I cannot fall asleep with my bipap/home ventilator. Hypoglossal nerve stimulator?

[SarcasticDave94]

You could buy CPAP if you want, but like I said if you want to try straight CPAP it's right there on the Astral. Don't worry about whether or not your failing compliance, you're going to at some point fail it anyway. Docs and insurance only care if you use the machine, not how it's setup.

As for settings on the ResMed AirCurve 10 ASV, there's humidity settings, heated hose if connected, therapy has Mode CPAP, ASV, ASV Auto. CPAP is straight pressure. ASV is single static EPAP and PS Min/Max, ASV Auto is EPAP Min/Max and PS Min/Max. IPAP is configured from EPAP and PS settings. There is no way to edit how the ASV delivers pressures other than the settings.

[Sleeprider]

Full disclosure, the ASV will identify a drop in minute vent and respond with higher pressure support. We can limit that response, and the ASV is faster to drop pressure support if you blow-back at it, but we need to meet it half-way. You need an attitude adjustment to the pressure support that entails recognizing that it is just a machine that is trying to maintain your respiratory volume and rate, specifically, the ASV determines your minute vent based on the tidal volume and respiration rate and will respond with pressure support when you fall below the target rate that was set in the previous 90 seconds. Here is the trick; before masking up your respiration has to settle back to normal. If you are breathing hard from finishing up in the bathroom or undressing, that high respiration rate is remembered as your "normal". Give yourself a moment to read or settle before masking, and it is less likely you will have dramatic drops in respiratory volume as you settle. People with central apnea often have clusters of events due to a disability to hand-off voluntary day time respiration to the autonomic sleep respiration. This is when the machine is likely to pop you with some breaths. You need to learn to control your reaction to that, because it is likely to be a common feature of all smart ventilators including ASV. The ASV will back-off faster if you blow back and show control of respiration, but it is going to be a challenge for your to experience this transition and not just pull off the mask.

[S. Manz]

Imagine trying to learn to drive, using a Ferrari for your driving lessons while driving on German Autobahns. It will take a lot longer to learn to drive that way, in comparison to learning to drive in a Prius and in an abandoned parking lot.
Having gone from a sleep study to a AVAPS machine and then straight to a full tilt ventilator, seems that way to me, so I think that you need to start slowing down and take one step at a time, step-1 being to start slowly and get oriented first. 

The Astral is doing what it is supposed to be doing, because you stop breathing. However since I am only versed with Resmed and DS ASV machines, I can tell you that the "three blasts" that wake you up are most likely because the machine has attempted to deliver breaths at much lower support pressures a while before the "blasts" alas it has failed to see a breathing feedback so it has increased pressure in subsequent attempts, only that higher pressure attempts tend to wake you up, instead of causing you to breath.. That is what my DS does anyway.
It seems to me that you have a very severe case of Central Apnea in which case Hypoglossal nerve stimulator option won't help you because that operation stimulates the wrong nerve for Central apnea, anyway. 
Central apnea is caused by missing signals through your  phrenic nerve that contract the diaphragm, thus expanding your lungs and creating inhalation.Transvenous phrenic nerve stimulation is therefore the correct operation for the permanent treatment of Central Apnea.

In regards to machine settings, you should be able to limit the pressure support maximum so as to not wake up with "blasts". In this case the machine should only raise the pressure to a lower and comfortable maximum level, when it successively raises the pressure in delivering breaths to compensate for your missing breaths and then keep repeating itself at that level until you start breathing again, without waking you up. Resmed Aircurve 10 ASV has a way of doing this while my DS algorithm delivers a more solid methodology (which is also a part of the reason why other respondents here are advising you to "blow into the machine, in case you end up with a Resmed ASV (or your current Resmed Astral) . 
Limiting support pressures is of course not great ASV therapy as you will not benefit from its full support spectrum, but what it will do is to help you adjust to using the machine and once you start having success with it, you can slowly raise max pressure support until you are at its full range. (amazing how our bodies can get used to repeated training. You as a retired "Occupational therapist should appreciate that fact".

