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Night 8, it's already Love - Hate. So glad I found you guys!
#41
RE: Night 8, it's already Love - Hate. So glad I found you guys!
One thing to note there is a contraindication for an ASV Machine if you have Congestive heart failure so your dr may want you to do an echo cardio gram to measure the LEVF as a value of less than 30% was used as a measure to not prescribe an ASV


But I think you would know if you are in that group ?
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#42
RE: Night 8, it's already Love - Hate. So glad I found you guys!
Before jumping to a new doc, share the document I linked with your current doctor. He seems open to suggestions, and should readily see the correct application for you considering your symptoms and health. If that doesn't work, he may consult an expert or refer you. He can even call Resmed to consult on your case. The main thing is to find a doctor familiar with central and mixed apnea. It was clearly in your diagnostic study, and I think the best approach is to check what sleep centers are in network for your insurance, then call and ask about their experience with ASV and mixed apnea.

I'm impressed, but not surprised with the improvements resulting from Thibault's suggested settings. You should read some of his earlier threads where he was faced with the choice between ST and ASV. For him, the ST was the right choice as he was badly afflicted with a hypoventilation issue. In his case I recommended ST, but his success came from a diligent effort to self-titrate, so he really knows how to get the most out of that machine. You on the other hand do not have any of the restrictive or neurological issues ST can help with, you just have a central apnea issue that is present with or without positive pressure therapy. I will caution that progress like we are seeing in your latest results can be inconsistent for CA until ASV is used.

With that said, your average inspiration time is only .84 seconds wit expiration over 2.5 seconds. Looking at your flow rate chart, that appears correct. Please post your Ti min and max settings, and we might be able to improve on that.
Sleeprider
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#43
RE: Night 8, it's already Love - Hate. So glad I found you guys!
Hi FE350,

Awesome! Some questions from my side though where I would like your inputs:
- What is your height and weight? (In cm please and kg please, I'm French haha) That will help us to set up a proper tidal volume according to these 2 settings. We need to start from there before playing again with the settings. Over night while sleeping, the tidal volume should be 5-6ml/kg.
- As Sleeprider requested, what is your current Ti min and Ti max? These settings are available in the Aircurve only. Your Ti is quite short 0,84s, so let's confirm it is not effected by the hard settings in the VPAP.
- What is your "trigger" settings as of today? (= sensitivity of the VPAP to detect an inhale attempt, and move from EPAP to IPAP) I've seen you changed some settings so I want to confirm with you :-)
- What about your "cycle" settings? (= sensitivity of the VPAP to move from IPAP to EPAP)
- Can you attach your last night screenshots with the graphs of tidal volume, insp time, exp time, minute vent please? That would help a lot too.

Small comment: Sleepyhead is displaying a median respiratory rate of 17,40. I am curious to understand why or how you had to play with a backup rate lower than 10, while in this condition you shouldn't set it below 13,40 if we want to be extremely precise :-)

Cheers
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#44
RE: Night 8, it's already Love - Hate. So glad I found you guys!
Thanks All!

Replying  to your specific questions Jas, Sleeprider and Thibault:

Jas, 
I believe my heart is strong, although, as previously posted, my SA node has been failing for several years (4 I know of) before I finally was DX'd Bradycardia and SSS in August of last year, and had a pacemaker implanted in October '17.  After reading that ASV may not be indicated if EF is below a range, I have asked my EP to do an electrocardiogram.  That is now scheduled for Nov 30.  I really expect I will come out OK.  I try to work out (cardio and resistance training), 4-5 days a week, and I am very active all days, I do not feel very limited in any way.  I had an echo done before my PM was implanted, in Aug of '17, and EF was noted then as "Estimated 55-60%".

To Thibault and Sleeprider,
My Ti min is .3 sec, Ti max is 2.0 seconds.  But as I mentioned, I feel the machine hurries me.  I note that when I first start it, it seems like it is giving me plenty of time to inhale, perhaps that is the max, 2 seconds?  But as time progresses, and usually in just a few minutes, I am breathing rather quickly.  I think they may have set the machine at a backup rate of 6 because I would have told them that my breathing cycle is between 5 and 6 seconds at rest.  That was from me trying to measure my cycles as I lay in bed.  But the truth is, my breathing is probably too slow, and shallow, for my own good.  When you suggested I set my backup rate to 10, I was definitely being rushed!  So I dropped it after a short time to 9, and still felt rushed, then 7, thinking this was quite a bit faster than 6 (in percentage terms) and thought it best to try it there.  It seemed to work better for me.  Recognizing my respiration rate might be better for me at a faster cycle time, tonight I plan to set it at 8 to start.  I honestly don't know how I get such a high median rate, but I do know, with the machine, I am breathing at an uncomfortably hasty pace. I feel it is rushing me.

I confirm, I did adjust the trigger from Med to High last night, at your direction.  I believe that was a good move.  But I wonder, I see the Rise Time is set for Min.  What I feel when the machine kicks into the IPAP mode is a very abrupt surge in pressure,  It requires my effort to breathe in at pace with the device.  Does this setting soften the slope of the IPAP surge?  If so, I'll bet my comfort would improve with a few ms added to the response.  Your thoughts?

Cycle setting is set to Med.

My height is 182cm, my weight 83KG.

