(03-20-2013, 10:42 AM)racprops Wrote: I am now betting that if I need adjustments (highly likely as I understand things WILL change as I adjust to having PAP) he will want another full nights study to readjust it.
Been very busy lately and haven't had time to read this thread and respond before now.
The ASV units are adaptive, so, unlike a standard fixed-pressure CPAP, the machine will adapt itself to your needs as you adjust to PAP therapy.
You will be able provide your doctor with reports from ResScan or SleepyHead which will provide sufficient information for him (or you) to make any needed machine parameter adjustments.
Another titration study simply to adjust parameters will not be needed.
I am assuming you will be monitoring your data using ResScan or SleepyHead and asking the forum for comments on anything you don't understand.
(03-20-2013, 06:18 PM)SuperSleeper Wrote: Hi Rich, I'm pretty sure that a second full night experimenting with ASV settings to optimize the treatment will be beneficial, but what I'm not so sure of is if you could simply do that yourself using an ASV and associated software to monitor your own data as you make adjustments over the course of several days, especially if your ASV auto-adjusts as you go. ...
In other words, given the tools now available to patients, used alongside an auto-titrating ASV machine and ResScan software, I'm not convinced that you couldn't do the setup yourself to save money. ...
But, I'm hoping to hear from others on this...
I agree that ASV self-titration can be done when other options are not available. In that case, though, I would suggest use of the ResMed S9 VPAP Adapt model 36037 (not old ResMed S9 VPAP Adapt model 36007), since it has a fairly simple "one size fits most" type of algorithm. (But I would suggest the PRS1 autoSV Advanced if it was known that an EPAP pressure of greater than 15 may be needed to adequately treat obstructive apneas.)
In the new S9 VPAP Adapt model 36037 (not old S9 VPAP Adapt model 36007), almost nothing is adjustable, other than a range for EPAP and a range for Pressure Support. (And the mask type and hose type and humidifer temperature, etc., of course.) I think the PRS1 BiPAP autoSV Advanced has many more adjustable parameters, which allows customized "tuning" but, on the other hand, having many more things to get properly adjusted may seem more challenging.
However, in your case, Rich, now that you have had your ASV titration, I would suggest the PRS1 autoSV Advanced may be the better way to go, since, based on your first Sleep Study, you may require an EPAP larger than 15 cmH2O in order to fully treat your obstructive events, and the S9 Adapt cannot do that and still have at least 10 cmH2O reserved on top of that for Pressure Support. The S9 Adapt can only go to a maximum of 25 cmH2O, whereas the PRS1 unit can go as high as 30.
(Although I have heard that the PRS1 unit may be harder to get used to, I wish I had the PRS1 unit, since I think I would benefit from higher pressure than the S9 Adapt can produce, but my need for higher pressure was not discovered during my ASV titration, and, unfortunately, I bought the S9 VPAP Adapt. More on that below.)
(03-20-2013, 09:49 PM)racprops Wrote: Well I would ask has anyone set up their own ASV-PAP machine??
Well, in a way I did, since I had an ASV titration but the titration was not done adequately, so when I received the machine I needed to fine tune parameters myself.
The titration Repiratory Therapist titrated the EPAP to 7, but after seeing obstructive events in my machine's data and researching ASV titration protocols, I discovered that I actually needed the same EPAP which I had been using with my earlier CPAP/APAP machine.
Also, a different subject, the lab titration machine had the old ASV mode but not the improved ASVauto mode, which has an auto-adjusting EPAP (as well as an auto-adjusting Pressure Support). Model 36007 S9 VPAP Adapt units manufactured before November 2012 do *not* have this improved mode.
(03-21-2013, 04:53 PM)racprops Wrote: OK Here is what I would like to know:
From what I have read, it seems hard to get a ASV_CPAP Machine that will read out central apneas.
As I am thinking of getting a ASV machine and doing the set up by myself (with all the help I can get from all of you…)
I need a machine that will provide the data to do this.
All feedback on this idea is welcome.
If my throat is closed my S9 Adapt will report an obstructive apnea if the maximum Pressure Support is not able to prevent the apnea. But a Pressure Support of 11 cmH2O (which I use) is ALWAYS high enough to treat my Clear Airway events, so I never see CA events reported.
