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Replaced my ASV, not happy, need help
#31
RE: Replaced my ASV, not happy, need help
I'll try that. it's not hard to exhale sharply through the nose with a nasal pillow mask though. takes about 1 second.
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#32
RE: Replaced my ASV, not happy, need help
Good morning, all. This is a long one, so forgive me if I’m oversharing. Before I post screenshots I think I should give some background. I am 68, normal weight, and have been sleepy (tired also, but mainly sleepy) most of my adult life, with ESS scores trending in the high teens and even 20+. My blood pressure tends to be on the low side of normal, and other than sleepiness I’m in good health. I’ve had several nasal surgeries, including a 2014 procedure to close a half-inch hole in my septum, followed by a turbinate reduction. I still have a fair amount of nasal airflow restriction, especially in my left nostril, but at this point any further surgeries could make it worse rather than better and I don’t want to risk that. I’ve had mixed opinions from ENTs on whether I have any palatial collapse. I also have a low arousal threshold and tend to wake up multiple times a night, sometimes I’m able to go back to sleep quickly, others not.

My first PSG was in 2013 and showed a total of 5 OAs (4 in supine, and I never sleep on my back), 42 centrals, 7 mixed, and 61 hypopneas, indexes 0.7, 5.6, 0.9 and 8.2 respectively, with an RDI of 12. My average saturation was 95% with a single dip to 88%, nothing lower. PLM index was 1.0. I was given an APAP with no guidance (though I did check this forum several times). That resulted in lots of centrals, sometimes severe aerophagia, and no change in sleepiness. I stuck it out for 8 months and gave up.

The second PSG in 2017 was cut short because I refused CPAP based on my experience. That one showed 4 OAs, 4 centrals, 14 hypopneas and 32 RERAs in 185 minutes, for an AHI of 7.1 and RDI of 17.5. Again no significant desaturation. Based on the number of central apneas, I’m inclined to think that at least some of the hypopneas in the PSGs were centrals. All of which would point to central/mixed apnea and likely UARS, which has a different profile than OSA.  
I finally got a good sleep doctor, and early this year started the bilevel—again few if any OAs, some hypopneas and lots of centrals each night, thus bringing me at last to the ASV. It seems that the goal of ASV therapy should be to provide enough inspiratory pressure to overcome the nasal restriction and just enough expiratory pressure to handle any collapse further down, without setting off pressure–induced leaks, aerophagia, puffy mouth, hypopneas, or arousals. And it was going pretty darn well until two weeks ago when I switched machines.

So to last night.  I was awake for a lot of it which I think skews things. I started as agreed with min EPAP at 6.4, but I couldn’t tolerate it – just pushed a lot of air into my mouth and got bubbly interruptions (not sure how to describe those). So I backed it off to 5.6. I also took the max PS back to 12 to make up the difference. That felt better, but the first time I woke up the AHI so far was 7.4--ouch. The rest of the night went better, ended up at 3.65 – but again for much of that I was awake. So this is what it all looked like:
First 2 ½ hours:
[attachment=16669]
Remainder:
[attachment=16670]
Total:
[attachment=16671]
These are close-ups of the big concentration of hypopneas and one more. It seems pretty clear from these that the leaks are in lock-step with pressure rises – but then the last three hours, no leaks at all.
[attachment=16672]  [attachment=16673]  

A couple of other things.  Even though the minute ventilation seems low, the tidal volume is in line with what it should be if I’m reading the references right. And given that the PSGs didn’t show desaturation, I don’t know that that is a problem. Also the EPAP, even when given free range, is just a bit higher than it was when things were going well—mid 5s compared to low 5s. Ditto the PS.

Re: blowback – I have a nasal cushion and can’t blow hard enough to change things. But actually the problem I’m having is not that the machine is trying to make me breathe. Quite the opposite--I can go what seems like a long time without breathing before the machine pushes back, and then much of the time the push is barely enough to notice -- which again seems odd.
So, thoughts?
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#33
RE: Replaced my ASV, not happy, need help
OK on the background. It helps us know historical info which surprisingly can be a benefit. IMO all makes sense there.

To the last night info:

This is how I handle setting edits for me, so apply as you feel OK on trying. Any edits are contingent upon 2 things IMO, data to say why and how much in what direction and then Feel and new data tells me it was good, bad, or no effect. If I ever get a bad or no effect, I returned it to the prior setting.