I am assuming that a sophisticated Ventilator like the Astral can be set this way, given that much less expensive ASV equipment can do the same, so perhaps asking your clinician to limit the upper support pressures to a level that won't shock you out of sleep, may work at training your body to get used to therapy.

[Jay51]

Thank you very much Dave and Sleeprider and S. Manz for those detailed explanations.  They will help me in explaining to the RT, PCP, RN's etc. why I need to be transitioned to the ASV. I will always have in hand documented and always mention:  1.  central sleep apnea 2.  cheyne stokes respirations and 3.  the ASV.  I plan on trying to get a brochure on the ASV.
Last night was almost miraculous.  Didn't use the Astral at all or anything else.  Slept like a baby.  Woke up maybe 2 times.  Barely noticed the "buzzing."  It didn't even seem like buzzing, but just my heart beating (that I became aware of when I woke up).  If I stopped breathing when I went to sleep, then my body used some mechanism to breathe again because I am alive and writing this right now.  It seems much more comfortable to let this happen unconsicously rather than struggling consciously with a pap machine/vent.  I realize long term this is not the best route to take though.  I do need an attitude adjustment, and I am trying my best.  You have to believe me.  Each night now decision is this:  How much sleep can I afford to forefeit tonight using the Astral again?  Last night my answer was zero.  I have a pretty large sleep debt accumulated I guess from several years of untreated sleep apnea already.  Yeserday's 1 and 1/2 nap was total bliss for me also.  Fell asleep and didn't wake up once.  
I want to try supplemental oxygen at night only.  I think I can easily get it from PCP or RT.  I give you credit Sleeprider, you mentioned this idea in your 1st post I think).  Dave you mentioned about the same thing and S. Manz by using the AStral in straight cpap mode as a temporay, "bandaid" until I get the ASV.  I just have a hunch.  And I know myself pretty well.  I think the supplemental oxygen at night will be easily tolerated.  I think it will keep my o2 sats much higher at night.  I  may even stop or will limit the buzzing (a-fib).  I will probably wake up less.  This is my fear.  I will tempted at this point to stop and give up here and try to use it as my permanent solution because I will be sleeping better than I have in 4 years.  I will though press on to try to get my shot at using the ASV.  
I figured this out the first night, too.  Just for me personally with the sleep apnea, they recommended only going to sleep with the ST-A and AStral when I am very tired and possibly an hour later than I normally do.  This works just the opposite for me.  If I can somehow sleep all day (or lots of naps), then I will have more energy to try to use and get used to the pap machine at night.  Works s the opposite for me with central apnea.  Trust me here.  
I found out something also that may be helping a tiny bit from talking to the RT and doing some research.  CO2 accumlates in a bedroom as a person sleeps overnight in the air around the person - especially lower towards the floor and causes the compostion of the inhaled air to become more co2 concentrated and less o2 concentrated the longer the person sleeps and stays in the bedroom.  The effect is multiplied with multiple people sleeping in the same bedroom and all windows closed and the door closed.  Cracking a window (not feasible in winter), opening the door and using a small fan in the doorway can keep the air composition around the sleeping person (people) with a higher composition of o2 rather than a higher concentration of co2.  It seems to help some.  Also I think supplemental oxygen (100%) oxygen will be better than cpap air strictly because of the compostion.   Any pap air will need to be a little higher pressure than bottle o2 air to equal out.  Could be a tiny help to people not tolerating pap or unable to use pap for some short term reason (traveling, power outage, etc.).  
Big question I have now, too - can a home sleep study or overnight polysomnography study vary (and vary widely) from day to day?  or will it usually be the same?  I remember the day I took the home sleep study I uploaded here, I was very stressed out.  I laid in bed that night about 7 and 1/2 hours, but only got 3 and 1/2 recorded hours of sleep.  Do you think my results (and categories - severe obstructive sleep apnea and mild central sleep apnea with Cheyne Stokes breathing patterns at times) have been different (much different) with the seemingly increable sleep I got last night?  
Feel free to challenge me, nudge, be blunt with me, encourage me, whatever to not stop until I get the ASV and give it my best shot.  My plan is to try to post here at least once a day (usually more) to give me extra encouragment, education, and motivation to keep going.  I believe supplemental bottle o2 at night will be "pretty good."  I don't want to stop there because the ASV may be "very good."  I will start resting more during the day when I get the ASV so I can use it more at nights to try to get sued it also.  I think once I am able to at least fall asleep with the ASV, I will be sold on it for life as my permanent sustainable solution to my unique blend of severe obstructive sleep apnea and mild central sleep apnea with Cheyne Stokes respirations.  Thank you very mucdh.

