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Help please with fine-tuning Resmed ASV pressures
#1
May I have advice again please? My fifth month with ASV and generally going very well but I continue to have some poor nights - with unrefreshing sleep but also reflected in the AHI. As with when I was using CPAP/APAP I seem to be sensitive to quite low AHIs - I tend to feel rested only after a night with an AHI below approx 1.0.

Last night, AHI 1.7, not feeling brilliant this morning. I have noticeable wheezing these last few weeks (but clinically 'mild' asthma) - very high pollen counts and, because of another illness, I cannot safely have any drug treatment for bronchoconstriction. I am doing my best to keep off my back. I haven't used a pulse oximeter for a while as I am no longer concerned about desaturations - using the ASV machine, no matter what the AHI has been my pO2 has always been excellent

The screen shot:

http://imgur.com/a/Dkq01

shows that I am reaching the max IPAP allowable by my machine (25, i.e. max EPAP plus max PS). I am also near to my tolerance limit of aerophagia.

My current settings are Auto-ASV, EPAP 11-15, PS 3-10.

Recently, the IPAP median has been 15-16, and IPAP 95% 18-21.

Should I change any of my settings to improve things? Maybe increase the Max (and Min?) EPAP to clear the remaining obstructive apnoeas and obstructive hyponoeas?

Thanks if you can help.


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#2
Hello, asjb. I'm still fairly new to xPAP use, so I'm not going to make any suggestions about your pressure settings.

I just wanted to ask if you usually experience worsened illness symptoms during spring pollen season.

If you do, does taking an antihistamine such as cetirizine help your symptoms any?

I know I tend to not take antihistamines during the spring unless I have allergic rhinitis, but I also have increased fatigue and diffuse muscle and joint pain during pollen season that can be helped some by daily use of antihistamines.

If that is something that works for you, it could be an alternative to increasing your ASV treatment pressure.
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#3
(04-23-2016, 07:14 AM)green wings Wrote: I just wanted to ask if you usually experience worsened illness symptoms during spring pollen season..............If you do, does taking an antihistamine such as cetirizine help your symptoms any?............If that is something that works for you, it could be an alternative to increasing your ASV treatment pressure.

Hello Green Wings,

Thanks for that - sorry, I didn't mention that I can't take any anti-histamines either. I have a genetic condition that affects the cell membrane of my skeletal muscle fibres and heart muscle causing intermittent muscle paralysis/weakness and crazy heart rhythms. A huge, huge, list of drugs is forbidden for me - either in principle or because I have had bad effects with them in the past. Anti-histamines are on that list. So I just have to adjust my machine pressures to compensate for the effects wretched pollens have on my nose, throat and lung-airways. And, yes, I too feel generally unwell during pollen season. Hate it.

I wake up saying "doesn't the garden look pretty with all that blossom", and two seconds later I start swearing gently! I have been unable to persuade my Better Half that a city apartment might be a better place to live...
................................................................................

My current pressures: Auto-ASV. EPAP 11-15. PS 3-10



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#4
(04-23-2016, 04:24 AM)Asjb Wrote: My current settings are Auto-ASV, EPAP 11-15, PS 3-10.

Recently, the IPAP median has been 15-16, and IPAP 95% 18-21.

Should I change any of my settings to improve things? Maybe increase the Max (and Min?) EPAP to clear the remaining obstructive apnoeas and obstructive hyponoeas?
If this data is typical, then increasing Max EPAP is not going to do a thing for you: You never hit max EPAP because there are not enough obstructive events clustered close enough together to warrant increasing EPAP all the way to 15cm

In the close-up snippet of data, for example, the two apneas occur within two minutes of each other (just barely), and the machine responds with a 1 or 2 cm increase in pressure as expected.

When the breathing becomes too shallow near the two scored Hs, we see the ASV part of the algorithm kicking in: Notice how the IPAP very high throughout this sequence of breaths and then drops back down as soon as normal sleep breathing resumes. The two Hs occur more than 2 minutes apart, so in the machine's view, they're not close enough to warrant an increase in EPAP.

Finally I want to make the following observations about the snippet of zoomed in data:

The whole cluster of 4 events in the zoomed in snippet of data has some earmarks of a short wake or semi-wake period following a possible arousal of some sort: Just before the first UA starts, there is a large inhalation that is NOT a recovery breath. That large inhalation might be evidence of a non-respiratory arousal.

At any rate, after an arousal or a mini-wake, the night time respiration pattern has to reestablished, and that sometimes includes a normal "post arousal central" that could be the UA, but your machine's ASV kicks in. There are several very large inhalations at the end of the UA. They could be "recovery breaths" or they could be a sign that the ASV kicking in caused you to wake up or arouse again.

At the end of the OA there are again some large inhalations. Again, they could be recovery breaths or they could be evidence that you still haven't gotten back to sleep ever since the beginning of the arousal that may have occurred before the first UA was scored.

