[Treatment] Need help with severe fatigue and brain fog - AirCurve 10 ASV (Help with settings)

[REMhunter]

Hmmm.  Sounds like you are really painted into a corner.  The typical response to flow limits is to increase pressure, but in your case that results in massive leaks so you are right back where you started but with a dry mouth.
I have the same issue with REM sleep, my sleep study showed exactly what you have: I was getting essentially no REM sleep at all.  Since starting treatment, the improvement has been dramatic.  It's worth the trouble.

Is it possible that the full face you are using isn't the best fit for you?
Did you go on a mask journey at some point?
I have a very narrow nose bridge, and it took me quite a few masks (probably 5 or 6) and tests with cloth liners before I found something that would work.  Maybe that full face is just a poor fit for you?  My "unicorn" full face happened to be a F&P, it was the only one that would seal on the bridge of my nose properly without any liners or pulled so tight my face was distorted when I took it off.

To me, it seems that your flow limits mean you need higher pressures.  Annoyingly, that precipitates mask leaks and those make the treatment useless.
Seems to me you have to fix the mask leak as the flow limits are beyond your control.
Do you know or could make an educated guess where the mask leaks are happening?  Mouth flopping open?  Jaw retracting away?  I struggled with that for a short while and ended up using mouth tape so I wouldn't "crawl out the bottom of the mask", but I quickly got used to it and didn't need it anymore.  I could never get to sleep with a chin strap on.
Side sleeper?  It's possible you are "shoving" the mask aside when you go limp in your sleep and pulling it off on the down side.  You might want to try arranging your pillows to give your mask a void to live in, or get a side sleeper CPAP pillow.

Don't give up entirely just yet!

[Sleeprider]

My take is that you are using far too much minimum EPAP pressure. In your case, we need EPAP to splint the airway to prevent obstructive UA and H events. Those were near zero, even when EPAP min was 9.0 and all the increases in EPAP to 12-14 were completely unnecessary, and mainly succeeded in increasing leaks.. As long as most of your night is spent with large leaks, you simply are not going to make progress. This looks like air escaping through your mouth, and you may need to move to a full-face or hybrid mask to equalize the pressure from your airway and mouth.

In order to learn more about what your real needs are, I suggest a significant reduction in EPAP pressure to EPAP min 7.0, EPAP Max 10.0. The pressure support is what you need to lean on to increase volume and overcome upper airway resistance or flow limitation. Let's move to a PS min 5.0, PS max 10.0. Plan on posting zoomed images of about 3 to 5 minute duration so that we can see what your actual flow rate looks like. I will want to see Events, Flow Rate, Mask Pressure, Tidal volume, Inspiration time.

[sms832]

Hi MAURS

I feel like we've got some similar problems.  I've started a thread seeking advice too... I habitually wake up early and cant' get back to sleep.   CPAP didn't help and I don't think I get much REM at all...  I'm deeply shortchanged on sleep hours every night.    Finally we spotted centrals on the most recent sleep study so we're trying ASV.

I hope you get it sorted.  CPAP didn't help, but at least during that period I finally identified a mask that works and other things helpful to me now.   You need to solve the leak problem or none of this works... The only way I could do it was by buying mask after mask and a lot of experimentation.    I also had the issue with nasal masks where the air enters the nose but comes right out the mouth.   I sounded like a leaf blower.   The full face mask fixed that.

I wish you the best of luck.

[MUARS]

Hi Sleeprider,

Thanks for the advice ,I've changed my machine to your recommended settings. I'll post some screenshots of a few minutes around my flow limitations / apneas tomorrow. I've changed to using my F20 face mask and also purchased a chinstrap to see if that helps. Do you think a cervical collar would be beneficial and what kind would you recommend?

[Sleeprider]

I'll reserve judgement on the SCC until your next chart(s). I don't recall if you had clusters of obstruction or not.

[MUARS]

I used the settings you suggested last night but I forgot to put the SD card back in the machine *facepalm*.

I've posted pictures from 9th of August because the settings are similar. Hopefully there is some useful information here
Min EPAP
12.00 cmH2O
Max EPAP
15.00 cmH2O
Min IPAP
14.00 cmH2O
Max IPAP
25.00 cmH2O
PS Min
2.00 cmH2O
PS Max
10.00 cmH2O

[MUARS]

I've given it a few days with the settings I've recommended and I've where there are flow limits it looks like there are also flat spots on the flow rate grath. Am I right in my understanding that these are likely to be RERA's?

[Sleeprider]

RERA consists of increasing flow limitation causing increasing respiratory effort to overcome, ending in arousal, usually seen as an increase in flow and some irregular breaths. It is nearly impossible to identify RERA with ASV because instead of respiratory effort to overcome flow limitation, the machine increases pressure support and provides mechanical assistance to maintain flow volume and rate. It is very hard to identify flow limitation (flattening) caused by inspiratory effort vs increasing resistance to high PS causing a breath. As a result, we generally ignore flow limits with ASV. Your charts might be easier to interpret with mask pressure rather than the pressure graph, but I don't interpret any of the segments you posted as RERA. In general, all of the disrupted breathing in your charts depicts times where PS ranges from 8 to 10 cm, and spontaneous effort would be minimal.

[robbob2112]

Hi Sleeprider, 

I am new to all of this and using an ASV.  Why do you say "we generally ignore flow limits with ASV"?  

Thanks, 
Robert

[Sleeprider]

Rob, we can't differentiate respiratory effort from pressure support in ASV. It is normal for an individual using ASV to have flattened inspiratory flow, when high PS is present. This is not due to obstruction or flow resistance but simply to the slowing flow rate of the lungs as they fill without spontaneous effort.