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Switched from ASV to CPAP, finally getting some sleep.
#1
Switched from ASV to CPAP, finally getting some sleep.
I was diagnosed with complex sleep apnea about 6 years ago and have been suffering miserably with ASV therapy ever since. The doctor who prescribed the machine told me my treatment was effective since my AHI was 0.0 consistently. Things came to a head earlier this year as my ability to function day to day declined to the point where I could barely work. I found a new sleep specialist who said that my experience was typical in people with a low arousal threshold and high respiratory loop gain. The high loop gain causes excessive pressure cycling (his term, not mine) which then causes microarousals on every breath. As he put it, this is pure misery and I certainly can attest to that.

At my last sleep study CPAP was tried along with 150mL of EERS and 250mg of Diamox, but my doctor felt my breathing wasn’t quite stable enough so wanted me to stick with ASV, but with a lower level of pressure support. Since I was eligible for a new machine I got a new Aircurve 10 ASV, the algorithm in this new machine is much more sensitive that the one in my old S9 and the pressure cycling was worse, leading to an even worse subjective outcome, which I didn’t think was possible.
 
A week ago I finally had enough so I switched the mode to CPAP at a pressure of 6.0 with 150mL of EERS and 125mg of Diamox and I’ve been sleeping better ever since. My AHI has been <1 the whole week, attached is last night’s data as an example.
 
So after more than 5 years of pure hell on ASV I feel I’m finally starting to turn the corner and improve my sleep. I just hope things continue to improve so I get to the point where I feel rested in the morning again.


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#2
RE: Switched from ASV to CPAP, finally getting some sleep.
That sounds like a miserable experience. I hope this success continues :-)

I'm new to this whole area, but I'm wondering to what degree doctors minimize apneas, assuming they are the same thing as sleep quality?
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#3
RE: Switched from ASV to CPAP, finally getting some sleep.
(07-10-2018, 12:07 PM)Stom Wrote: That sounds like a miserable experience. I hope this success continues :-)

I'm new to this whole area, but I'm wondering to what degree doctors minimize apneas, assuming they are the same thing as sleep quality?

I believe this is often the point stressed by the gurus on this forum: the lowering of AHI to what the science feels is successful treatment, that being 5 or under/hr on average, but ALSO the subjective experience that makes the patient feel he/she is getting acceptable quality of sleep, rest, and subsequent day-time clarity and function.

The physician can't be with us each hour of the day...or the night.  They can interpret the data for the night and seek to help the patient to get 'better'.  As is always the case, the patient has to have a large measure of efficacy, of control, and of responsibility for, their proper functioning 24 hours a day.
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#4
RE: Switched from ASV to CPAP, finally getting some sleep.
Low fixed pressure with no pressure support or EPR has been used successfully on members with complex apnea syndrome. It is our first go-to when someone new to CPAP is on the forum and has mixed apnea. It works for some and not others. You seem to have a very good result in terms of respiratory volume and pace without the ASV backup and pressure support. The only caution I will hold out is that complex apnea tends to be inconsistent, so you may not see excellent results like this consistently, but hopefully it is more often than not.

Just curious what were your ASV settings?
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#5
RE: Switched from ASV to CPAP, finally getting some sleep.
(07-10-2018, 12:34 PM)Sleeprider Wrote: Low fixed pressure with no pressure support or EPR has been used successfully on members with complex apnea syndrome.  It is our first go-to when someone new to CPAP is on the forum and has mixed apnea.  It works for some and not others.

My bad luck was to go to the head of the department of sleep medicine at my local teaching hospital and put all my trust in her. She obviously never heard of this approach and was very dismissive of my complaints.

I also did not come across this mode of treatment when searching the web. The ApneaBoard Wiki specifically says that CPAP can't be used to treat complex apnea. This is one of the reasons I decided to post this, I'm hoping to help spread the word that ASV may not be the best option for CSA in many cases.

(07-10-2018, 12:34 PM)Sleeprider Wrote:  You seem to have a very good result in terms of respiratory volume and pace without the ASV backup and pressure support.

This is due to the EERS, my respiratory volume is much lower without it.

(07-10-2018, 12:34 PM)Sleeprider Wrote: Just curious what were your ASV settings?

