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[Diagnosis] Low Leak, High UAs, Flow Limit?
#11
RE: Low Leak, High UAs, Flow Limit?
Hi Sheepless

Re-reading my post in #4, I found it was pretty poorly worded, so sorry about that. But thanks for your reply, as it certainly does help me to know what experience you've had with this machine.

Thanks
Dream
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#12
RE: Low Leak, High UAs, Flow Limit?
Hi John

Certainly a bunch of things to try out there. Yes, following Bonjours suggestion yesterday I did use a different pillow, which will take a couple of days to get used to. After that take on the idea of the collar if the smaller pillow isn't helping. 

But thanks also for the ideas with the EPAP and PS. I'll make some adjustments accordingly and see how that goes. 

I'm picking up the full- face mask today, to once again try out. All my attempts so far with one have not worked. I really want to be able to use one, at least as a backup, if nasal congestion occurs down the way.

Cheers
Dream
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#13
RE: Low Leak, High UAs, Flow Limit?
Hi Dream, welcome to Apnea Board.  The UA events on your Aircurve 10 CS pacewave are of course apnea that are not responding ot the pressure support that we assume would resolve or mitigate a central apnea. So we can safely conclude the problem is obstructive. Part of the problem is that your are using a fixed ASV mode with EPAP at 4.0 cm.  If you machine allows for ASVauto mode, then you should definitely be using that with a range for EPAP between 5.0 and 15.0 (we know EPAP 4.0 does not work).  If you must use a fixed EPAP, then start titrating upward until those events respond to pressure support.  It's possible that this is positional apnea as suggesed by Bonjour, but I'm pretty sure that this is just a classic case of EPAP being too low to keep your airway patent.  Knowing more about your diagnosis and any titration would help here.  So it would not hurt to use a soft cervical collar to address potential positional obstruction, but I would like to see you on AutoASV mode with EPAP min 5-15 and PS 3-15.

I'll include the Resmed ASV titration guide here, but it is basically what I said to do.  You definitely need higher EPAP or EPAP min.



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Sleeprider
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#14
RE: Low Leak, High UAs, Flow Limit?
Hi Sleeprider

That's great, thanks, and it all makes sense so now looking forward to tonight to see if I can beat this full-face mask into submission. yes, I can set it to ASVAuto, and have done that once realising that the clinicians incorrectly set my machine up to ASV.

Two other questions I thought of when reading your post, and are related to my previous (failed) experience with the full-face mask are:

(1) The Titration guide also has a dot point about feeling claustrophobic under the 'ASV Auto Protocol' heading. I am not sure if that has the same meaning has a feeling of suffocating because not getting enough air during inhalation. But my experience with the full face mask was a feeling of having to effortfully inhale, which of course is pretty unhelpful when trying to relax and fall asleep. Is adjusting Min EPAP or Min PS the best way to tackle this issue?

(2) Do you know if an increasing problem with leaking occurs as the Min EPAP and/or Min PS is increased? If it does, does this come down to making sure the mask is as correctly fitted as possible, or is there some other tips for handling higher mask leaks as the EPAP and/or PS increases?

Regards
Dream
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#15
RE: Low Leak, High UAs, Flow Limit?
(03-10-2020, 12:38 PM)70sSanO Wrote: The "standard" Resmed ASV protocol is EPAP 5, PS 3-15.  That worked pretty good for me, but after a while I went to ASVAuto with a fairly tight range, 5-7, 6-8; 7-9 is where I am right now.  Regardless of where you set your EPAP, you need to max out the PS, to see what happens with your pressure.  On an ASV the max IPAP is 25, so if your EPAP is 5 your max PS will be 20.  On my EPAP 7-9 my PS max is 18.
This is very interesting. The idea of a self-titration study using a tight range with the Min and Max EPAP (I presume) seems to make sense if I can see where the EPAP pressure needs to be with airway patency. One of the problems I have experienced is with this vicious circle that many on this forum seem to have with using full-face masks and this so-called "chipmunk" experience they have with their mouth filling with air. This has also been my experience with full-face masks. 
Was this the reason you have found that a tight range for your Min/Max EPAP, while ensuring you maxed out the Max PS?
Also , what Min PS setting did you find worked?
I realise, of course, that everyone is different and there is no such thing as one size fits all with getting used to these machines. It's all a big jigsaw puzzle for me at the moment. But the picture seems to coming together slowly.
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#16
RE: Low Leak, High UAs, Flow Limit?
Hi Dream,