[Jay51]

I forgot this Sleeprider.  Sorry.  I have a nightly routine where I unwind starting a few hours before bedtime.  Destress.  Lights dimming to very low.  Withdrawl from electronics.  I am very ready to go to sleep each night when I lay my head on the pillow (and put on the mask").  I think my respirations and BP and everything else should be as good as possible before I "put on the mask."  I don't think I have ever gone directly from an aroused state (higher heart rate, just doing some physical activity, etc) imediately to putting on the mask and trying to fall asleep.  I did not know how Astral and ST-A (and ASV) calculate my rates.  I know now.  I now know that I need to be completely relaxed before I put on the mask so as not to skew the rate the machine will calculate and provide for me. 
I think I have had to get into this routine out of necessity (instictively) in order to get any sleep at all at night because of my unique and advanced sleep apnea condition.

[Jay51]

I am going to start doing research on the Transvenous phrenic nerve stimulation.  Thank you S. Manz.

[Sleeprider]

To get the most complete information on the Resmed Aircurve 10 ASV, request the clinical manual from the forum. https://www.apneaboard.com/adjust-cpap-p...manual#ASK The manual is very detailed and will help you fully understand the application and function of the ASV.

[Jay51]

Thank you for the information about how to obtain the ASV manual Sleeprider.  
S. Manz - you have both central sleep apnea and have personally used the ASV and DS algorithm.  It sounds like you like the DS better.  Correct?  
Sleeprider and Dave, I know you both have been moderators here for 7 years.  You are both steering me towards the ASV.  You have probably heard both the good and bad about both the ASV and DS algorithm.  ASV better?  Insurance and Docs like it better?  Better results for centrals.  If I can get 2 manuals I guess the 2nd one I will try to get is the DS algorithm.  Which specific one is that?  Thanks.  
I am assuming that the RT has my upper support max set as low as possible.  I texted her on Monday again, and surely she would know from the "3 blasts explanation" that this means the upper support maximum.  Correct?  
I am going to try to get my overnight sleep study and 2nd home sleep study results and post them here.   Should give the most accurate diagnosis for me. Is there any way to get any diagnostic data from the AStral?  
The reason I am reluctant to try to set the Astral to cpap mode is because of all the alarms.  When I looked at the online manual, it has about 25 different alarms.  But each alarm can have several subheadings.  Means possibly around 100 or so different things could set off an alarm.  I am really afraid if I try to do this it will trigger multiple new alarms on the Astral.  A new alarm went off the other night I was trying to sleep with the AStral, too.  I'm afraid if this happens I am going to have to call the RT to come bail me out and reset the machine.  This AStral can be a life support vent for a homebound patient I think. Very sophisticated. When I had the ST-A not one time did any alarm go off.  Not intimidating to me at all.   Simple to set probably.  I would have tried to set ST-A to cpap mode if I still had it.  
"Blow back at it" - Thank you for this Sleeprider, Dave, S. Manz.  I understand the concept but how specifically is that defined? One forceful inhalation breath by me? A voluntary inhalatin and exhalation?  Several cycles?  Am I going to have to find out by trial and error what will cause the AStral to back off after it tries to pop me?  
My new job now becomes learning to blow back at the machine in order to fall asleep.  (Oh, Sleeprider, I usually use the bathroom and brush my teeth right before I lay down in bed put the mask on and turn on the Astral.  When I lay down now though, I will put the mask on, but not turn on the machine for a few minutes as I relax and slow my breathing even more.  Just as I am feeling like I am about to fall asleep, I will turn the Astral on so it will calculate my rate from here.  If it tries to pop me before I fall asleep, I will try to blow back as soon as I feel it try to pop me.  If I can fall asleep, then I am unconsious, and hopefully the next pop won't wake me.  If it does I can maybe try it one more time (to blow back when it tries to pop me so I can fall asleep again.)
I may have something wrong in my thinking here too.  It seems like everyone is making a bid deal about my central issues.  Since the home study I uploaded said I have severe obstructive and mild central, I thought the bulk of the problem would simply be keeping my airway open from obstruction.  S. Manz, do you have Cheyne Stokes respirations, too?  Correct my thinking for me here please if I am wrong.  When the ST-A would pop me with the higher pressure settings than the Astral currently has, the 1st part of the pop would go into my stomach.  I could both hear and feel it.  Wouldn't this mean that I was just about 100% obstructed for this to happen?  Or can air go into my stomach even if my airway is open?  My min epap was 8 on the ST-A (the "airsplint" function of keeping my airway open at all times.)   Why was the aerophagia happening?   Thank you again.