Finally, I think I've responded to all your great questions, attached is the screenshot showing my tidal volume, minute ventilation, insp and exp times.  I sure hope I learn to understand all this as great as you all do.  I just can't tell you thank you enough.  Heading to bed now, it's 9:35 pm here in California.  I look forward to reporting tonights results in the morning.  Thanks
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#45
RE: Night 8, it's already Love - Hate. So glad I found you guys!
Fe350,

Wait before going to bed. Please change the following settings before falling asleep:

- "trigger" settings to "very high" instead of high: this will help you to trigger IPAP even during very shallow breath, resulting in even less UA in your chart.
- rise time : 300ms: this will smoothen the transition from EPAP to IPAP, don't go beyond 300ms. 300ms is good! This will also have a direct impact on your inspiratory time which will be longer, so I guess you should be having a Ti of around 1,0s with that settings.
- ti Min = 0.5s (Must be greater than rise time, since rise time = 0.3s, you are good)
- ti max = 3.0s (Today your Ti max = 2.0s, this is too short as I can see you reach often the treshold and the Vpap stops the IPAP automatically to get back to EPAP. So let's put 3.0s. This has no incidence at all in your treatment, and is more a comfort settings. I know the feeling of being cut off air while not sleeping yet, especially when yawning, lol)
- IPAP back to 12: your tidal volume should be 6*83 = 498ml, and you are getting 420ml with a pressure support of 4.6 cmH20. Let's see how much tidal volume is there with PS=5. You will probably get something like 430 or 440ml. Let's not push it too much, goal being for you to feel comfortable and not to swallow any air. (My tidal volume is supposed to be 400-420ml but I was swallowing too much air so I reduced my PS a bit to get something around 360-380ml. I am not doing any hypopneas and I don't swallow air anymore, so that is the best I can do for myself!)
- Keep the backup rate at what you set (6 or 8, I don't recall). We will check this settings last thing.

This should improve your conditions a lot. Good luck and tell us tomorrow your results !

Thibault
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#46
RE: Night 8, it's already Love - Hate. So glad I found you guys!
It's great to see your improved results. However, a word of caution - some patients with predominantly central apnea can achieve good outcomes with machines other than ASV. But in many cases, the results are erratic and not sustained night after night. Given the results of your original sleep test it wouldn't surprise me if you have a few excellent nights and many horrible nights. There comes a point where you can't sustain good results with an ST and have to graduate to an ASV.

Hopefully you will be one of the few and your machine will do a good job for you.
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#47
RE: Night 8, it's already Love - Hate. So glad I found you guys!
Thanks DB, noted.  Believe me, I cannot wait to get out of this wrong tool...

So T,
I set the changes I mentioned and went to bed.  It wasn't until I woke up, with a very uncomfortable nose, at 3 am, and took the mask off to pee and take a break, that I saw your message about making a few additional changes.  After a break from about 3:10am until about 4:30 am, I reset the machine to the exact specs you described, and viola! Got the result you see on the attached file.  Good on you!  Merci beaucoup!



Questions, 
What is the craziness you see between 1:45 and 2:45?  
In the side bar on the left side of the page, I see it states "Total Time in Apnea 18:51.  Is this the actual cumulative elapsed time when I am not breathing during this night?  If so, I had one night where that value was an hour and a half!  That cannot be good.

So off I go to bed again, intrepid in my search for the ultimate settings.  Wish me a better finish to the night.  So far, the night before last has been my best.
JP
FE350
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#48
RE: Night 8, it's already Love - Hate. So glad I found you guys!
FE350,

A lot of improvements have happened from 4:30am: almost no apneas anymore and much less hypopneas! WOW!
18:51 means you spent 18min and 51sec in apnea/hypopneas over the whole night. No worries, we will bring it close to 0 very soon!

Between 1:45 and 2:45, maybe there was few leaks?

We are definitely on good track here. Since you haven't completed a whole night with all the settings I've recommended, we can't trust them all on the left hand side.

So what I would recommend for tonight is only one change from now:
- Moving back to IPAP to 11.6 (Your tidal volume is a bit high vs your target one of 500ml, so 0.4 cmH20 less should bring us somewhere close to that)


Did you feel any discomfort after 4:30am? Or we are all good?
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#49
RE: Night 8, it's already Love - Hate. So glad I found you guys!
Hi T
I felt I slept well that last part of the night!  

Better news, I’m awake now since about 3 am, but my machine has reported a 5 hour session of just 5AHI, my best score yet!  

I’m happy to drop the IPAP a bit, when I start I always feel like I’m being fed by a fire hose. I’ll do that now. And try for another 3 hours of sleep. 

A question, after I woke up at 3, I used the bathroom, checked my readings, and tried to restart my therapy. But I noticed I was exhaling so very little. It troubled me, and I stopped for another break after just 20 minutes or so. Any thoughts about that?

Also, tinnitus is horrible since I’m using the machine. Are people finding the machine is causing hearing damage?

Thanks, keep your fingers crossed for me!!
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#50
RE: Night 8, it's already Love - Hate. So glad I found you guys!
Hi FE350,

Excellent! For the "fire hose", it seems you are not using the ramp, ain't you?

I would recommend you start with the ramp with a pressure (in this case it will be EPAP) of 3, for a duration of 30min.
With a pressure support of 4.6, it means you will start your night with 7.6/3, and it will gradually increase to 11.6/7 in half an hour.

How long you usually need to fall asleep?
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