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[Treatment] Fine Tuning my Resmed ASV Machine with Incremental Wins
Fine Tuning my Resmed ASV Machine with Incremental Wins
First let me start by saying this is my first post.  I'm looking for confirmation that I am doing the right thing in analyzing my SleepyHead data and adjusting my machine for my particular needs. But before that, perhaps a brief background might be in order.

I was diagnosed with Sleep Apnea over a year ago. Going through Kaiser has been quite a rollercoaster ride for me. I went through 6 studies over about 8 months with 5 different machines at home, 8 masks and one in-house study. During that time I read everything I could find on the internet about SA and countless threads on this forum. Study #6 finally got me a Resmed ASV loaner and the resulting data was compelling in the fact that I do indeed have CSA and the ASV provided effective therapy. To say I am a little bitter with Kaiser would be an understatement. Their lack of sharing information with me, so-so knowledge, and processes that take over a month to make little baby steps has prodded me into being very proactive in my SA journey. My main goal was to get a Dr's prescription, buy the equipment and be done with them.

So I have been using my Resmed ASV machine for about 7 months now and have been learning how to work through this love-hate relationship. I have had much help from searching and reading various topics on this forum. Many thanks to its many contributors. Now I wanted to figure out the optimum settings for my machine.

My Sleep MD prescribed a setting of EPAP Min 4CM, Max 8CM, PS Min 4CM, Max 15CM. (4, 8, 4, 15) While this works, I felt it was only a starting point. I read somewhere on this forum where somebody posted to open up the machine's settings and let it do what it is supposed to do - figure out what the best therapy pressure is necessary and when it it needed. It made perfectly good sense to me to let it do what it wants to do without me restricting it.

So I opened up the settings (4, 15, 0, 20) and after a few evenings I looked at the SleepyHead data. Immediately I knew I didn't like the PS Min setting of 0 as I felt like I had to labor somewhat to inhale. So I bumped it to 4 and later to 5. That was a "comfort" setting change for me and it feels perfect at 5. Next I started to log the EPAP & IPAP Daily Statistics into a spreadsheet and started scrutinizing the "Time at Pressure" graph. What I observed in SleepyHead was the ASV IPAP pressure was trying to get up to the machine's max of 25 on occasion but had to wait for the slow acting EPAP pressure to rise over many minutes before it could get there. And in the mean time I would get clusters of event flags (8 to 15) before EPAP pressure would rise enough to allow IPAP to max out where needed.

I logged these stats for about 2 weeks and looked over the SleepyHead graphs carefully and decided to bump the PS from 15 to 20, its maximum allowable setting. Now at (4, 10, 5, 20), I have only had one night at these settings. I realize one night is insignificant, but I am excited that my optimal settings are within my grasp. I think that is partly why I am writing this - to share my progress in a positive direction.

My successes... Last night I had 7hrs, 50min of sleep on the machine (a record for me). And I had 14 events total of which 13 were in clusters within minutes of waking. So those I feel are insignificant throwaways. I recently had one sleep session just short of 5 hours - another record for me. Haven't slept for more than 2 hours at a time in probably 20+ years.

So, I would like to thank the many contributors in helping me, a predominantly silent member, have many little wins along my journey to better health. And I do feel so much better.

Note - Why the 10CM max for EPAP? My SleepyHead stats regularly max out around 7.5 to 8.0 but on rare occasion only approach 10.


Ray B.
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RE: Fine Tuning my Resmed ASV Machine with Incremental Wins
Your original settings were essentially a starting point as described in the ASV titration, with the exception, most people are started at a PS min of 3.0 for comfort rather than zero.  I'll post the titration protocol below. We have many members using the ASV and it would be more helpful if you attached some Sleepyhead data so we can understand why your pressure is pushing so high. Normally I would only increase EPAP min for obstructive apnea and use PS min for hypopnea and flow limitation. In most cases people using ASV are more comfortable with lower pressures, and the idea is to minimize the obstructive events and use the pressure support backup to pick up the centrals.  With complex and central apnea, a higher minimum pressure support and higher pressure overall can increase reliance on the ventilator because both of these conditions exacerbate the number and severity of CA. It's hard to say whether your approach which is aggressive on pressure is the best tact, however you indicate you're now more comfortable.

