[Treatment] Acclimating to ASV treatment

[trumpetmuppet]

I have been diagnosed with 6.3 AHI, mostly centrals. Titration studies with CPAP and BiPAP made it worse. Finally I got prescribed ASV with max pressure 25, EPAP max/min 16/7, PS max/min 18/4, ASVAuto mode.

I received a ResMed AirCurve 11 ASV and Dreamwear with nasal pillows. They also gave me a F&P Vitera full face mask to try and I bought a nasal cushion to try with the Dreamwear.

It has been a struggle so far. I have to remind myself it has been only 9 nights, but I'm feeling discouraged, that I will not be able to tolerate this. Every night so far, I fall asleep using the ASV no problem, feeling relaxed and comfortable. Then I wake up a couple of hours later and the rest of the night is a battle to relax and get my four hours for compliance.

The problem in the beginning of this journey is the awful feeling that I'm being forced a larger breath than my body is demanding, and trying to exhale against an amount of pressure that makes me feel like I'm suffocating. I struggle with anxiety and these feelings I've experienced with these machines trigger the anxiety, making me want to rip the mask off.

I discussed my issue with exhaling against too much pressure, also with having dry mouth, with my sleep center. They adjusted the pressure to EPAP 6 to 13 and PS 4 to 17, and recommended I try setting the humidifier manually. Both of these changes helped noticeably but I feel there is still room for improvement.

The worse problems I have now would be swallowing air and mouth leaking. Every night I have eventually been preoccupied with burping up air, and twice started the day feeling very bloated. Later into the night, my mouth fills up with air like a balloon and then leaks air like a cartoon with flappy lips.

The nasal cushions are comfortable, but the breathing experience does not feel natural. Like too much air being pushed into my nose through too small an opening.

The full face mask is surprisingly comfortable and provides a very natural breathing experience, but the fit is not right and it leaks badly however much I try to adjust it. I suspect I need a large mask and/or headgear.

With both masks, my mouth wants to come open and has been leaking and drying out. I have been using my mandibular advancement device to help hold my mouth closed.

This was a lot. Bless you all who stuck with me here. Don't know if I am getting useful data, but I will include some charts if that may be helpful.

[SarcasticDave94]

Howdy, there's room to improve, maybe not drastic but it may help out.

I'll give you an EPAP and PS edit to see what can work better, and included is the ResMed ASV Titration guide image.

I want you to edit this yourself. Wake the ASV screen, and touch the blue and purple squares together for about 5 seconds to access the clinical menu.

Edit EPAP Max to 10. You have yet to hit this on the 3 charts, so it's worth a shot.

PS Min, you can try 3 if you want, and on PS Max down to 15 for now.

There's 5 points less overall to a degree, but the ASV IPAP max would only have been 25 regardless.

Here's the Titration guide, study and decide if you want to do a fresh do over with that.

[trumpetmuppet]

Thank you for your suggestions. Since you didn't suggest a change for EPAP Min, are you thinking it would be good to leave at 6?

Last night went much the same as the others before it. Slept really good for a couple of hours, then fought dry mouth and aerophagia for the rest of the night. I'm going to try increasing humidifier to 4 and tube temp to 80.

[SarcasticDave94]

You can try EPAP min 5 if you want to go down slightly.

[trumpetmuppet]

Dave, I tried your suggested changes over the last two nights, thank you again for offering them. I feel like this was a step in the right direction. Still not able to use the ASV all night, but these were some of the most restful sessions I've had.

Dry mouth and aerophagia have been my biggest obstacles preventing me from falling back asleep. Both issues were improved with these settings, but I am still waking up burping. I have also noticed that my mouth, while closed, occasionally fills with air before trumpeting out of my lips.

I set the humidifier to 6 and tube temp to 82, which improved dry mouth, but I don't know if I can get any more improvement there since I had water in the tube this morning.

I followed your suggestion, Dave, of trying EPAP Min 5, but it felt like I was not receiving enough air and got a touch claustrophobic. So I went back up to 6 last night.

Judging by my data, do you think there is any more margin left in adjustment to improve the aerophagia?

[trumpetmuppet]

Had a two week follow up with my sleep center. Because of my air swallowing problem, they made another adjustment. So now I'm at EPAP Min 6, Max 10 and PS Min 4, Max 13. I'm going to leave it alone for a while and evaluate.

Meanwhile I'll continue to see if I can figure out a mask that is comfortable without leaks. This whole process is making me miserable!

[SarcasticDave94]

OK, you can also try this edit based on the recent charts and to help with aerophagia: not editing EPAP min 6 but EPAP Max you can try 9 here, PS of min 4 and PS Max 10. This would give a calculated Min IPAP 10, and IPAP Max 19. This would decrease your overall max by 6.

Your range looks like this then:
EPAP Min 6 + PS Min 4 = IPAP Min 10
EPAP Max 9 + PS Max 10 = IPAP Max 19

Your ASV will then range between EPAP, PS, IPAP editing itself as needed.

[trumpetmuppet]

Very good. I may give the current settings a few days and then try these adjustments.

I had been slightly elevating my head with a blanket, and removed it last night for comfort reasons. I swallowed a ton of air and had really bad reflux.

I have a fairly large hiatal hernia, and last night it occurred to me this condition could possibly be playing a role in this treatment.

[trumpetmuppet]

One month of treatment later...

Good:
Aerophagia has improved noticeably. I hope there is still room for improvement.
Less problems with dry mouth.
Overall comfort with the mask and using the machine is improving.

Not so good:
I'm still having trouble getting much more than 3 hours of sleep with the machine per night. I don't understand why this isn't getting better with the improvements in comfort.
Leaks. I have settled on the Dreamwear nasal pillows for now, but I seem to have a leak problem. I prefer the nasal cushion, but it's even leakier. I have tightened the headgear a few times, but comfort-wise now it feels too tight.
The machine seems eager to increase IPAP in the latter part of the night. I wonder if this is disturbing my sleep.

[trumpetmuppet]

I tried dropping PS Max by one, while keeping the other settings. The machine gives me EPAP 6, IPAP 10 when I first put the mask on and fall asleep, and I find it very comfortable. I used the nasal cushion, to me it is the best choice, but ended up with a significant leak.

It was only one night with PS Max 9 and the nasal cushion, but not the best looking chart.