Newbe with Complex Apnea - Best ASV to get?

[vsheline]

Current settings are:

Min EPAP: 6.5
Max EPAP: 15.0
Min Pressure Support: 0.0
Max Pressure Support: 10.0
Max Pressure: 18.0
Flex Setting: 2
Backup Rate: Auto


...
things fell apart last night:

AHIApnea / Hypopnea Index 53.54
HypopneaHypopnea 10.01
ObstructiveObstructive Apnea 3.88
Clear AirwayClear Airway Apnea 39.64
RERAResp. Effort Related Arousal 0.00
Flow LimitFlow Limitation 0.00
VSnoreVibratory Snore 14.51
PB/CSRPeriodic Breathing 10.10%

...
So unless you see something really wrong or bad for me I plan on leaving the settings alone for at lease a week.

Hi Rich,

Another name for "Max Pressure" is IPAPmax.

The low value of IPAPmax is limiting the amount of Pressure Support the machine is allowed to use and therefore is disallowing the machine from adequately treating your central apneas.

You might want to put the IPAPmax back to 25, which was the doctor's original prescription, and leave it there. (The machine will never go there unless it needs to, to prevent central apneas.)

When sleeping on your back (and especially if flat on your back in a horizontal bed) the EPAP may need to raise itself as high as 13 to 15 in order to prevent your obstructive apneas. With the Max Pressure set to 18, whenever the EPAP automatically adjusts up to 13-15, this leaves room for only 3-5 cmH2O for Pressure Support, not enough to keep you adequately ventilated during your central events. The PS may need to go as high as 10 cmH2O in order to prevent what would otherwise become central apneas.

If the Max Pressure is put back up to 25 as your doctor prescribed, this would allow PS to go as high as 10 when needed, even when EPAP may be as high as 15 in order to treat your obstructive apneas. Get the picture?

Take care,
--- Vaughn

[racprops]

YES BUT I may have a problem with this machine.

It was going so high it was blowing my mask seal open, and I checked the display and it was reading 18-19-20CM and over 18CM my mask leaked and it seem better to keep the mask seal..

ALSO:

Respironics DS950HS Pressure creep??

Is this normal?? I have my ASV Respironics DS950HS EPAP min Set for 6.5CM, BUT as I inhale the readout shows it jumping to 8CM…and dropping back to 6.5 for my exhale…

And I was trying to fall asleep and things seem a little off and I checked the readout and now it was running a 10CM??


It seemed to have creeped up on the EPAP Min Setting.

Rich

[vsheline]

YES BUT I may have a problem with this machine.


It was going so high it was blowing my mask seal open, and I checked the display and it was reading 18-19-20CM and over 18CM my mask leaked and it seem better to keep the mask seal..

ALSO:

Respironics DS950HS Pressure creep??

Is this normal?? I have my ASV Respironics DS950HS EPAP min Set for 6.5CM, BUT as I inhale the readout shows it jumping to 8CM…and dropping back to 6.5 for my exhale…

And I was trying to fall asleep and things seem a little off and I checked the readout and now it was running a 10CM??


It seemed to have creeped up on the EPAP Min Setting.

Rich

Hi Rich,

This is completely normal for an ASV machine. All bi-level machines boost the pressure when we inhale. And the ASV models will sometimes boost IPAP even more than normal Bi-level machines do. We gradually get used to it. But it takes time.

Also, when we are falling asleep it is not unusual to have some low-level snoring or central events, so the pressure will boost itself up. If it is bothersome just turn off machine for a couple seconds and pressure will re-start at low level.

Your central apneas cannot be treated unless you eliminate leaking when the pressure gets high.

To adjust the mask so it won't leak and wake you up when pressure gets high, take a couple fairly deep breaths and then hold your breath. Your machine will immediately shoot the pressure to max. Adjust mask. Take a few more breaths and hold it. Adjust mask. Repeat, until mask does not leak at max pressure.

Then turn theachine off for a few second to restart pressure back to normal.

Take care,
--- Vaughn

[racprops]

Thanks,

That is what I did and it is now somewhat painfully tight...I don't think I can get it any tighter.

But I will try.

That is when it seemed maxed out at 18CM.

Nice to know it is OK.

Rich

PS I am off to bed and I will reset the ranges and re-tighten my mask.

[vsheline]

Thanks,

That is what I did and it is now somewhat painfully tight...I don't think I can get it any tighter.

But I will try.

That is when it seemed maxed out at 18CM.

Hi Rich,

It is very important to adjust left and right mask straps evenly. And we need to wash the mask with soap every morning to remove oils and rinse very well and let dry out. And right before sleeping, we need to wash face with soap to remove all oil, and dry well. Doing these things really helps.