But I can easily see evidence in the High Rate Pressure waveform that the machine is treating/preventing what would otherwise have become CA events.
(03-21-2013, 05:16 PM)SuperSleeper Wrote: Also wanted to bring up the question of whether or not CPAP-induced central events are something to worry about extensively at all, especially if the vast majority of events are obstructive rather than open-airway events.
We've had several discussions on whether higher pressures induce centrals in most patients or not... but I think the more important discussion should be "do a few pressure-induced centrals really matter a whole lot?" (as long as they are not extensive in number)?
I suggest an important question is how long do the centrals last.
For examle, a central apnea which lasts 25 seconds is going to be less damaging than an obstructive apnea which lasts 45 seconds.
(03-21-2013, 05:16 PM)SuperSleeper Wrote: Certainly, there's going to be a "sweet spot" of pressure and other settings where obstructive events are lowered to acceptable levels without inducing an unacceptable level of central events. The procedure for finding that sweet spot for an ASV should be close to the same procedure for doing it with an CPAP or Auto-CPAP, I would think. There are other additional settings on an ASV (see the manual), but the general concepts are the same.
The "sweet spot" of pressure if using a standard CPAP or APAP or bi-level machine might not achieve an AHI below 5. Some people, like me for example, had Central Apeas during a baseline Sleep Study without CPAP treatment. So even with a CPAP pressure of zero I would still have centrals occuring.
With an ASV model, however, the sweet spot is simply setting the range for EPAP so that obstructive problems are avoided, while leaving room for the max Pressure support to be set to at least 10, so that the machine will be able to adequately treat/prevent all central events. According to ResMed literature, unless a person has diseased lungs or something like that, a Pressure Support of 10 will be adequate to fully ventilate a person experiencing a central apnea.
(03-21-2013, 07:33 PM)SuperSleeper Wrote: I second jgjones1972's suggestion for an oximeter. Low cost piece of equipment that will tell you a lot of what's going on during the night.
Yes, an oximeter is very important, even if one has an ASV machine.
The ASV machines key off your recent breathing pattern, targeting 90% (ResMed) or 95% (Philips Respironics) of your recent amount of breathing.
One of the kinds of central events which can sometimes happen is that breathing may slowly get progressively more and more shallow, until an hyponea occurs. When this happens on an ASV machine, if it happens very gradually, the ASV machine will see no sudden reduction in breathing and will do nothing, allowing the gradual hypopnea to occur, leading to oxygen desaturation and arousal from sleep. To reduce how often this happens to me, I have found it helps to adjust the Minimum Pressure Support to 6, which is the highest it can be set on the S9 Adapt. (On the PRS1 ASV machines the minimum PS can be set higher than 6, and I suspect that 7 may be better for me.) But, on the downside, a higher minimum PS is harder to get used to. Also, one should be cautious and careful if raising the minimum PS, since it is important to prevent overventilation which could be caused by setting the minimum PS too high.
(03-21-2013, 09:14 PM)racprops Wrote: I really like the way a ASV works, it does nothing until I fail to breath, then it cuts in and makes me breath and as soon as I take over it shuts down and waits until it is needed again. AND it uses my breathing rate as well..it does not try to make me breath at a preset rate.
ALL other PAPs even a Bi-Level seem to push air no matter what I am doing.
Correct me if I am wrong
The ASV machines will push the normal amount of air that a bi-level machine would push when you are breathing normally (enough EPAP to keep your airway open) and Pressure Support will cyclically increase the pressure as high as necessary (ventilating you) when you stop breathing, whether because of a central event or because of an obstructive event, although if an obstruction is bad enough the maximum pressure support may not be able to adequately treat it, so it is important that the EPAP be high enough to treat your obstructive events.
(03-21-2013, 09:58 PM)Shastzi Wrote: This looks like more of a product comparison but maybe it could be some help.
(03-22-2013, 01:47 AM)racprops Wrote: Thanks Shastzi...
Sad to say that did not really offer any clear winner...between makers, it did clear up some info on some models...
And help explain some of the settings needed...
The comparison was for the older ResMed VPAP Adapt SV, not the newer S9 VPAP Adapt model 36007, nor the newest S9 VPAP Adapt model 36037 (manufactured starting November 2012). The newest model 36037 has fewer adjustable parameters and, like the PRS1 BiPAP autoSV Advanced, can adaptively vary the EPAP just like a standard Auto PAP machine, such as the S9 AutoSet, can.
