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Replaced my ASV, not happy, need help
#1
Replaced my ASV, not happy, need help
So I was doing so well with my ASV, but. . .I have Kaiser, and it turns out the deal with them is that the machine is a permanent rental—i.e. you pay the copay for 11 months and then no longer have to pay rent, but you don’t own the machine, which means if you leave Kaiser they take the machine back. Since there is a good possibility we will be moving to New Mexico in the next year or so, and therefore leaving Kaiser, I was looking at losing the machine after paying around $900. Plus I would be faced with finding another sleep doctor and going through the whole process of qualifying for an ASV. Given what I’ve been reading here I’m concerned I would have problems getting it prescribed and covered—and even then would have to start all over paying for it. And in any case I would be without one in the interim.

So I talked with my doctor and she gave me a lifetime prescription, which I used to buy a “gently used” machine from Secondwind. So far so good. But since I started using the new machine I now get why people feel like they are fighting with it. But to me it feels almost like the opposite of what others are saying, in that I feel like I am struggling to breathe much of the time and that the machine takes way too long to initiate a breath. I was hypothesizing that my original machine was maybe a newer model and that Resmed has improved the algorithms, because I was comfortable with the other one from the beginning. Whether or not that’s true, I now have this one and I need to make it work. So I need help.

The overview shows how much everything changed – I started the new machine on October 18th. I thought at first that the problem might be the mask since the leaks went up – but that would be too much of a coincidence. Still I replaced the cushion and the headgear, no help there. I think now that most if not all of the leaks are from my pulling at the cushion trying to get more air. I’ve also tried adjusting the humidity – it has gotten much colder here in Colorado so the room air is drier, but that hasn’t helped either.  
 
[attachment=16618]

These are from October 16th – about as good as it gets. The prescribed settings for the new machine were wider than these, so I set them back to match this in hopes of getting the same results.
 [attachment=16617]  [attachment=16619]

And these are last night. Ugly.  Lots of awakenings. I thought that most of the hypopneas might be false flags while I was awake, but it seems obvious a number were while sleeping.

[attachment=16620]  [attachment=16621]

One thing that jumps out at me is the respiration rate and especially the inspiration and expiration times, which are wildly out of whack. The last session this morning I consciously focused on relaxing and letting the breaths happen from my diaphragm and with the machine, which definitely helped, but I don’t know how that would carry over to sleep.  I also upped the PS minimum to 5 so that I could get more air while waiting to go to sleep – actually felt like that might be a bit much but I’m inclined to keep it there. I’m also thinking about lowering the EPAP minimum and range so that exhalations are easier--in the sleep studies and with Bipap I had almost no obstructive apneas, they were all hypopneas, centrals and RERAs, so I should be able to keep the EPAP pretty low, right?  Where do I go from here?

I will say that despite the bad numbers, I am still feeling better than before any ASV. I just want to keep that going. Thanks in advice for your help -- don't know what I would do without this forum.
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#2
RE: Replaced my ASV, not happy, need help
OK a few questions to make sure we're on the same page. You do have an ASV that you're keeping? Hope so.

Do you use Ramp in any way? If yes, try to get to the place where you can minimize timing or turn it off. The entire Ramp time will equal near zero therapy.

Do you feel air starved still? If so, bump your EPAP Min up at least to 6. It may go up more later. Your PS Min isn't going to be noticed at the very beginning according to what I've experienced.

Very important, keep large leaks to the lowest you can. That ASV doesn't want leaks if at all possible.

Last one for now, if when you're drifting off to sleep and your ASV blows hard awakening you, assuming you're using a full face mask you can Blow Back. Literally blow back moderately forceful into the mask and it'll back off.

Post more data and let's track your progress.

PS list your pressure settings for me please.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
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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#3
RE: Replaced my ASV, not happy, need help
Yes, I am keeping it -- I really am feeling a lot better since I started with the original one so I am determined to make it work for me.

I don't use Ramp at all, never have.

It seems counter-intuitive to me to raise the EPAP if I am starved for air on the inhale. Doesn't it make more sense to raise the PS, so that the IPAP minimum is enough to keep me happy? Because otherwise I have problems on the exhale. Right now the beginning pressure is at 9 (EPAP 4 plus PS 5) which at least this morning seemed ok.

I don't really have any large leaks -- the Dreamwear has been working quite well. I do think most if not all of the leaks happen when I pull on the cushion to reposition it so I can get more air.

Current settings (just changed so haven't slept with them yet):
EPAP min 4, max 7
PS min 5 max 15

Before today was:
EPAP min 5 max 8
PS min 4 max 13
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#4
RE: Replaced my ASV, not happy, need help
What other data do you need to see?
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#5
RE: Replaced my ASV, not happy, need help
OK got it thanks. I just wanted to see pressure settings to track what you're using. Mask leak was just a tip, not that I was stating you had any; a zero on large leak is always good to see. Good news about ramp as well.

Your call to try EPAP or PS Min edit, but my understanding is the EPAP Min is your Obstructive Apnea air splint so you most likely will not want 4 and maybe not 5 either. Again your call though. Balance numbers and comfort. When I felt air starved, I got better results by an EPAP Min bump up. And I'm running my EPAP Min about 2-3 below my median.