Your Respironics FitLife Total Face Mask is very large, which increases the force pushing the mask off your face, making it all the more difficult to keep from leaking when pressure gets above 20, which is where you will sometimes need to be. Other mask types are also hard to keep from leaking, but I think FitLife TFM is extra hard.

With the ResMed Mirage Quattro FX, I use RemZzzs Large Full Face Mask liners (which are too small to use with a Total Face Mask). With the ResMed Mirage Quattro (which is different than the Mirage Quattro FX) I use ResMed Gecko nose pad. The Gecko pad really helps to protect the bridge of the nose from getting hurt and seals leaks around the nose and eyes. I rotate masks to help not get sore spots. Because with high pressure I find mask needs to be fairly tight.

Everybody agrees the mask is hardest problem to solve, especially when our pressure needs are above 20. It is going to take much time and experimentation to control the leaks.

Take care,
--- Vaughn

[racprops]

Great tips, I will add them to my system.

I am lucky to be a much dryer state...AZ.

But still need to do more clean up.

Rich

PS Guess both of us are not doing too well sleeping...

[robertbuckley]

With the almost infinite combos of settings we let the machine make decsions and think that is good. It isn't always, as I have found out. I am an extremely light sleeper and in addition to the obstructive apnea, have frequent ca events and "arousals" during the night.
We have found (my patient all suffering MD and I) after years of futzing arouind that I am better off with as little change as possible, consistant with good treatment . I have recently upgraded to BiPAP SV, and we have actually set a constant for the EPAP at 15 (Iknow it is high, but my apap auto floor was 14 and this is also isn't going up and down) and then the variable is with the IPAP with a low of 4 and a high of 10 (so max of 25 - also machine max). This really works for me (everyone is different). The airway is OA open, and the CA gets treated as needed. The constant up/down of the EPAP may be causing you discomfort.
Then the mask - always tough to get right especially at high pressure, and I also have a bump in the middle of my nose. I had been using the ResMed Mirage Quatro FX. They tried to get me to use a Resprionic Comfort Gel Full to go with the Resp. BiPAP SV. Leak city, unless so tight a spanish inquisiter couldn't make it tighter, and it still leaked at the bridge of the nose. "Best Mask there is ! " Might be, but not for me. Went back to my old reliable Quatro FX and everybody is looking at reports and going "WOW - no leaks." Bottom line is mask wise you gotta do what ya gotta do, YOU are the one wearing it. A note concerning the ResMed masks - I find the sizes run a bit large. If you have been using a large something else, sometimes a medium sometimes is a better fit. Aslo, take advantage of your insurance (if you have it) and get a new mask cushion every mounth.
I guess my bottom line message for you is to let the machine assist by changing levels, but sometimes by reducing the range of the changes it can make provides sounder more consolidated sleep. (My opinion is to raise up that EPAP bottom and limit the spread). And, one night isn't going to tell the story, because your body is adjusting. AND, the MASK,master, look the MASK. It has to be comfortable with no leaks. So tight it causes discomfort will only disturb sleep. GOOD LUCK and hang in there. I been doing this 15 years, and maybe in another 5 will have the "perfect" system.

[vsheline]

We have found (my patient all suffering MD and I) after years of futzing around that I am better off with as little change as possible, consistent with good treatment . I have recently upgraded to BiPAP SV, and we have actually set a constant for the EPAP at 15 (Iknow it is high, but my apap auto floor was 14 and this is also isn't going up and down) and then the variable is with the IPAP with a low of 4 and a high of 10 (so max of 25 - also machine max). This really works for me (everyone is different). The airway is OA open, and the CA gets treated as needed. The constant up/down of the EPAP may be causing you discomfort.
...
I guess my bottom line message for you is to let the machine assist by changing levels, but sometimes by reducing the range of the changes it can make provides sounder more consolidated sleep. (My opinion is to raise up that EPAP bottom and limit the spread).

Hi Robert, welcome to the forum!

These are really good suggestions.

I think it is a valuable feature to have an ASV machine that can automatically adjust the EPAP as needed, but perhaps a good use of this feature would be to observe from the SleepyHead plots how high the EPAP raises itself most nights to prevent obstructive apneas, and then (in consultation with one's doctor, if possible) set the EPAP to a fixed number which is high enough to cover about 95% of the time.

A new patient who cannot manage to fall asleep when trying to breathe against a high fixed pressure might need a range for EPAP, such as the 10-15 range prescribed by Rich's doctor. And, as Rich's doctor has prescribed, the Max Pressure needs to be about 10 higher than the EPAPmax, to allow Pressure Support (PS) to raise the inhalation pressure as high as 10 cmH2O above the EPAP, whenever needed.

