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New to ASV, new to SleepyHead
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tmoody Offline

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Post: #31
RE: New to ASV, new to SleepyHead
Note: I finally got a copy of my ASV titration study. For the curious, it's attached.


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04-08-2016 08:53 AM
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richb Online

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Post: #32
RE: New to ASV, new to SleepyHead
(04-08-2016 08:53 AM)tmoody Wrote:  Note: I finally got a copy of my ASV titration study. For the curious, it's attached.

I just read through your report. One thing that stands out is that the machine used during the titration had a pressure support max of 15. Is your machine set this way. The reason I ask is that while your sleep study focused on Epap settings the Ipap was probably most helpful in stimulating you to breathe. I suggest you download the clinicians manual if you have not already done so. Check your settings for pressure support and report back. One other thing is that the nasal pillows might not be good enough under higher pressures when the machine is working hard.

Rich
04-08-2016 09:59 AM
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tmoody Offline

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Machine: PR System 1 BPAP AutoSV
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Post: #33
RE: New to ASV, new to SleepyHead
(04-08-2016 09:59 AM)richb Wrote:  I just read through your report. One thing that stands out is that the machine used during the titration had a pressure support max of 15. Is your machine set this way.

Yes. PSmax is set to 15. IPAP max is 25, though. EPAP max is 23.

Quote: The reason I ask is that while your sleep study focused on Epap settings the Ipap was probably most helpful in stimulating you to breathe. I suggest you download the clinicians manual if you have not already done so. Check your settings for pressure support and report back. One other thing is that the nasal pillows might not be good enough under higher pressures when the machine is working hard.

Edit: It's interesting that the study report recommendations don't mention IPAP pressure at all.

Rich

I hear you. It's interesting that they chose the nasal pillows for the study (and for the prior diagnostic study); I had never even heard of them before. I used a nasal mask for nine years on CPAP. I have to say, though, that I really like the nasal pillows. I'll only go back to mask if it becomes clear that I have to. Last night I had those leaks, but I'm pretty sure that had to do with the pillow.

The only problem I sometimes have is a little aerophagia when the machine is really pushing hard, but that's not going to be any different with a mask. Same thing goes for the occasional mouth breath.

Or is there some other sense in which you think the nasal pillows might not be good enough?
(This post was last modified: 04-08-2016 11:36 AM by tmoody.)
04-08-2016 11:19 AM
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richb Online

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Post: #34
RE: New to ASV, new to SleepyHead
Quote:I hear you. It's interesting that they chose the nasal pillows for the study (and for the prior diagnostic study); I had never even heard of them before. I used a nasal mask for nine years on CPAP. I have to say, though, that I really like the nasal pillows. I'll only go back to mask if it becomes clear that I have to. Last night I had those leaks, but I'm pretty sure that had to do with the pillow.

The only problem I sometimes have is a little aerophagia when the machine is really pushing hard, but that's not going to be any different with a mask. Same thing goes for the occasional mouth breath.

Or is there some other sense in which you think the nasal pillows might not be good enough?
I was worried about excessive leaks. Seems like you have things under control.

Rich
04-08-2016 02:53 PM
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vsheline Online

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Post: #35
RE: New to ASV, new to SleepyHead
(04-05-2016 09:19 AM)tmoody Wrote:  As you can see, my AHI went up last night, from 3.8 to 4.2. It's not a huge increase, and the trend for the past three nights has been upward anyway (1.6, 3.3, 3.8, 4.2). Centrals went from zero to 1, not a significant change. PB dropped to .4%, so really the only significant change is another increase in hypos, which is consistent with the recent upward AHI trend. There appears to have been one major OA...151 seconds? if I'm reading it right.

Sorry - but I don't see any data posted for 4/04.

If there really was an OA for 151 seconds, that would be 2 minutes 31 seconds, which would have been an enormously long OA and quite alarming, really, if it actually happened. Perhaps you are reading it wrong, or perhaps your tiredness from your workout contributed.

If you get a second very long OA (longer than 60 seconds) I would suggest an immediate call to your doctor to discuss an immediate increase in Min EPAP by at least 1 or 2 cmH2O.

The ASV titration protocol from Respironics which DeepBreathing posted is very clear that the Min EPAP should be increased when obstructive events are observed.

As DeepBreathing has pointed out, hypops are almost always obstructive if occurring during ASV therapy, especially when the Max PS setting is very high, as yours is. When Max PS is high, the ASV algorithm will probably be able to prevent all central events, so any hypops which occur will most likely be obstructive in type.

I agree with DeepBreathing that it would be advisable to gradually increase Min PS to at least 2 cmH2O (for example, 3 or 4 is more common, I think), and to gradually increase Min EPAP until the hypopneas become rare (less than 1 per hour on average).

