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[Pressure] New xPAP user - Question about Centrals on OSCAR
#31
RE: New xPAP user - Question about Centrals on OSCAR
*Correction to my post with the BiPAP titration summary: I was having "spontaneous arousals" at a rate of 75 per hour, not centrals. My rate of centrals at that pressure was 34/hour. See the scanned image.
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#32
RE: New xPAP user - Question about Centrals on OSCAR
Based on my history of central apneas with CPAP and BiPAP (if trigger isn’t set to very high) and several of your expert recommendations, I bought a used S9 VPAP Adapt (ASV) off DotMed. We discussed this on a non-therapy thread, so I am summarizing that discussion here for this therapy thread.

I have now received the machine, and I am ready to begin testing it out. It’s my understanding with ResMed ASVs that EPAP is fixed in ASV mode and variable in ASVauto mode. Because this is a titration with a new type of machine, I will use ASVauto mode in order to get an idea of where the machine thinks my EPAP should be for most of the night.

Sleeprider provided the ASV titration protocol, and I am reposting it here for reference. Based on the protocol, it looks like I should begin with: 

ASVauto default settings:
Min EPAP: 4 cm H2O
Max EPAP: 15 cm H2O
Min PS: 3 cm H2O
Max PS: 15 cm H2O

Anything I should change?

Thanks!


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#33
RE: New xPAP user - Question about Centrals on OSCAR
OK, so the numbers from the first night with ASV look good, but in terms of how I feel, I don't know if ASVauto at default settings is ideal for me. I am still waking up with the feeling that I can't return to sleep unless I get room air pressure. I try to address this by getting up until I feel like I can return to sleep with pressure, but sometimes I fall back asleep without my mask in the process of doing that.

First, an overview of the night, showing time at different pressures (if that will help narrow the pressure range for future nights) as well as periodic flow limits (I use a soft cervical collar and sleep with an elevated head of bead. Unfortunately, I have to sleep supine due to aerophagia in lateral position):

   

The only time I have those nice, sinusoidal flow rate curves are when IPAP is raised. This is a very zoomed out shot, but you can see the flow rate curves are less "dense" when IPAP is higher. The less dense patches of waves correspond with sinusoidal flow rate curves:

   

Here's a close-up of that, anyone have any idea what's going on:

   

Should I narrow down the pressure ranges/increase min pressure support to make those waves more sinusoidal?

Thanks!
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#34
RE: New xPAP user - Question about Centrals on OSCAR
A quick note on charts, if I were asked, I would drop flow limits and snore down and bring into view mask pressure. Compared to VAuto or AutoSet, your FL may look a bit needy but ASV doesn't look for FL for therapy targeting. And it'll be opposing goals of CA versus FL. As for snore I never looked at the chart much and it's taking space for other charts IMO.

OK try this edit, EPAP Min 5. That's it. See if it helps with more air as that's what I'm interpreting needs addressed from your comments. Give it a night and see if it's headed in the right direction. Default is a starting point, then edits are done to make it your therapy set.

Is there any Ramp set on this? No then ok. But if there is, it'll need to go off or shorten the time to minimum of you really need it. I found Ramp was the enemy regarding ASV therapy.
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#35
RE: New xPAP user - Question about Centrals on OSCAR
Thanks for responding Dave, I don't feel "air-starved" when I feel like I have to take off the mask to return to sleep. I think it has more to do with aerophagia (air slurps down my esophagus constantly when EPAP gets into 5.5-6), and distraction with the breathing process. Sometimes I have to get up out of bed and sit on the couch for a bit to return to sleep. I am reading Dr. Krakow's book Sound Sleep, Sound Mind, and that's one of the strategies suggested for sleep maintenance insomnia. I don't know if it's insomnia per se that I am experiencing because I can return to sleep pretty quickly once the mask is off and the air isn't slurping down my throat, but I'm also not completely clear minded when this happens. I'll need to take better note of exactly what the issue is when I feel the urge to take off the mask.

I have read that there are many causes of central apnea. Change in CO2 concentration due to too much pressure support is one possible, common cause, but again, during my BiPAP titration, I had fewer central apneas at higher pressure support, suggesting possibly that these central apneas are not necessarily due to overventilation. It's also possible they are a pressure support issue and they are just being consistently inconsistent?

I raised EPAP to 5, and I still woke up several times with no difference in how rested I felt during the day. I have been using a five minute ramp to try to fall back asleep before the air starts snaking down my throat and distracts me. I will try no ramp. 

Here's the overview:

   

I am still noticing these changes from sinusoidal to non-smooth breathing that then result in recovery breaths. I notice this tends to happen when PS bottoms out and drops toward 0, which seems odd because PS min is set to 3. Is it supposed to drop out like that? No leaks were detected either. Anyone seen this before?