For myself, I bumped numbers by 1 either up or down to gauge whether it was helpful or not. I tried it 1 night and if it was negative I knew it quickly. If you're not certain on an edit, unless your numbers go bad on you keep the edit a few days and continuously evaluate. Then decide to keep it or not. And remember you can bump fractionally if desired in 0.2 steps.

You can post your setting results via OSCAR and we'll see what you get. Note how you feel regarding the therapy, this will eventually be a better indicator than the numbers.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
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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#6
RE: Replaced my ASV, not happy, need help
OK. My median EPAP is running around 5.5-5.6, so I think I'll be safe with 4, especially since I never have had a lot of obstructives.

But. Looking more at the last week it does look like there is a correlation between leaks and events, even when the leaks are relatively small. So I need to address that. As I said I've replaced the cushion and headgear, so it has to be something else. I guess I need to get a new frame? And maybe try replacing the climate line tubing as well. I have a spare tubing, but will have to wait on the frame.

So will keep you posted on how it goes.
Thanks!!
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#7
RE: Replaced my ASV, not happy, need help
Welcome and keep us posted. Post new charts as you wish. And keep all this in this thread for historical use. Trying new mask parts can't hurt. Best to ya.

PS we'll pick up pointers on your respiration rate and corresponding times as we go along.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
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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#8
RE: Replaced my ASV, not happy, need help
Hello Bemused!

Sorry to hear of the ASV struggle.  

I do believe between Dave and the many others here with ASVs we can sort some things out. 

The things that caught my eye in your first post ...
  • The good sample Minute Vent was 4.63 and the new / Bad was 3.88.    It see it often published that the normal Minute Vent is range between 5-8L/min.   So if you are an average height female your Minute Vent looks noticeably low.   
  • Is this 4.63-3.88L/min Minute Vent number a concern to you or does that seem right to you and we should keep looking for things to work on?
  • I noticed the full average range of Airflow in your Flow Rate chart looks smaller, narrower than on Oct 16th.
  • There are many leaks in the new chart.  If these leaks are common across all new days the Leaks will be a big source of frustration with the ASV and might alone be something that explains why the new machine is 'different.'         


Before today was:

EPAP min 5 max 8
PS min 4 max 13

Dave has helped a lot of people with ASVs and so I recommend you give his recommendations a whirl.   Dave convinced me to get my ASV.      

I would be remiss if I did not share my first gut response when I saw your first post was to recommend loosing the Leaks and to raise your Min EPAP 1.5 cmH2O without changing pressure and see how much help you get to increase the amount of oxygen you are getting.   

Beyond just killing OA events a higher EPAP (aka PEEP) drives greater Tidal Flow and Minute Ventilation which increase oxygenation.   In normal ventilation ~EPAP/PEEP is raised until the oxygen saturation reaches 95% then Pressure Support is applied to provide comfort to the patient.    

On the ASV you have Min EPAP and Min PS to adjust to raise oxygen.   On the ASV at some point I see best results raising them a wee bit at the same time but right now your EPAP/PS mix looks out of balance to me, your EPAP Min looks too low.  Generally EPAP should always be 1-3 cmH2O higher than PS even if the when total IPAP is low.   Generally a PS min of 4 should have a EPAP min of no less than 6 or 7.   So if you were running Min EPAP 5 in the Oct 29th chart then I at some point if you have not yet found relief I would recommend you try EPAP Min at 6.5 and leave PS where it was on the 29th to see what happens. Also unless you know for sure you don't want that I would raise EPAP Max to 10. It is Sooooo hard to get EPAP to go up much on an ASV there is usually very little risk leaving the upside a little more open and the ASV needs EPAP Max room to use EPAP to help counter Leaks and when that happens the higher EPAP is not really something we feel much because it stops when the Leak stops.

If you would like more input now posting two Oct 29th charts might help provide clarity. A two min chart showing Flow Rate, Pressure,  Tidal Volume, Insp Time and Exp time and at 1:55am and a two min chart when EPAP and PS pressures are both near the highest and there are no active leaks to confuse things.  



"I don't really have any large leaks -- the Dreamwear has been working quite well. I do think most if not all of the leaks happen when I pull on the cushion to reposition .."     OK Good

Good Luck. 


WillSleep

INFORMATION ON APNEA BOARD FORUMS OR ON APNEABOARD.COM SHOULD NOT BE CONSIDERED AS MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF A PHYSICIAN BEFORE SEEKING TREATMENT FOR MEDICAL CONDITIONS, INCLUDING SLEEP APNEA. INFORMATION POSTED ON THE APNEA BOARD WEB SITE AND FORUMS ARE PERSONAL OPINION ONLY AND NOT NECESSARILY A STATEMENT OF FACT.
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#9
RE: Replaced my ASV, not happy, need help
I forgot to address your humidity settings. You may be aware there's 3 settings to edit: heated hose settings, humidity settings, and humidity mode of manual and automatic. If not tried yet, go to manual with the others as is and see if it's better.
Dave

OSCAR
Standard OSCAR Chart Order
Mask Primer
Dealing With A DME
Soft Cervical Collar Wiki
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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#10
RE: Replaced my ASV, not happy, need help
I notice you've got Oscar set to report obstructive apnea. However the Resmed ASV doesn't differentiate between types of apnea, it reports them all as unclassified. So on your charts you should turn off OA and turn on UA, and see if that throws some additional light on what's happening.
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