EPAP=4.     

Would be good to post the OSCAR report of her nap with the Autoset for Her. 
 
WillSleep

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#6
RE: Experimenting with CPAP titration for my wife
I think the ASV CPAP mode does not have the EPR feature, which is a key feature of CPAP mode in all other models. The problem with using ASV or ASVauto mode is that PS max must be set from 5 to 20 cm, so it is not possible to zero the pressure support. The ASV acts like an ASV and will supply pressure support when it detects a drop in minute vent rate.

Here is a summary of JesseLee's experience on the ASV machine, and why he eventually traded it to Supplier #2 for an Aircurve 10 Vauto. http://www.apneaboard.com/forums/Thread-...#pid249489
Sleeprider
Apnea Board Moderator
www.ApneaBoard.com

____________________________________________
Download OSCAR Software
Soft Cervical Collar
Optimizing Therapy
Organize your OSCAR Charts
Attaching Files
Mask Primer
How To Deal With Equipment Supplier


INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#7
RE: Experimenting with CPAP titration for my wife
Thanks Sleeprider.  

I went and checked on my ASV and what you posted looks to still be true.  

So that does change things a little.   The OP has maybe then three choices with the current ASV. Again this is not medical advice.      

1. Try the ASV in CPAP mode just slowly titrating Pressure (maybe down at .2 to .4cm increments to see at what pressure the UAs go away and OAs do not yet appear).  The value being to define a perscription settings for use with a better CPAP or Autoset. 

2. Try the ASV for titration with his wife using the settings posted below.   This is not the start from the simplest and build to more complex therapy Medicare and ResMed propose.  Some valuable learning might come from using the ASV this way with the lower risk minimum settings mentioned below.  Somebody out there might even find a configuration close to this valuable (but PS might be too constrained for CSA).   

3. Switch himself to the ASV (based on what he already knows about his therapy needs and what is posted for starting ASV minimum PS settings below) and use Autoset 10 to titrate his wife with access to the Autoset's CPAP, autoCPAP and EPR.  
 
If using the ASV maybe something like a starting tritation setting of:

Min EPAP 5cm H2O
Max EPAP 15cm H2O
Min PS  0.0cm H2O
Max PS 5.0cm H20    

On the ASV I would expect this configuration to technically start at a total pressure (IPAP) 5cm H20 but most likely very quickly PS would rise between 1-5cm and I would expect 80-100% of rising movement to be in PS until PS rises to 5.    

When total pressure (IPAP) is UNDER 10-12 I would NOT expect the ASV to function  close to Autoset or VAuto
When total pressure (IPAP) is OVER under 10-12 the ASV might function like a VAuto with PS set to 5.0 while rising, but PS is more likely to fall faster than EPAP.  

To be sure you are starting with a comfort setting like EPR = 2 you would need to set Min PS = 2.0, Max PS = 7.0.  However I would first check to see if for this user PS already naturally hovers above zero so the lower starting setting above can be used Min=0, Max=5.  

AND .. there is the reality that ASV may not at all be a tool that helps you with this process.   

WillSleep

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#8
RE: Experimenting with CPAP titration for my wife
Great information everyone, thank you! It sounds like a CPAP machine could be beneficial for her. I know a sleep study would be the preferred choice in this situation but buying a new AutoSet 10 For Her would be half the cost of the studies in my area. Plus, trading in the ASV machine would cover the cost so it wouldn't be anything out of pocket for us.

Just to clarify, the mode on the ASV machine has always been set to CPAP only which does limit it to a fixed pressure and also removes the EPR option. I've never tried to use ASV mode and I have no intentions to. I started having some very concerning issues the last few weeks with that machine, notably tightness in my chest and shortness of breath throughout the day. I'm starting to realize that I probably shouldn't put my wife through any more testing with that machine either.

I'll post a chart of her nap with my new machine shortly.
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#9
RE: Experimenting with CPAP titration for my wife
thanks for that reminder Sleeprider. I'd forgotten about that. I agree that your suggestion of moving to a cpap/apap is better.

meanwhile, I understand there are algorithm differences; just looking to see if there's an interim quasi solution since it can take hundreds of dollars, some time and possible hoops to get another machine. also, I'm asking about ps 1 (not 0), to have a similar setting to cpap 8 with epr 1, so you'd be in asv mode with epap 7, min ps 1 max ps 5, and ps would only go up to 5 if 'needed'. mine rarely stays at the upward reaches of max ps for more than a few seconds but of course max 5 may still be too much; this idea may not be ideal and may not be good at all, but no harm in trying in the interim? worst case is it's intolerable and like Jesse, quit using it. just a thought.

edit: I posted after walkingdead so I guess it's moot anyway. I am curious though.
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#10
RE: Experimenting with CPAP titration for my wife
(10-17-2019, 05:26 PM)walkingdead Wrote: Great information everyone, thank you!  I know a sleep study would be the preferred choice in this situation but buying a new AutoSet 10 For Her would be half the cost of the studies in my area. Plus, trading in the ASV machine would cover the cost so it wouldn't be anything out of pocket for us.
...

I'll post a chart of her nap with my new machine shortly.




Sounds like a plan.

And there is good news. If she slept 14 hours her first night with a CPAP set to 7.4 cmH2O with no comfort settings (e.g. EPR) enabled she has already demonstrated ability to adopt and take advantage of the xPAP therapy.  

A good chunk of the first battle is already won.      

WillSleep

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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