Q1: not getting enough air issue was addressed by self on my ASV via bumping up EPAP Min, stepping up 1 at a time until I had enough air, Alternative is you can bump up fractions of the whole step if you want (I needed a bigger bump than fractional), you may use whole steps to get in your ballpark then fine tune with fractional steps.

Q2: I've had to do mask fit and adjustments for a set of pressures, adjust pressures to get it dialed into my optimized settings and revisit mask adjusting, probably had to do this a few times until I had it right

Note that on the ASV and your Pacewave that EPAP Min represents the absolute lowest operational pressure it can deliver in any given condition.
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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#17
RE: Low Leak, High UAs, Flow Limit?
I didn’t do as well with a wider range EPAP and wider Pressure Support range. Not sure if that many variables pushes the limits on how well the machine responds.

And for me, by setting a slightly higher tight EPAP gap of 7-9 I got better results, especially with flow limitations. My EPAP usually stays in the 7’s, but I have had it in the low 8’s. I view it as “almost” fixed EPAP.

My Pressure Support (PS) of 2-12 covers all of my events with a buffer. I don’t max out my pressure like your charts show.

I’ve used a FFM since 2001. The only time I notice the chipmunk cheeks is when the ASV suddenly ramps up. I blow back at it and things calm down.

I wear a soft cervical collar and that seems to have helped with my mouth breathing. I don’t have leaks, so that is a big factor with a FFM. There is no way I’d wear a collar, chin strap, and mouth tape just to go to a nasal/pillows; unless I had to because of high leaks.

John
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#18
RE: Low Leak, High UAs, Flow Limit?
Hi John

Thanks for that reply. Once again helpful. I'm thinking of starting to experiment with tighter EPAP, as intuitively it seems it could help with the escalating vicious cycle of increasing pressures that actually do nothing to contribute to the therapy. I've been looking at my recent results using the P10 (nasal pillow) where leak tends to be taken out of the picture, and I can see a pattern where the EPAP pressure seems to effectively dealing with the OAs.

More recently (unlike the attached that is still a bit of a mystery to me) I was maxing out my PS pressure owing to this escalating cycle of increasing pressure that seems to occur for a number of reasons such as (leak > pressure increase > leading to increased leak > leading to pressure increase and ...) unless, as some have said, they manually intervene by switching off the machine to reset it, or something else akin to that.

Blowing back at the chipmunk cheeks - how is that achieved?

Also, I take it that you find using a soft cervical collar, much preferable to using a chin strap. Did it take long to get used to the collar.

I started looking into these, and one article I read said that long term use may cause problems like stiff neck muscles and the like. I take it also, that has not been your experience?

Regards
Dream
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#19
RE: Low Leak, High UAs, Flow Limit?
Blow back: typically the ASV/Pacewave may decide wrongly that you need a big blast of air while awake and mask on, or in the wake to sleep transition time. It will very likely wake you. If this happens, literally blow back through the mask to tell ASV/Pacewave to back off.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
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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#20
RE: Low Leak, High UAs, Flow Limit?
The thing about a cervical collar is that it is not intended to stop mouth breathing, but keeps your head from dropping on your chest (chin dropping). Once your chin gets there, it ain't coming back... until you are starved for oxygen, have a massive obstructive event, and have your sleep disrupted. As bonjour said there is no pressure setting that can overcome the weight of your head. I never had this problem until I lost a lot of weight. All of a sudden, I had 90 second obstructive events.

I'm probably not a good one to assess how easy it was to adjust to a cervical collar. I have been lucky enough to adapt pretty easily to the ins and outs of xPAP, so it was easy for me. I did find that it takes a bit of a technique to not make it to tight where you feel like you're being choked and too loose where your chin just falls inside of it.

John
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