After the end of the large inhalations following the OA and the 1cm increase in EPAP, there's some evidence that you may have fallen asleep very briefly: Although marked as the first of the two Hs, most of the breathing right after the large inhalations is not really that much shallower than your normal sleep breathing (as shown outside the cluster.) It is slower than your normal sleep breathing, however, and the size of large inhalations around the two apneas has likely reset the running baseline for inhalation size that is used to determine when the airflow into the lungs has dropped enough to warrant scoring a H. My guess is that the ASV has kicked in because of the combination in slowed respiration with the perceived drop in airflow.

The second H looks to be a real hypopnea: The airflow into your lungs has dropped from the previous level and appears (at this scale) to be a bit more ragged. The machine's ASV algorithm continues to force the high IPAP, and at the end of that second H, it appears that you arouse or wake up again for about 30 seconds. Possibly you've noticed the leak that started as you were trying to get back to sleep after the OA. At any rate, after the large inhalations after the end of the second H, two things happen: (1) The leak has been fixed and (2) you transition back into real sleep instead of getting stuck in "sleep-wake-junk."

In other words, this particular cluster of events might include 1-4 events that are not "real" in the sense of being scored on a PSG: If you were awake according to the EEG during parts of this time frame, one or more the events might have been considered "sleep transitional" and not have been scored.

And what might have caused a non-respiratory arousal/wake before that first UA was scored? Well, the timing is right for a normal post-rem wake. Many people with normal sleep briefly arouse or wake after most rem cycles, but they quickly establish nothing is "wrong" and nothing needs their attention, so they go back to sleep almost immediately. And because the post-rem wake lasted under 5 minutes, they don't remember it in the morning. But in this case, it looks like you had a post rem wake and in the immediate aftermath of that wake, the ASV algorithm kicked in and possibly it or the leak (or both) made a bit harder for you to quickly get back to a full sleep: Every time you started to drift off, you wound up becoming conscious of either the leak or the sharp change between IPAP and EPAP, which caused another arousal as evidenced by the sequences of large inhalations. Once you fixed the leak and established real sleep, the breathing looked great to the machine and the ASV quit using an IPAP that was 7-10cm above the EPAP.
Questions about SleepyHead?
See my Guide to SleepyHead
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#5
(04-23-2016, 07:48 AM)Asjb Wrote: Hello Green Wings,

Thanks for that - sorry, I didn't mention that I can't take any anti-histamines either. I have a genetic condition that affects the cell membrane of my skeletal muscle fibres and heart muscle causing intermittent muscle paralysis/weakness and crazy heart rhythms. A huge, huge, list of drugs is forbidden for me - either in principle or because I have had bad effects with them in the past. Anti-histamines are on that list.
Have you ever tried saline nasal sprays or a neti pot (or sinus rinse bottle) to help deal with the allergies? They are both non-drug ways of dealing with the nasal congestion from allergies or colds. They don't work for everybody, but for some folks, they work really well.
Questions about SleepyHead?
See my Guide to SleepyHead
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#6
(04-23-2016, 08:51 AM)robysue Wrote: In other words, this particular cluster of events might include 1-4 events that are not "real" in the sense of being scored on a PSG: If you were awake according to the EEG during parts of this time frame, one or more the events might have been considered "sleep transitional" and not have been scored.

Dear Robysue,

Thank you very much indeed for taking the time to give such a superb explanation. I have looked over my traces again and what you say makes so much sense. I hadn't previously thought of 'sleep/wake junk' as being a typical feature that could occur at any time during the night (particularly when I have not been aware that I had been woken up) but now you point it out then I realise of course why not?

Now though! I am slightly concerned that I may have been 'chasing' the correction of sleep/wake junk for weeks, even months, by increasing my pressures, particularly EPAP, and an implication of your explanation is that this might well have been unnecessary.

So, given my stats:
Recently, the IPAP median has been 15-16, and IPAP 95% 18-21 (and Sleepyhead pressure/time graph shows that each night I spend at least 10 minutes with an IPAP of 20-25). And the EPAP median usually at 12, range 11-13
- do you think that my current settings (Auto-ASV, EPAP 11-15, PS 3-10) are sensible, or would you recommend that I try reducing the EPAP?

I did have 'mixed' apnoea induced by CPAP/APAP but the centrals were never at an awful level. Perhaps, a thought, I don't need such a high PS either? Would that make sense?

I think that, mostly, I sleep well but I can imagine that I would sleep even better without these huge breath-by-breath machine pressure increases during the night - all of which are the result of my changing my pressure settings (I've not been given any advice from my sleep doctor about appropriate pressures - there don't seem to be a lot of domiciliary ASV machines around in France).

Thank you again - I am very grateful for your expertise.

with best wishes

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#7
(04-23-2016, 05:26 PM)Asjb Wrote: Recently, the IPAP median has been 15-16, and IPAP 95% 18-21 (and Sleepyhead pressure/time graph shows that each night I spend at least 10 minutes with an IPAP of 20-25). And the EPAP median usually at 12, range 11-13
- do you think that my current settings (Auto-ASV, EPAP 11-15, PS 3-10) are sensible, or would you recommend that I try reducing the EPAP?

