[Treatment] ASV Settings

[WayTooTired]

Hi.  I was prescribed an ASV 3 weeks ago by an out of state sleep lab who I had seen to assess whether or not I was a candidate for an INSPIRE device (as it turned out the lab had limited experience with INSPIRE and I am no longer considering them as a possible provider).  I'm transferring to local support, agreed to give the ASV a try and would like to refine my ASV settings in preparation for my upcoming appointment.   I have had 3 sleep studies.  First study qualified me for nocturnal oxygen with an AHI 0f 35. AHI at the second sleep study was 65.  I have treatment emergent central sleep apnea.  AHI for the most recent sleep study was around 30 with most of the events occurring while sleeping on my back which I avoid now.  Titration study was less than conclusive with a sleep efficiency of 50% during diagnostic mode and I was prescribed the default settings for the machine: EPAP: 5, PS 4-15.  Sleep doc was agreeable to increasing the EPAP a cm or two of H20.  The arousal index at 4/3/4 and 5/4/4 during the diagnostic study was significantly lower than at the other settings but a few hypopneas were experienced (AHI of 4 and 5).  Current settings are EPAP: 6.8, PS 3.8-8.8 (I tweaked the PS down due to instabilities in inhale time, exhale time, etc).  Any thoughts on how I might tweak the settings over the next week in preparation for a review with my new sleep doctor?  Any key features in the OSCAR data that need to be considered? 

           

[SarcasticDave94]

I'm surprised you're getting ASV to combat treatment emergent CA. I had to fight to get ASV to cover predominant CA.

Musings; are you having to pay any of this ASV purchase?

Where is your detailed redacted sleep diagnostic?

TECA typically diminish once you're used to PAP therapy.

TECA not normally treated via ASV.

The settings you're running can be had with VAuto and almost with AutoSet on EPR 3. But neither VAuto or AutoSet can treat CA. Then again, your settings aren't close to treating actual CA needs.

You aren't running ASV Auto, your PS is static and low for ASV needs.

Try OSCAR screenshot with F12 button for better images.

[Sleeprider]

With the ASV your apnea index is very low and you appear to be well treated. Normally ASV is prescribed for central or complex apnea, and only after failing CPAP and bilevel therapy. Your machine has an ASVauto mode that will self-titreate for obstructive events, so I would suggest you consider using ASVauto mode rather than ASV fixed EPAP mode and use a range of EPAP min 6.0, EPAP max 10.0, PS min 3.0 (or 4.0 if you are happy with current minimum PS), and allow up to 10.0 PS max. I'd be very interested to hear more how you came to be using ASV and any sleep study or titration that was used to establish these settings.

In future charts, we can get better information with a single chart using the screenshot from the Daily Details screen. Examples are given in the Organizing your Oscar Charts in my signature links.

[WayTooTired]

Thanks for the reply Dave.  My insurance provider previously purchased an APAP machine for me with no co-pay.  I battled the machine for 10 months and was never able to work through the central apneas and non-periodic breathing events.  At the time I had to beg a sleep therapist for the detailed data (I didn't have OSCAR at that time) and in hindsight a more proactive team of therapists and sleep specialists might have been able to make the system work.  To their credit COVID created some challenges with timely access to medical expertise.  My insurance company was agreeable to an ASV because more than half my events during the therapeutic session on CPAP were central.  I believe all of my apneas were central on CPAP and I had an AHI of 20 (all central).  My co-pay on the ASV is minimal and after 10 months I will own it.  The sleep study showed that the ASV cleared up all of my centrals and only left me with a few hypopneas.  That being said I don't fully understand your comments on why my current settings won't touch my centrals since the settings are in-between what was run during the last sleep study and centrals were eliminated.   I backed the PS down because of fragmented sleep, instabilities at the higher pressures and the relatively high number of desaturation and pulse events (75-100 pulse events/night) at the higher PS settings.  For now I have the system I have.  It will run in CPAP, ASV and AutoASV.  Are there any variables that you or others would recommend tweaking  given my current ASV settings and the OSCAR data?  I have one night in ASV auto that I can post if that will add more insight.

[SarcasticDave94]

OK the extra info gives things we didn't know prior. As for settings, currently on this snapshot, they're OK because it's well treated, but CA are wildly variable, as in consistently inconsistent. If me, I'd get ASV Auto mode back online and consider making EPAP a range of 6-10 and PS a range 3-8 or so.

If insurance is happy to pay up OK go for it. Which one have you BTW? Maybe all PAP users need it. It sounds like you CA were more than treatment emergent or the pulmonary staff goofed.

[WayTooTired]

Thanks SleepRider.  I provided some background on my path to an ASV in my response to Dave.  I've attached screen shots from the only night I had on ASV Auto and a comparable screen shot with my settings from last night.  Please let me know if i should consider alternate settings to those recommended in your prior post after taking a quick look at the ASV Auto output.  

What I ran previously: ASV Auto, EPAP 6, PS 6-12
Your recommendation prior to seeing the ASV Auto data: EPAP min 6, EPAP max 10, PS min 3 or 4, and allow up to 10 PS max

Thanks,

Don

[WayTooTired]

Thanks Dave.  The info you provided and SleepRider provider gives me a good starting point for tonight.  I have a FEPBLUE insurance plan, basic option.  I believe I pay 20% on DME.  There was no co-pay on the prior APAP machine because of the copay I negotiated with the DME provider.  I didn't have the option of using the prior provider on the ASV because I got caught in the middle of the Respironics recall and ResMed cancelled all of their prior order commitments and at the time hadn't specified a date when they would be accepting new orders.  Don

[SarcasticDave94]

It appears that the last chart, the one with ASV Auto mode, EPAP was set as if it's static negating the Auto mode. Hypopnea increased there in what appears could be positional clusters.

And PS min 6 is too high. Drop it to PS Min 3 or 4 at most. This PS min 6 is showing on your attempt at ASV Auto mode.

What I mean by static EPAP is if EPAP Min and Max are identical. Example

ASV Auto mode
EPAP 6.0-6.0 PS 6.0-12.0

Equals

ASV mode
EPAP 6.0 PS 6.0-12.0

For ASV Auto mode to do anything, EPAP Min and Max need to be different, a range.

[Sleeprider]

Your chart does not show what the settings were with ASVauto, but they effectively did not allow changes in EPAP pressure. This resulted in that night having a lower EPAP pressure which may account for the higher hypopnea and UA event rates. The ASVauto trial shows that in your case, EPAP needs to be higher, and that the PSmin of 6.0 is too high, creating more events. Your therapy efficacy is not apparently dependent upon PS above 8.8 cm. Based on that my suggestions for ASVauto mode would be to set EPAP min at 6.8, EPAP max at 10.0, PS min at 3.0 PS max at 10.0. I don't think your settings in this trial disqualify ASVauto as less effective, instead it just shows you needed lower settings for PS min. That said, I have no argument for your titration in ASV mode which has produced exceptionally good results and is apparently comfortable.