I think the plan you described in a more recent post (Min PS set to 1 and Flex set to 2) is a good start, and when it is time for another adjustment I would suggest trying Min PS set to 2, because although I wouldn't expect higher Min PS to help prevent the hypopneas, my general impression from listening to other ASV users is that ASV algorithms tend to work better when the Min PS is set to at least 2 cmH2O.

One other thing - If feasible, please consider investing in a recording pulse-oximeter, to monitor your average SpO2 at least once in a while, plus whenever starting or stopping a medication. When worn all night, the type worn on the wrist with separate finger sensor cup is far more comfortable.

If you ever see deep dips (like below 80%) I suggest letting your doctor know right away. And if your average SpO2 (ignoring the brief dips) is low (like below 90%), raising Min PS will help that, too.

Take care,
--- Vaughn

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.
(This post was last modified: 04-10-2016 02:40 PM by vsheline.)
04-10-2016 03:35 AM
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tmoody Offline

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Machine: PR System 1 BPAP AutoSV
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Post: #36
RE: New to ASV, new to SleepyHead
(04-10-2016 03:35 AM)vsheline Wrote:  If there really was an OA for 151 seconds, that would be 2 minutes 31 seconds, which would have been an enormously long OA and quite alarming, really, if it actually happened. Perhaps you are reading it wrong, or perhaps your tiredness from your workout contributed.

I may be reading it wrong. Concerning the workouts...I tend to go to the gym later in the day, just before dinner. My workouts tend to involve high-intensity intervals of one sort or another: either strength training with weights (once a week), or alternating walking and running on the treadmill. I've read that working out late in the day can give rise to spontaneous arousals, so that presents a dilemma, since it's difficult for me to find time for workouts in the morning. But maybe it's not related to OAs or hypos.

Quote:The ASV titration protocol from Respironics which DeepBreathing posted is very clear that the Min EPAP should be increased when obstructive events are observed.

As DeepBreathing has pointed out, hypops are almost always obstructive if occurring during ASV therapy, especially when the Max PS setting is very high, as yours is. When Max PS is high, the ASV algorithm will probably be able to prevent all central events, so any hypops which occur will most likely be obstructive in type.

It's true that I'm getting very few centrals on ASV; zero most nights. Almost all of my AHI is hypos, such as last night:

[Image: 1lJnZdYm.png]

Quote:I agree with DeepBreathing that it would be advisable to gradually increase Min PS to at least 2 cmH2O (for example, 3 or 4 is more common, I think), and to gradually increase Min EPAP until the hypopneas become rare (less than 1 per hour on average).

I think the plan you described in a more recent post (Min PS set to 1 and Flex set to 2) is a good start, and when it is time for another adjustment I would suggest trying Min PS set to 2, because although I wouldn't expect higher Min PS to help prevent the hypopneas, my general impression from listening to other ASV users is that ASV algorithms tend to work better when the Min PS is set to at least 2 cmH2O.

Actually, I've set flex to 1 and left PSmin at 1, for a few days now. As far as I can tell, my typical night's numbers are the same, usually around 3, mostly hypos. I've only seen AHI below 2 on about three occasions; never below 1. And when I set flex to 3 I got a five-day trend of rising AHIs, possibly coincidence (but it dropped back down when I set it to 1).

I think tonight or tomorrow I'll bump PSmin up to 2 for a few days and see what happens.

Quote:One other thing - If feasible, please consider investing in a recording pulse-oximeter, to monitor your average SpO2 at least once in a while. When worn all night, the type worn on the wrist with separate finger sense cup is far more comfortable.

I'll check into this.

Thanks for your advice!
04-10-2016 07:15 AM
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tmoody Offline

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Posts: 175
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Machine: PR System 1 BPAP AutoSV
Mask Type: Nasal pillows
Mask Make & Model: Swift FX nose pillows
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CPAP Software: SleepyHead

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Sex: Male
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Post: #37
RE: New to ASV, new to SleepyHead
(04-10-2016 03:35 AM)vsheline Wrote:  If there really was an OA for 151 seconds, that would be 2 minutes 31 seconds, which would have been an enormously long OA and quite alarming, really, if it actually happened. Perhaps you are reading it wrong, or perhaps your tiredness from your workout contributed.

If you get a second very long OA (longer than 60 seconds) I would suggest an immediate call to your doctor to discuss an immediate increase in Min EPAP by at least 1 or 2 cmH2O.

The ASV titration protocol from Respironics which DeepBreathing posted is very clear that the Min EPAP should be increased when obstructive events are observed.

As DeepBreathing has pointed out, hypops are almost always obstructive if occurring during ASV therapy, especially when the Max PS setting is very high, as yours is. When Max PS is high, the ASV algorithm will probably be able to prevent all central events, so any hypops which occur will most likely be obstructive in type.

I agree with DeepBreathing that it would be advisable to gradually increase Min PS to at least 2 cmH2O (for example, 3 or 4 is more common, I think), and to gradually increase Min EPAP until the hypopneas become rare (less than 1 per hour on average).