A bit of insight on how/why I edit: I look at my pressure settings in groups. In ASV Auto we can edit EPAP Min and Max then PS Min and Max. That's all we can directly edit since IPAP is machine algorithm chosen. However, since IPAP is whatever current EPAP and PS are you can indirectly choose IPAP range. Example: EPAP 9-13 PS 3-15 equals IPAP 12-28, for me if I decided to cap IPAP Max to 25, I'd change PS down 3 to 12. Follow similar if you wanted to influence an edit of IPAP Min. I am not saying it's the right thing to do, but that's what I do. My EPAP range has needed edited when I started, and I tried upping my EPAP Max to 15 recently and I instantly disliked the feel. It went back and that's it for those EPAP edits. Since my EPAP range is small compared to PS, I leave it as is now. Small range means there's not much room to adjust and my results show it's OK as is. For me, PS edits are easier and the results look OK on data. I consider EPAP Min my absolute lowest pressure I can get away with while maintaining an air splint. The EPAP range is there to edit the splint on the fly if need arises, as I see it. Lastly, I group EPAP Min and PS Min edits separate from their Max settings. If I want a Min change, it would be either EPAP Min or maybe PS Min. Same on the Max side except I won't up EPAP Max for now.

Let's see if we can help duplicate at worst your "Remainder" info. I don't see pressure edits on these so good vs bad maybe was random. The leak chart shows a bit more activity on the bad so there's that. No large leaks so I'd say excellent on that aspect.

I noticed that the bad section shows on the pressure chart that it topped at 13 quite a bit but the good section shows it went to 17 at times. Sounds like a setting induced pressure cap may be hindering optimal therapy at times, but I don't see where/if pressure settings did change...

Your pressure settings, which was better to you on EPAP Min? Sounds like 5.6 would be your more liked of the two mentioned. I think eventually EPAP Min will need to be higher, but let's go with what is most comfortable for now.

I find that wake sessions of the ASV never look good. Probably because it's a sleep therapy machine I guess.

Hypopneas I find respond to upping EPAP, probably better on the Min side. And hypopnea can have attributes of either obstructive or central I believe. I'll be honest, I've not studied out my TV, MV or other similar charts much. There's some ways to use settings to modify it, I want to say PS would be more likely to modify that.

Blow back can be filed away in case it's useful if it is needed then.
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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#34
RE: Replaced my ASV, not happy, need help
(11-01-2019, 12:49 PM)bemused Wrote: And it was going pretty darn well until two weeks ago when I switched machines. 

I finally got a good sleep doctor, and early this year started the bilevel—again few if any OAs, some hypopneas and lots of centrals each night, thus bringing me at last to the ASV. 

I was given an APAP with no guidance ... I stuck it out for 8 months and gave up.
Which BiPAP model?  OSCAR?

So to last night.  I was awake for a lot of it which I think skews things. I started as agreed with min EPAP at 6.4, but I couldn’t tolerate it – just pushed a lot of air into my mouth and got bubbly interruptions (not sure how to describe those). So I backed it off to 5.6. I also took the max PS back to 12 to make up the difference. That felt better, but the first time I woke up the AHI so far was 7.4--ouch. The rest of the night went better, ended up at 3.65 – but again for much of that I was awake. So this is what it all looked like:  

(The Positional Cluster) These are close-ups of the big concentration of hypopneas and one more. It seems pretty clear from these that the leaks are in lock-step with pressure rises – but then the last three hours, no leaks at all.
  

Re: blowback – I have a nasal cushion and can’t blow hard enough to change things.


Hi Bemused!

Thanks for putting in the hard work to write this us.  The context helps a lot. 

There is a lot here so I will write separate replies to try and keep it easier to follow.  

Quick questions from the history above.
  • Was the APAP a Dreamstation?
  • What can you tell us about the BiPAP you used.  Was it a Phillips DreamStation?  ResMed Vauto?  Other?
  • Do yo have a Pulse-Oximeter at home that will record data while you sleep? 


First I assume you here working for three goals.   Please correct this if wrong
  1. Get the ASV running nicely for you.
  2. Get a Great Night Sleep.
  3. Feel Better 
  

On Goal #1 - Get the ASV running nicely for you.

"And it was going pretty darn well until two weeks ago when I switched machines." 
Is using that machine still an option?  You seem to like it better.


A much better night.  Congratulations!

Before getting into some of the detailed topics lets cut to the chase on key learnings and next steps. 


NEXT: What we learned from last nights results and what we do next.  

Blowback:  Saw it is not much of an issue.  If you ever are feeling too much of a push of air from the ASV try just opening your mouth and take one relaxing natural feeling breath and it seems the machine resets (at least for me).  

Lowering AHI - Positional Clusters:  The cluster around 1am looks positional anything you can do to stop those will really drop the AHI events that sometimes disrupt and desat.  Apart from that cluster the results look pretty good so setting EPAP Min was a big help.  

Lowering AHI - Leaks:  Maybe it is good news a good number of the remaining Hypopnea are associated with Leaks because we can work on and improve the leak rate.  Have you already skilled up on killing leaks or want our inputs. 

Next - Configuration changes:   If the goal is a low AHI then you are pretty close.  