It might be helpful to review your experience on CPAP and BPAP prior to obtaining the ASV. It is probably typical in that higher CPAP pressures and EPR likely increased events, and BPAP would have been worse than CPAP.  Anyway, post some data and we might be able to identify some issues to help you improve further.

[Image: attachment.php?aid=4210]
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RE: Fine Tuning my Resmed ASV Machine with Incremental Wins
Hi Sleeprider and thanks for the help.

My apologies. I should have been more clear on the Dr's original parameters. They are close to the ones in your graphic. My Dr's initial settings were EPAP 4 min, 8 max, PS 4 min, 15 max.

I have put together some good screenshots of SleepyHead for you.

I have included an Overview showing the VAuto in Study #5, ASV in Study #6 and my ASV.

These "Ugly" two screenshots are from the worst night on the VAuto in Study #5.

Here are a couple screenshots that are typical of the the ASV machine with the Sleep Dr's parameters of EPAP 4 min, 8 max, PS 4 min, 15 max.

The following screenshots were from a couple nights ago, Mar 13, with the settings of EPAP 4 min, 8 max, PS 5 min, 20 max.
  (Running out of Allocated Attachment Usage so I'll try links to my DropBox. Not sure if this is going to work.)

  (Oops - it says I can't include links until I have at least 4 post. I'll see if I can do a couple separate replies instead.)

I think I jinxed myself - I was outdoors yesterday playing around with the firewood and likely got a dose of pollen. So my nose was somewhat stuffed up and I couldn't breathe through my nose well, let alone have the mask on. So I fought it, struggled, got a belly full of air, and finally gave up for the night. So another "Ugly" screenshot.

  (Ditto - Oops - it says I can't include links until I have at least 4 post. I'll see if I can do a couple separate replies instead.)

And lastly a screenshot of the Statistics page that shows the parameters I have played with and learned with.

  (Ditto - Oops - it says I can't include links until I have at least 4 post. I'll see if I can do a couple separate replies instead.)

If these screenshots don't work out, I can share them another way.  I think this is the proper way according to the posting protocols I have read here.

Thanks again Sleeprider.  Now I'm going to study your graphic a little more.

Ray B.
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RE: Fine Tuning my Resmed ASV Machine with Incremental Wins
My apologies.

I can't seem to find a workaround for the file attachment size limit and the "can't post links" restriction right now.  Will have to figure out how to share these screenshot images later.

Ray B.
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RE: Fine Tuning my Resmed ASV Machine with Incremental Wins
Your allowed image attachment limit will increase rapidly as you gain post count. Feel free to send a PM to SuperSleeper who is the admin and site owner to let him know about this problem. His intention is to not limit the important attachments, but prevent too many by newcomers that might be intending to post spam.

Your images are pretty revealing. The results on the Vauto are what I would have expected for complex apnea with PS 6.0...terrible central apnea! Impressive. Your current results on the Aircurve 10 ASV are much better and AHI is entirely hypopnea. Current settings are EPAP min 4, EPAP max 8 and PS 4-15. This does resolve all of the apnea. I think a lot of the issue here is your low respiration rate of 10 BPM, but your tidal volume is good and results in a decent minute vent. As you note in your graphs, the hypopnea seem to occur in clusters, and this may be a positional apnea issue that we often address with the use of a soft cervical collar. Don't confuse "positional" with the idea of sleeping on your back, we are talking about tucking the chin which can restrict the airway. Read the Positional Apnea section of this wiki article http://www.apneaboard.com/wiki/index.php...onal_Apnea