   

Thanks!
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#36
RE: New xPAP user - Question about Centrals on OSCAR
This last chart indicates EPAP doesn't fluctuate much. You can try ASV Mode to change to a static EPAP, that is without a Min/Max EPAP range. You'd want to choose a single EPAP base pressure, maybe that 5 that I suggested for EPAP Min in the current setup. My thinking of doing this is forcing all pressure increases to be PS, which might be of a shorter burst duration. And yes maybe in practice it doesn't help or isn't comfortable. Just options to consider and things to try.

Conversely, right now most of your pressure increases in this chart are via PS anyway, maybe indicating action against a Central that isn't flagged because the ASV prevented it from occurring.

When I used an ASV, I had aerophagia at the beginning of usage, maybe the first month after starting on therapy. I found that I used a left side sleeping position with my head and foot of my bed raised a bit helped. That's the same sleep positioning I needed for extreme back pain and GERD, so I just naturally maintained that for a while.
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#37
RE: New xPAP user - Question about Centrals on OSCAR
That's good advice re aerophagia, thanks Dave. For some reason, it seems worse on my sides. I did elevate the head of my bed.

My nights with ASV seem to be even less restful than BiPAP. I am thinking about returning to BiPAP (with my usual very high trigger/cycle sensitivities) for some nights to see if this is random exhaustion or due to sleep disturbance from ASV changing pressures all the time. How long did it take for you to feel rested after waking up with ASV?
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#38
RE: New xPAP user - Question about Centrals on OSCAR
I had to self titrate the ASV, meaning adjust settings to gain best therapy. There's not many settings on these ASV machines, but I felt I needed to try as many variables as I could. And this was before finding the ResMed ASV Titration guide so I was winging it.

Mode ASV Auto was pretty easy to choose for my needs. Then I raised EPAP Min for more air, and dropped EPAP Max some, ending at EPAP 8-13. I tried PS Min 4 but PS 3-15 was what I eventually ran with. 1 night of Ramp and I turned it off forever.

That was maybe 2 weeks or so of trial and error. Then another 2 weeks of focus on using ASV all night. From there it began to pay. I think the main reason it took that long was learning to keep the mask on all night as the experience with the prior DreamStation Auto BiPAP was so extremely terrible.
INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEBSITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#39
RE: New xPAP user - Question about Centrals on OSCAR
have you verified or ruled out plm? gotten treatment for it?

I've discussed my experiences with apap, asv and vauto in the context of my mixed apnea and plm all over the forum including a little in this thread. asv's fluctuating ps wears me out. I find vauto very slightly preferable with epap+max ps=max ipap (effectively fixed epap and ipap) and trigger at very high. I've had some partial success treating plm but it still occurs for an hour or so about 50% of my nights so fixed bilevel pressure is usually better for me. I do still switch between vauto and asv whenever I feel things going south with one or the other.

in my experience, no machine modality will help plm and plm makes it difficult to titrate and get good results from any machine.

regarding your question about how long to feel better rested with asv, I think whatever benefit I got from asv occurred pretty quickly once I got my settiings dialed in (that took a long time though). I don't think I can say I still feel exhausted because I feel light years better than even a couple years ago (5 years since first apap) but I still wake up so often I'm still tired whether using asv or vauto; again, usually slightly better rested with vauto. I wish I could say that plm was/is the only reason for my fragmented sleep; it's probably only about half the battle, but significant enough that I only started feeling noticeably better after addressing my plm. still trying to understand what causes my non-plm related awakenings. probably flow limitations and leaks. maybe some poor sleep hygiene habits like eating salty snacks before bed and during some awakenings.
  Shy   I have no particular qualifications or expertise with respect to the apnea/cpap/sleep related content of my posts beyond my own user experiences and what I've learned from others on this site. Each of us bears the burden of evaluating the validity and applicability of what we read here before acting on it.  
 
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#40
RE: New xPAP user - Question about Centrals on OSCAR
Thanks for the info about your ASV experience Dave.

Sheepless, I have read some of your posts about PLM, and it makes sense that it can complicate PAP therapy and be an additional source of awakenings. Thank you for posting on the topic. What are you currently taking for PLM?

Regarding my PLM, my ferritin was low. Ferritin is a marker for iron stores in the body and for some people with RLS/PLM and low ferritin, taking iron supplements to raise the ferritin level can improve restless leg syndrome/PLM, so my doctor prescribed iron supplements and he is monitoring my iron levels. From what I’ve read ferritin below 50 ng/ml is considered an iron deficiency. RLS/PLMD patients with an iron deficiency seem to experience some improvement in symptoms when their ferritin is above 70 ng/ml. When my ferritin was first tested 8 months ago, it was 20.5 ng/ml. After taking iron supplements every day since then, it’s currently about 48 ng/ml, so I am getting to where I need to be. My most recent titration showed reduced PLM, but these things can be inconsistent, so only time will tell.

This is probably more than most of you care to know about ferritin, but maybe someone will find it helpful at some point.
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