I did have 'mixed' apnoea induced by CPAP/APAP but the centrals were never at an awful level. Perhaps, a thought, I don't need such a high PS either? Would that make sense?

I think that, mostly, I sleep well but I can imagine that I would sleep even better without these huge breath-by-breath machine pressure increases during the night - all of which are the result of my changing my pressure settings (I've not been given any advice from my sleep doctor about appropriate pressures - there don't seem to be a lot of domiciliary ASV machines around in France).

Sorry to all for bumping my post back up the list but does anyone have an opinion as to should I try reducing my pressures? - EPAPs and/or PS?

Be very grateful for any thoughts, thanks.
.......................................................................................

My current pressures: Auto-ESV EPAP 11-15 PS 3-10

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#8
Well, I'm kinda in the same boat with the max ps questions. I had dropped my max ps to the point where it created familiar daytime symptoms reflecting poor sleep. So I increased it quite a bit to give it full reign and back to zero AHI and I felt great. Now I'm lowering max ps a bit at a time. Maybe I'm playing around too much, but I like to know the limits and whether I can find greater comfort.

Should you do the same? I dunno, I wouldn't want anyone to feel a day of poor sleep because it sucks. I absolutely hate it.

No ideas on epap adjustments. I only adjust epap for oxygen levels, and this new 2015 S9 adapt seems to be gentler than the older ones and last nights O2 was just a tad lower than usual so I might up min epap a little. Min epap now is about 1.0 below the minimum pressure that cleaned up my obstructive apneas with an S9 autoset.

One other reason for the the experimenting with max ps is due to aerophagia which I thought was gone when the acid reflux subsided with treatment, but last night I thought for sure my stomach was taking in air but I didn't wake up all the way to confirm it. Another reason is some upper abdominal discomfort the gastroenterologist will be pursuing from both ends, but it took quite a bit of effort to get the good doctor to focus on where it hurts, like doc, you can't get all the way up here from that entrance. So after rejection, the doc is now better focused and will be be happy to make additional money through his doctor group that appears to own the medical center where the procedures will be performed. Maybe the high max ps was affecting the upper abdomen, but not likely, seems more like an ulcer in the small intestine.






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#9
Hi Asjb,

You are still having obstructive events, so I suggest not lowering Min EPAP.

Lowering Max PS would likely reduce air-swallowing and perhaps reduce arousals caused by high PS. But PS lower than 9 or 8 likely would not be able to handle central apneas as well.

Overall, for now I suggest lowering Max PS by 1, or at most by 2.

Eventually, I think you may also find that an increased Min EPAP also helps, by reducing the severity of your occasional obstructive events.

Take care,
--- Vaughn

(04-26-2016, 04:48 PM)Asjb Wrote:
(04-23-2016, 05:26 PM)Asjb Wrote: Recently, the IPAP median has been 15-16, and IPAP 95% 18-21 (and Sleepyhead pressure/time graph shows that each night I spend at least 10 minutes with an IPAP of 20-25). And the EPAP median usually at 12, range 11-13
- do you think that my current settings (Auto-ASV, EPAP 11-15, PS 3-10) are sensible, or would you recommend that I try reducing the EPAP?

I did have 'mixed' apnoea induced by CPAP/APAP but the centrals were never at an awful level. Perhaps, a thought, I don't need such a high PS either? Would that make sense?

I think that, mostly, I sleep well but I can imagine that I would sleep even better without these huge breath-by-breath machine pressure increases during the night - all of which are the result of my changing my pressure settings (I've not been given any advice from my sleep doctor about appropriate pressures - there don't seem to be a lot of domiciliary ASV machines around in France).

Sorry to all for bumping my post back up the list but does anyone have an opinion as to should I try reducing my pressures? - EPAPs and/or PS?

Be very grateful for any thoughts, thanks.
.......................................................................................

My current pressures: Auto-ESV EPAP 11-15 PS 3-10

Membership in the Advisory Member group should not be understood as in any way implying medical expertise or qualification for advising Sleep Apnea patients concerning their treatment. The Advisory Member group provides advice and suggestions to Apnea Board administrators and staff on matters concerning Apnea Board operation and administrative policies - not on matters concerning treatment for Sleep Apnea. I think it is now too late to change the name of the group but I think Voting Member group would perhaps have been a more descriptive name for the group.
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#10
(04-27-2016, 02:27 AM)vsheline Wrote: Hi Asjb,

Overall, for now I suggest lowering Max PS by 1, or at most by 2.

Eventually, I think you may also find that an increased Min EPAP also helps, by reducing the severity of your occasional obstructive events.

Take care,
--- Vaughn

Hello Vaughn - thanks very much for that.

Just changed to your suggestions (EPAP up 12-15, PS down 3-9) and will give it a week or two.

I sometimes think I should start at almost-zero pressures all over again and creep up each week until I find the sweet spot...

Also, as posted before, I find morning 'symptoms' difficult to interpret a the moment given we are in the 8th week now of the most awful pollen levels. Lovely!

Thanks again, best wishes,

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