As Rich becomes more tolerant of high pressures and is able to set his machines's settings back to his doctor's prescribed settings, and as he learns how to reduce or eliminate mask leaks, I think he will be able to achieve great results. I think his initial difficulties were caused by his intolerance to high pressure (which is improving), plus mask leaks were preventing the PS from eliminating his central apneas (and hopefully mask leaks will be improving). Now, Rich's low setting for Max Pressure is also (in addition to mask leak) preventing the PS from eliminating his central apneas.

Also, I think it would be helpful to Rich if the PSmin were at least 0.5 cmH2O or whatever is comfortable, to help him get used to receiving Pressure Support. I suspect a higher PSmin would also help prevent the occasionally low tidal volume shown in his SheepyHead plots.

Take care,
--- Vaughn

[robertbuckley]

Right you are, Vaughn. In fact if I hadn't started out with a CPAP in C-Flex mode years ago to get used to treatment, I don't know that I would be curling up and going to sleep with a Bi-PAP Auto SV Advanced and being in love.
Sleep Well,

[vsheline]

I am just completing a 14 day trial with a RESMED S9 Autoset. With this forums help and a bit of studying the subject I have analysed my data from the SD card with RESMED SW and Sleepyhead and found a fair amount of OSA and CSA events (OSA about 1/3 and CSA about 2/3), with some few Hypopnea events as well.
...
I am having an average treated AHI 5.45 (AHI ranging from 2.3 - 16.8 per night), Min pressure 5, max pressure 12 at EPR3. (Resmed S9 Autoset with FX Mirage Nasal mask)
I have included some of the data from Sleepyhead below:
Recent AVG 7days AVG 30 days
AHI 5.65 6.32 5.45
Hours per Night 10:05 09:21 09:41
Average Pressure 7.97 7.45 6.54
95% Pressure 10.40 11.76 11.62
Average Leaks 0.94 1.97 1.82
95% Leaks 18.00 20.40 18.00

I am feeling better after most mornings, except after nights with "high events". I am reasonably sure that I benefit from the APAP therapy. Can anyone help and recommend what kind of machine I require APAP, Bilevel, or ASV?

Hi Nord, welcome to the forum!

Your data looks pretty good, especially for just 2 weeks on PAP therapy.

Too early yet to tell whether you need more than the S9 AutoSet, which is a great machine.

By the way, for reference, I think the Medicare guidelines in the USA are that central apneas have to outnumber obstructive apneas, and, also, the CAI (all by itself) has to be above 5, in order for Medicare to approve payment for an ASV machine. Or, if you can pay for it yourself (about USD$1800 from Supplier #2), all you need is a prescription from any physician.

Turning EPR down (gradually, maybe one notch a week) to 2 or 1 or Off may improve the CA Index (average number of clear airway apneas per hour).

Using EPR can increase (make worse) the CAI number, for the minority of patients who are susceptible to central events. Some long-time CPAP users have found that their CAI numbers improved a lot when they turned off EPR.

At the same time, it is fairly common for the CAI to become smaller anyway during the first few months of CPAP therapy as our system gets used to the pressure while sleeping. So you may be able to turn EPR back up, in a few months time.

Your starting pressure of 5 is way lower than your 95% pressure of close to 12, your max. This may make the machine spend a fair amount of time working up to the pressure you occasionally need to treat obstructive events, allowing obstructive events until it reaches the needed therapeutic pressure. If it were me, I would probably gradually raise the minimum pressure from 5 to 8 or higher.

I would probably also raise the max pressure to at least a couple higher than my 95% pressure, to around 14 or higher.

Let's consider: Your pressure is most often around 7 or 8. If many or most of your central apneas are occurring around 7 or 8, I would think that shows that CAs are occurring not only or predominately at high pressures like 10 or 11, but pretty much independently of pressure.

On the other hand, if your central apneas occur predominately at pressures of 10 or 11 and only very rarely at 7 or 8 where the pressure spends most of its time, then I would tend to think the higher the pressure gets the more central apneas will occur, and therefore I would reconsider whether I wanted to raise the minimum up to 8 or higher, or raise the maximum pressure to around 14 or higher. I would try to find some happy medium where the AHI number is smallest, or where the average length of time spent in apnea is minimized.

If you can swing it, I suggest getting a Pulse Oximeter, such as are available from Supplier #19 on the Supplier List, a link for which is at the top of most Forum pages.

The wrist-mounted oximeters are more expensive but more comfortable. (There are several threads on the forum which discuss Oximeters.)

Neither Apnea Board nor its members derive a commission from members using the suppliers on the Supplier List. The list is offered as a service to members but without any blanket endorsement. I think suppliers on the Supplier List have a reasonably good reputation or they will eventually get removed from the list, but we still need to compare prices and investigate products for ourselves, just as we would with other suppliers.

Take care,
--- Vaughn