New to Resmed Aircurve 11 ASV, need help with settings

[gcoll]

I was recently diagnosed (10/22/24) with severe mixed sleep apnea (CSA and OSA). My AHI was an impossible sounding 56 per hour. I got a Resmed Aircurve 11 ASV machine from my doctor. For the past week I have had difficulty sleeping with the mask and waking in the night. At first, I thought it was just the masks I was trying not fitting right. But now I have some comfortable nasal pillows and was still experiencing the same issue. I posted about my frustrations to Reddit and they directed me here for further guidance. The responders to my post asked me for my prescription and were appalled by it. Said the pressures my doctor prescribed were akin to malpractice. I was told these pressure settings would likely cause too much pressure when I experience apnea and knock me out of REM sleep.

Doc's Rx:
EPAP: 5.0-15.0 cm H2O
PSmin: 0-15.0 cm H2O
PSmax: 25 cm H2O

One helpful responder who is training to be a sleep study tech and has his own CPAP gave me a new titration to try. I tried these settings last night and felt like I slept much better. 

Redditor's Rx:
EPAPmin: 6.0-8.0 cm H2O
EPAPmax: 10.0 cm H20

PSmin: 0 cm H2O
PSmax: 4 cm H2O
IPAPmax: 25 cm H2O

The Aircurve 11 ASV only allows me to set the EPAP range and the PS range, so I set my EPAP to 6.0-10.0 and my PS to 0-5.0 (5.0 was the lowest PSmax it could go).

I am using OSCAR to analyze my data and I am still getting good ventilation and having <5 apnea events per night, as was also the case before I changed the settings.

My questions are: Why was I told to change my settings to these numbers? How would I know if I need to titrate these pressures any further? Are these actually correct/better settings for me? Did I input these settings correctly into the device?

Thank you for the help

[SarcasticDave94]

Welcome to Apnea Board,

1. Not exactly sure the why, except the doctor's recommendation was a bit off.

2. You can self Titrate if you want. I may have the ASV Titration that I'll add.

3. Settings are better but still not an ideal starting place.

IPAP is not directly accessed, but is indirectly set via EPAP and PS settings that you can edit. IPAP = EPAP + PS

I would try a PS edit more than anything else right now. You want some PS at all time to be in effect, so change PS Min to 3, Max to 15. This is PS default, and by having Min 3 it will help with some pressure differential at all times inhale.

When I used an ASV, I wanted EPAP to be shorter in range than the PS. As the PS addition to breathing is shorter, it'll probably be easier to tolerate. We can manipulate the PS duration slightly with the lower EPAP Max and having a positive number in PS Min.

Recap of my suggested settings:

ASV Auto Mode
EPAP 6-10
PS 3-15
Nets you an IPAP range of 9-25

See if this feels acceptable. Follow-up with an OSCAR chart tomorrow, with comments on how it felt.

Below is the ResMed ASV Auto Titration protocol

   

[Sleeprider]

We have many members here using ASV, and I have helped coach hundreds over the years to get effective and comfortable treatment.  Your Doctor's settings are EPAP min 5.0, EPAP max 15.0, PS min 0.0, PS max 15.0.  This is nearly textbook default as recommended by Resmed for ASVauto mode. My only suggestion would have been to use the recommended PS min of 3.0. (see Titration Protocol below).

Your Reddit friend's suggestion includes a PS range that the ASV will not accept as you need at least 5 cm of difference between PS min and PS max. That said, we often suggest a lower PS max if the user experiences any discomfort or aerophagia.  In truth the ASV does a pretty good job of limiting pressure changes to what is actually needed. So I actually would not completely agree with either setup.   Your eventual solution in the chart of EPAP 6-10 and PS 0-5, is okay but I think you will find a PS min of 3.0 will work much better. The limit on maximum PS (less than 15) is an option done for individuals that have problems with higher PS. Remember in most cases, your ASV will only go as high as needed to maintain a normal volume and rate. Some individuals, like yourself, can use a lower PS max because the pressure support stimulates and helps spontaneous respiration. So there is no harm with using PS max of 15, but since you seem to maintain a good rate and volume with lower PS max, that is also acceptable and perhaps less disruptive.  So my suggested setup based on what we know so far and see in your chart is:
EPAP min 5.0
EPAP max 9.0
PS min 3.0
PS max 9.0-12 (Suggest you start at 9.0 and increase if any hypopnea occur)

If this causes any discomfort after a trial, we have room to lower some of the pressure settings. The use of a PS min of 3, gives you a consistent minimum PS that will help with flow limitation and make your baseline breathing easier and smoother.  The PS max of 9.0 gives you up to 6-cm of PS to stimulate inspiration when you might otherwise have CA or hypopnea, but it significantly limits the the maximum range of PS you might encounter at the default maximum PS Resmed suggests in the titration protocol.  Before masking up, allow yourself some time to relax after getting in bed for your respiration rate and volume to settle. A common problem is masking up immediately on getting in bed, and the higher respiration rate and volume becomes the target for your ASV. That why you had to restart therapy in the graph above. It appears  your current settings are doing a pretty good job, but I think this will be more comfortable.  Give it a try and let us know what you think.