It's possible you need a higher EPAP pressure. These events seem to extinguish when your pressure is at 5.6 to 6.0, so an increase in EPAP min to that range may resolve the problem. I would try that first, and if they continue to recur, then consider using a soft cervical collar to prevent your airway from being restricted. You can probably test this by sitting and relaxing in a comfortable chair and letting your chin drop to your chest. If you notice air restriction, that is the mechanism of your hypopnea. We can see the flow limitations correspond with the hypopnea events, and either EPAP pressure or a collar should avoid this. The other problem is simply short therapy time. Your therapy is extremely fractured as shown in the summary overview graph. Recently, this has been improving, but we need to understand what causes you to break therapy and not sleep with the machine.
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RE: Fine Tuning my Resmed ASV Machine with Incremental Wins
Thanks Sleeprider. I just sent a PM to SuperSleeper. Perhaps I'll be able to share the other screenshots soon that I prepared.

You mentioned my respiration rate is low at 10 BPM and I agree. My waking respiration rate is about 7 BPM. It has always been that way as was my mother's. Not sure if that has anything to do with it.

I have read a lot about CSA and the types of people with various ailments as a root cause of CSA's. It's weird, because I have none of those issues, never smoked (anything) either. No opioids, no drugs, no alcohol - I guess I'm pretty boring. The only health cause is probably my being overweight. And that has always been a struggle. I have had a few health issues as a result of my CSA which is what eventually lead to the discovery of my having CSA. We connected all the dots a bit over a year ago. Hopefully with consistency on the ASV machine, I can improve my health and finally be able to lose some weight. I eat generally on the healthy side and hit the gym for an hour, 5 to 6 days a week. I feel good, but just can't lose weight. I'm hopeful that this machine will help turn things around.

You mentioned "head tucking". Yup, that's me. Especially during the cold months. I sleep on my side and hibernate like a bear under the covers. I'll definitely look into a soft cervical collar. It looks like Amazon has quite a variety available for a pretty good price.

Also, I will be going back to my Sleep MD's initial settings and slowly work in little adjustments as you mentioned. I'll wait a couple weeks per adjustment and see how my comfort level is and note any changes in the stats.

The numerous breaks at night are interesting and kind of funny. For more years than I can remember, I have had to get up every hour or two to urinate. Another classic SA symptom. Now I seem to wake up because my internal clock says "it's time to go", but there's nothing there. Weird. Funny. Hopefully that will resolve over time. My primary MD explained to me why this happens and is a common symptom. He also rattled off more than a dozen other symptoms of OSA and CSA and I checked just about all those boxes too.

On the 3rd, I logged 4hr 47 min in uninterrupted sleep. I can't remember how long it's been that I could say that. So things are definitely improving.

Many thanks and have a great weekend.

Ray B.
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RE: Fine Tuning my Resmed ASV Machine with Incremental Wins
Ray, I'll be interested to see if the collar helps you. Many of our members benefit from its use, and it avoids the need for elevated pressure. I think you will see a dramatic decrease in hypopnea events. Sleep disruption is a matter of good sleep hygiene and training yourself to a new normal where you push through the arousals and maintain therapy rather than getting up. As far as weight, we share that issue in common, although I don't suffer from hypoventilation, I am also active but need to take of weight.

You converted to a regular member with your last post and limitations on attachments should be removed.
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RE: Fine Tuning my Resmed ASV Machine with Incremental Wins
I will keep you posted as to my progress. Also, here are the other screenshots I prepared the other day (not my current settings though, but interesting data showing treatment areas). And of course my settings starting last night are now different. I'll be testing out the following settings - EPAP 5-8, PS 5-15 and bumped ramp time from 5 min to 10min. Last night my stats were: Time - 6:37 and AHI - 1.6 and overall system comfort was very good. Of course just one night proves nothing. And I haven't had the time to download the data into SleepyHead yet. Well off to the gym for now.

All the best.

Ray B.
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