(03-22-2013, 08:52 AM)archangle Wrote: I'm a bit puzzled why S9 ASV machines apparently don't distinguish central apneas from obstructive, but it's my understanding they don't.
The statistics report in ResScan for S9 ASV machines do not give a breakdown of CA versus OA events, but the S9 ASV machines do identify obstructive apnea events. Obstructive apneas are marked as such in ResScan detailed data (waveform plots).
A Clear Airway event would need to last longer than 10 seconds to be reported as an apnea, and in the Flow waveforms I have never seen a non-obstructive apnea last longer than one second, because the ASV Pressure Support immediately responds, and an adaptive Pressure Support of 10 cmH2O will be able to prevent the central apnea or hypopnea from happening. At least, that is what I see in the data from my machine.
I don't know what would be plotted in the detailed data for my S9 Adapt unit if I set the Pressure Support so low that a central apnea lasted longer than 10 seconds because the machine was unable to prevent it. Maybe in that case it would plot a Clear Airway event.
(03-22-2013, 09:14 AM)racprops Wrote: "I'm a bit puzzled why S9 ASV machines apparently don't distinguish central apneas from obstructive, but it's my understanding they don't. "
That is one reason I am looking at the Respironics System One BIPAP Auto SV Advanced Machine with Heated Humidifier...it does try to read OAE (Open Airway Events) and reports them as such and granted they may be misreported as you point out...but it is trying...
If the centrals are being adequately treated (prevented from lasting as long as 10 seconds) then I see no benefit in reporting them. If they are not lasting 10 seconds, by definition they are not reportable events.
(03-30-2013, 10:22 AM)racprops Wrote: OK Just got home from my second sleep study, the one to figure out rather Bi-Level or ASV…
ASV won, I was switched over after the first hour.
Ran into a problem: Seems I stop breathing just as I start dreaming, or skip a breath of two..with the Resmed ASV it powers up and pushes max pressure into my face mask and keep waking me up.
And it also had a habit of taking control and making me breath at its rate…
This seemed to get better as we went along.
I think I read somewhere that the Resmed machines do this.
I hope the newer Resonanoic machines are a little more forgivable. OR that I can get it to start as a bi-level and switch to ASV once I am sleeping and it begins tracking my breathing cycles.
I think the PRS1 autoSV Advanced may offer a Ramp feature in ASV mode which may help. The S9 Adapt does not offer a Ramp feature in ASV mode, only when operating in constant-presure CPAP mode.
(03-30-2013, 07:49 PM)racprops Wrote: So with what I have read on apnea boards which tell of the breaking in and getting used to these treatments I can only hope things will settle in and I begin to see improvements around 4 to 6 weeks.
As I had originally feared, the cure is almost as bad as the illness….
Hey, guy. Hang in there. It is sure to be a struggle, but well worth it.
You will need to try many things to make your mask work OK for you. I think nasal pillows and hybrid masks, which are the favorite masks for many, cannot be used, since they may leak badly when the IPAP gets above 20.
The important thing when using high PAP pressure is to wash your mask with soap or non-concentrated Dawn dish detergent every morning and lay out to dry completely before using, and to wash your face until it is completely free of face oil right before bed.
If you try the ResMed Mirage Quattro full face mask (FFM), be sure to try with it a ResMed Gecko Nasal Pad to protect your nose. (Supplier #2
has best price on the Gecko pad, I think.) A single Gecko pad can last for 3 months or longer (and also needs to be washed free of face oil every morning).
The ResMed Quattro FX is a great FFM, but at high pressures I find that the headgear stretches quickly and needs to be re-adjusted daily. To adjust it, I simply hold my breath (the Pressure Support will immediately raise to its maximum) and check for leaks.
The higher the IPAP the harder to control leaks.
If your EPAP really needs to be up there around 19 or 20, I would really feel for you. I am struggling with EPAP=14, PS=11. This means sometimes the IPAP reaches 25. If your EPAP needs to be 19, and the max PS needs to be at least 10, your IPAP may occasionally reach 29.
It won't be easy by any means, but do yourself a huge favor and make it work. It will surely take at least a few months of suffering, but you can make this work and live a long and happy life.
(another happy PAPper)