I just want to follow up on this.

The long OA did occur. Here's a zoomed screenshot of it:

[Image: WtcsOTfm.png]

I haven't seen anything like that before or since. As a general thing, my OAs have been zero since starting on ASV. Once in a while one sneaks through, generally short duration (maybe 15 seconds).

I bumped PSmin up to 2 last night. My AHI was 4.1, all hypos, with some Flow Limitations. Periodic breathing 1.5%.

Interestingly, the previous night's AHI was 3.6, but I felt very ragged yesterday. If I hadn't seen the 3.6 in the morning, I would've guessed it was over 15 (based on experience). Today I feel pretty refreshed. Since my titration study also mentioned a significant number of spontaneous arousals (not apnea-related, I gather), maybe I had a lot of those the night before last.

I'll leave PSmin at 2 for a few days and see what happens. My next adjustment will be to increase EPAPmin from 8 to 8.5 and see if I get any reduction in hypos.
04-11-2016 08:53 AM
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richb Online

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Machine: Resmed AirCurve 10 ASV
Mask Type: Nasal mask
Mask Make & Model: ResMed Mirage FX
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CPAP Software: ResScan SleepyHead

Other Comments: Idiopathic Central Apnea

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Post: #38
RE: New to ASV, new to SleepyHead
(04-11-2016 08:53 AM)tmoody Wrote:  
(04-10-2016 03:35 AM)vsheline Wrote:  If there really was an OA for 151 seconds, that would be 2 minutes 31 seconds, which would have been an enormously long OA and quite alarming, really, if it actually happened. Perhaps you are reading it wrong, or perhaps your tiredness from your workout contributed.

If you get a second very long OA (longer than 60 seconds) I would suggest an immediate call to your doctor to discuss an immediate increase in Min EPAP by at least 1 or 2 cmH2O.

The ASV titration protocol from Respironics which DeepBreathing posted is very clear that the Min EPAP should be increased when obstructive events are observed.

As DeepBreathing has pointed out, hypops are almost always obstructive if occurring during ASV therapy, especially when the Max PS setting is very high, as yours is. When Max PS is high, the ASV algorithm will probably be able to prevent all central events, so any hypops which occur will most likely be obstructive in type.

I agree with DeepBreathing that it would be advisable to gradually increase Min PS to at least 2 cmH2O (for example, 3 or 4 is more common, I think), and to gradually increase Min EPAP until the hypopneas become rare (less than 1 per hour on average).

I just want to follow up on this.

The long OA did occur. Here's a zoomed screenshot of it:

[Image: WtcsOTfm.png]

I haven't seen anything like that before or since. As a general thing, my OAs have been zero since starting on ASV. Once in a while one sneaks through, generally short duration (maybe 15 seconds).

I bumped PSmin up to 2 last night. My AHI was 4.1, all hypos, with some Flow Limitations. Periodic breathing 1.5%.

Interestingly, the previous night's AHI was 3.6, but I felt very ragged yesterday. If I hadn't seen the 3.6 in the morning, I would've guessed it was over 15 (based on experience). Today I feel pretty refreshed. Since my titration study also mentioned a significant number of spontaneous arousals (not apnea-related, I gather), maybe I had a lot of those the night before last.

I'll leave PSmin at 2 for a few days and see what happens. My next adjustment will be to increase EPAPmin from 8 to 8.5 and see if I get any reduction in hypos.

It looks to me that the Obstructive event was about 30 seconds long. There is a resumption of breathing at about 1:55.10.

Rich
04-11-2016 09:51 AM
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tmoody Offline

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Machine: PR System 1 BPAP AutoSV
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Post: #39
RE: New to ASV, new to SleepyHead
(04-11-2016 09:51 AM)richb Wrote:  It looks to me that the Obstructive event was about 30 seconds long. There is a resumption of breathing at about 1:55.10.

I guess I'm reading it wrong. Apparently the OA is followed by a lengthy period of very shallow breathing, lasting several minutes.
04-11-2016 11:15 AM
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DeepBreathing Offline
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Post: #40
RE: New to ASV, new to SleepyHead
(04-11-2016 11:15 AM)tmoody Wrote:  
(04-11-2016 09:51 AM)richb Wrote:  It looks to me that the Obstructive event was about 30 seconds long. There is a resumption of breathing at about 1:55.10.

I guess I'm reading it wrong. Apparently the OA is followed by a lengthy period of very shallow breathing, lasting several minutes.

During that period of shallow breathing your machine is pumping out maximum PS, with IPAP reaching 25 on every breath. But it's getting very little response in terms of air flow. You say this was a one-off, but if it happens again I'd be concerned enough to see the doc tout suite. Do you recall anything unusual from that time - sleeping on your stomach perhaps, or the hose getting tangled up?

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04-12-2016 12:17 AM
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