My old S9 was set to EPAP of 5 and PS of 3-8, when I got the Aircurve 10 it was set to EPAP of 5 and PS of 1-6.
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#6
RE: Switched from ASV to CPAP, finally getting some sleep.
The wiki was five years old and not very well researched. What we refer to as a "stub" put together by Supersleeper in hopes of being edited and expanded. I'll make a note of editing the article. http://www.apneaboard.com/wiki/index.php...leep_apnea

We seem to have a relatively high membership representation of complex apnea on Apnea Board. Most arrive with a new prescription to CPAP, no titration study, and not understanding why their AHI is over 30. Most of the time, we will encourage them to remove Flex and EPR, and to LOWER pressure and use fixed pressure. My typical suggestion is usually 7 to 8 cm pressure. This usually results in an immediate improvement in AHI, although there are exceptions. It usually takes about a month to see if treatment emergent complex apnea will adequately resolve on CPAP, and I would estimate less than 1/3 of the people with this problem find CPAP to be a good solution. Enough to be notable, but worth discussing ASV as something to get educated about. Most insurance requires a trial of CPAP before allowing BPAP with a backup rate or ASV, so your case is unusual in not trying CPAP for at least a month or two, which is a typical period for treatment emergent complex sleep apnea. I will probably lean on this article when I clean up the wiki: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700705/

Your ASV settings are unusual in that they use a low pressure support that would not resolve a CA event for most people. You also did not avail yourself to the autoASV mode. I don't know your diagnostic and treatment history, but I think it may exemplify why a CPAP trial may have merit to verify whether you can adapt and use CPAP. Now you have a $4K machine doing the job if a $800 or less machine. Most of the complex apnea members here would probably be envious of how easily you acquired ASV.
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#7
RE: Switched from ASV to CPAP, finally getting some sleep.
(07-10-2018, 01:27 PM)Sleeprider Wrote: The wiki was five years old and not very well researched.  What we refer to as a "stub" put together by Supersleeper in hopes of being edited and expanded.  I'll make a note of editing the article. http://www.apneaboard.com/wiki/index.php...leep_apnea

We seem to have a relatively high membership representation of complex apnea on Apnea Board. Most arrive with a new prescription to CPAP, no titration study, and not understanding why their AHI is over 30.  Most of the time, we will encourage them to remove Flex and EPR, and to LOWER pressure and use fixed pressure.  My typical suggestion is usually 7 to 8 cm pressure.  This usually results in an immediate improvement in AHI, although there are exceptions.  It usually takes about a month to see if treatment emergent complex apnea will adequately resolve on CPAP, and I would estimate less than 1/3 of the people with this problem find CPAP to be a good solution. Enough to be notable, but worth discussing ASV as something to get educated about.  Most insurance requires a trial of CPAP before allowing BPAP with a backup rate or ASV, so your case is unusual in not trying CPAP for at least a month or two, which is a typical period for treatment emergent complex sleep apnea.  I will probably lean on this article when I clean up the wiki: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700705/

Your ASV settings are unusual in that they use a low pressure support that would not resolve a CA event for most people.  You also did not avail yourself to the autoASV mode.  I don't know your diagnostic and treatment history, but I think it may exemplify why a CPAP trial may have merit to verify whether you can adapt and use CPAP.  Now you have a $4K machine doing the job if a $800 or less machine.  Most of the complex apnea members here would probably be envious of how easily you acquired ASV.

Well there is a little more to the story. After my first study about 12 years ago I was prescribed what today would be called a brick machine. I may of tried it for a couple of hours for 2-3 nights before sending it back. I then waited 5 years before going back and getting another sleep study, this time the doctor made the CSA diagnoses and prescribed ASV, maybe my previous go around with the CPAP that I never really used qualified me, don't know. 

My original S9 ASV had the old ASV firmware and did not have autoASV as an option. My new machine obviously does and I did try it for a few nights with little change in the pressure cycling behavior.

Agree about the cost. I'm 3 months into the 10 month rent to buy agreement. Insurance will end up paying about 50%. If I traded it in now for an Autoset I'd probably still save a lot of money.
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#8
RE: Switched from ASV to CPAP, finally getting some sleep.
(07-10-2018, 01:27 PM)Sleeprider Wrote:   I will probably lean on this article when I clean up the wiki: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3700705/
 
You might want to consider this as well, which was written by my current sleep doc. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3998090/
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#9
RE: Switched from ASV to CPAP, finally getting some sleep.
Makes a lot of sense. Do you have an image, or can you describe your EER? I am not familiar with the devices as a commercial item but the concept has been out there for a while. I think I have even suggested the use of some in-line humidity chambers, but the flushing rate of CPAP is too high for that to be effective. How about EER in combination with ASV?
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#10
RE: Switched from ASV to CPAP, finally getting some sleep.
I'd like to know this, too. With some quick googling, I've found Resmed and other companies make non-vented mask that are meant to be used with ventilators, that must be used with specially designed vented exhaust valves when using them with PAP or else they're unusable/lethal. Masks already have dead space. The bigger they are, like those like FFM or those facehugger masks, the bigger the dead space.
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