EPAP Min:  Seeing what you wrote about the struggle with 6.4 and going to 5.6 I would just methodically try to increase EPAP Min over time.  Slowly adding .2 or .4 incremental increases only going as fast as your body adjusts well to the increased EPAP.    

PS Min:  Increasing ASV PS will sometimes and sometimes hurt.  I would try adding .2 or .4 increases to slowly increase PS over time and just see what happens at each new level.  Sometimes we can make a small change each night and sometimes only one change a week to really know the impacts.  Bias for faster but know sometimes you will need to go slow.  

PS Max:  I still have a bias to lower PS Max to 9 or 10 for one or a few cycles to see if it helps or hurts.
  • From your screenshots, the majority of your night you use that pressure and were not using it during your best three sessions of the night.
  • It is has not yet been clear yet in our work together that the higher PS Max is adding any value
  • Apart from the positional cluster area, it appears the most or all of the remaining Hypopneas are related to a Leak.  Leaving PS Max higher increases Leaks and the ASV gets wonky and starts adding Hypopneas around Leaks.
  • The less leash (range of PS between PS Min & PS Max) we give that sometimes wild dog (ASV) the fewer unexpected crazy things happen with the moon comes out.    
  • The less leash (range of PS between PS Min & PS Max) we give that always faithful dog, always ready, always eager to Uber-responsively and rapidly bounce PS pressures up and down all night the less trashing pressure changes happen which means we might see our average nightly heart rate down, get more real rest and feel more rested.

So for tonight I recommend you:
  • EPAP: Either stay at EPAP Min 5.6 or add .2 or .4 and see if it works for you, whatever you think best.
  • PS Min: I recommend you add back .4 to PS Min and lets see how that works out.
  • PS Max:  I still would like to see you try lower values 9-10 and see if it reduces events that disrupt your sleep.   Of course this is all your call.
Your thoughts?

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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#35
RE: Replaced my ASV, not happy, need help
I don't remember what the APAP was, too long ago, but Apria seems to stick with Resmed so it was probably that. The bilevel was an Aircurve 10. I used it for 3 months before being able to go to the ASV. Just for comparison -- the left side is the bilevel:
   
The previous ASV was an Aircurve S10, same as the one I have now. But it was going to be a permanent rental courtesy of Kaiser, and since I am likely moving out of their area they would take it back. So I bought a used one from Second Wind and turned the rental back in. I now kind of wish I'd hung onto it a little longer for comparison. The used one had just 392 hours, but I have wondered if it's an older model or even has something wrong with it since I've had all these issues. Hopefully not the case.

I don't have a pulse oximeter and am hesitant to buy one as none of my studies showed any desaturation to speak of, and I am not really concerned about oxygenation. My main issues are sleepiness and fatigue along with fragmented sleep. So yes, those 3 goals are exactly what I'm after.

I changed out my nasal cushion, headgear and tubing and am waiting on a new frame for my Dreamwear mask. That seems to have helped at least some with the leaks, so now just have to stop the pressure-related ones.

Looking back I was doing better with a smaller range on the PS. So I think your suggestions are good ones. I think I'll keep the EPAP minimum at 5.6 for the time being and not to try to raise it just yet. I could also dial back the EPAP max, but it never seems to get there so that may not matter. I'll cut the PS max back to 10 and add .4 to the PS minimum, so that will be 4.4. And let you know what happens.
Thanks again!
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#36
RE: Replaced my ASV, not happy, need help
Cool.  

Thanks for the update!

"The previous ASV was an Aircurve S10"

The Aircurve 10 S is not an ASV, but a ResMed BiPAP supporting Spontaneous breathing.    If you were using a different machine that might help sort things.

I the OSCAR stats section of the previous ASV what does OSCAR publish as the machine type?

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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#37
RE: Replaced my ASV, not happy, need help
I'm not answering for bemused, but she could still be referring to the ResMed ASV as in it's a ResMed S10 ASV, S just a shortened version of Series.

Not a sarcastic comment at all intended by me, but S10 seems to indicate that can mean ASV still, whereas if she said "10 S" or similar I'd likely think the S for the Spontaneous version just like you are.
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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#38
RE: Replaced my ASV, not happy, need help
It was an ASV, the exact model I have now. Sorry for not being clear.
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#39
RE: Replaced my ASV, not happy, need help
Realized I never updated the profile. Sorry!
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#40
RE: Replaced my ASV, not happy, need help
No problems here. A great eve to ya. And like WillSleep said, any edits etc. are your choice. I think both he and I are on the right track to assist. What actually works? Try an edit and see the results. Wish it were easier for all of us here but it's what we got stuck with unfortunately. We could still be using original type CPAP machines with big belt drive motors, basically vacuum cleaner hoses, and helping make our own masks at the hospital.
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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