[Sleeprider]

Jay, the majority of people treating central and complex apnea do better with the Resmed ASV. S. Manz is entitled to his opinions, and seems to be treating other respiratory issues that benefit from the manually set backup rate and somewhat lower response of the Philips BiPAP SV. In fact I think he covets your ST-A. I have seen or heard nothing that suggests you have more complicated respiratory problems, or that ST, ST-A or Trilogy NIV was ever warranted in your case. You just kind of blew-by the obvious solution.

We have coached individuals with aerophagia that needed ASV and normally find a good compromise between pressure support and the threshold pressure that causes air to go to the stomach. The lower esophageal sphincter acts like a gate to pressure in the airway, preventing it from entering the stomach. Think of it like a gate that closes with a spring. The spring is stronger on some people than others. We just need to figure out where yours opens or remains closed.

[SarcasticDave94]

I have used the ResMed AirCurve 10 ASV from late summer 2017 for almost exactly 2 years in 2019. Therapy was excellent with 4 pressure settings and a Mode setting. The synchronization between ASV and my breathing got off track in July '19 with a bout of pneumonia, and a month later with bronchitis. My COPD got incrementally worse then too.

My diagnostic sleep study in early '17 showed 124 CA to 24 OA, N/A on the Hypopnea events. The ASV in 2 nights of my self Titration at home got me to AHI 3 ish I think (definite sub 5 AHI) on the report tool prior to OSCAR. I would frequently have sub 2 AHI. It's not at all a difficult PAP. Yes it'll feel different but the learning curve is cake compared to the Astral.

Blowback is literally blowing back through your mask, moderate single blow to tell ASV to back off. It will period. This blowback is an exhale.

I've not used the Philips Respironics DreamStation SV Auto, a similar machine to the ResMed. Philips includes a breath timing set that ResMed didn't include in ASV. It's to help with synchronizing breaths but I wasn't interested in a parallel change. My RT said I needed either Philips Trilogy or ResMed Astral. I did borrow a ResMed AirCurve 10 ST-A and it was fine for my needs.

That's my background on my self. I've had to fight and self advocate for every little thing PAP wise. For now, I'm hung out to dry. I'm making progress towards ST-A or Astral.

For you however, ASV will be correct in all we've discussed as evidence. It's the Goldilocks level of therapy for you. Make them allow you to try it somehow, you'll never look back.