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jillkam
Unread post  Post subject: Jillkam's therapy thread  |  Posted: Sun Jul 12, 2020 1:31 pm

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Hello! I'll try to keep this short, but ask if you need more info. I've been on DreamStation Auto CPAP for 14 months. My AHI averages around 8 and the lowest I've ever had is 4.5. I generally have more central than obstructive events, sometimes twice as many, and generally a lot of hypopneas too. Much better than the 35 I started with but always wanted to see if I could lower it. A year ago I had a sleep study with an ASV machine that was awful, overall AHI in the high 50's; Jason looked at the report and said the tech wasn't so good. Last week I got a deal on a used Respironics System One autoSV advanced machine with 200 hours on it. Figured it's worth a try.

A note about me personally: on the APAP, I do MUCH MUCH better when the pressure is limited. My best pressure setting is 5-12.5 and my best nights are when my 95% is below 9 or so. I'm a petite female, don't know if that has affect. When there's too much pressure, I get leaks which cause more pressure, more leaks, etc -- til I wake up and hit the ramp button to "start over". I swallow a lot of air with more pressure too; when pressure is lower like the 5-12.5 I've been using, I can control the aerophagia by lip-taping. *** Hoping you can take this into account on my ASV.... more pressure isn't the solution for me personally. ****

I did 5 nights this week on the autoSV. In general all week, I've been awake a lot during all the nights, and I find the inhalation support pretty weird and uncomfortable (of course I recognize this is the feature that I'm hoping will help my numbers!!). The AHI ranges were 12-19 roughly, with a notable exception of 56 one night >> the night that I let the max pressure be real high according to Jason's suggestions on another thread and video. Loads of aerophagia, I barely slept, it was like the sleep study.

Attached are screenshots from the 5 nights of autoSV and also a typical night on the APAP.

Questions are:
- Can an autoSV/ASV be titrated to help ANYONE with the majority of central's, or are there people who it just doesn't work for?
- How come the machine gives me inhale support (inhales for me) when I'm not even sleeping and when I'm clearly breathing on my own?
- What settings should I try next?

To those of you helpful folks who are successfully on autoSV/ASV, many thanks in advance for your help,
Jill


Attachments:
File comment: 4th and WORST night autoSV
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File comment: 3rd and best night autoSV
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File comment: 2nd night autoSV
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File comment: First night on autoSV -- I might have changed settings during the night...
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File comment: Typical APAP night for the past year or so
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jillkam
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Sun Jul 12, 2020 1:33 pm

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last screenshot


Attachments:
File comment: 5th night autoSV
screenshot-20200711.png
screenshot-20200711.png [ 127.66 KiB | Viewed 725 times ]
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DeltaBravo3.8
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Sun Jul 12, 2020 1:53 pm
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Location: Greencastle, Pennsylvania, USA
PAP Mask: ResMed F20 N30i P30i
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Pressure Setting: EPAP 8-15 PS 4-12

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I have been on a ResMed AirCurve 10 ASV for almost 3 years. I'm not claiming to be expert, but I had to set my settings myself from day one. The doc writing the script didn't know what he was doing. The RT at the DME told me she didn't know how to set my ASV "properly" so she guessed. Yes, she actually said it. With that group of support, I went rogue and set my machine by myself in a months long titration. Until several months ago, it was doing very well. FWIW I have Complex Apnea and COPD, so it is really complex.

I will look over your charts in a bit and give some feedback, tips I've gleaned, etc. I'll be back on later this eve. I am in the middle of an errand or I'd get into details now.

And welcome to the forum.

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Pugsy
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Sun Jul 12, 2020 1:56 pm
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First thing...the screenshots...don't try to cram so many graphs in one image....it makes all of them too small to evaluate and we don't need all those.
With is machine the only graphs we need on that right side
Events
Flow rate
Pressure
Leak
That's it. No need to redo these at the moment though.

The PS setting you have it set to...it can't treat the centrals with the max of 5...I know why you did it but the way ASV machines treat the centrals is by a big burst of PS...the very thing you don't like. If you think 5 PS is high...most people need 10 or more PS to deal with centrals.
This PS burst is critical to central apnea therapy because the machine is essentially breathing for you when you have a central apnea and don't breathe.

As to why it does things while you are awake...because the machine doesn't have anyway to know if you are asleep or not. All it can measure is air flow and our awake/semi awake breathing is very irregular when compared to asleep breathing and the machine will misinterpret awake breathing irregularities as some sort of apnea event and try to fix it.
What you have to do is make a concentrated effort to breathe slowly and smoothly when you first turn the machine on so the machine thinks your breathing rate is lower when it sets the overall auto rate average.

ASV isn't easy for some people. The centrals it is designed to deal with have to be dealt with a burst of high PS and if it can't get a high enough burst to breathe for you...it isn't dealing with the centrals.

Do you still have the other machine? If so, I wonder what would happen with your centrals on it if you just turned off the Flex exhale relief. Did you ever try that?

Finally go here and watch the videos that explain how to look at the flow rate and figure out awake vs asleep flagged events.
Some of what you are seeing might be awake breathing flagged by mistake and if you are awake they don't count.
http://freecpapadvice.com/sleepyhead-free-software

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DeltaBravo3.8
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Sun Jul 12, 2020 5:53 pm
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Location: Greencastle, Pennsylvania, USA
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Good pointers there by Pugsy.

Here's my suggestions for you to consider, try the APAP again if you wish. Edit the settings to turn off Flex. It's adding to a pressure swing the central apneas won't like. If you are using Ramp, it needs to be very short on time, but best is to turn it off period. This also can add to pressure swings.

On the APAP, try 6-13 pressure, again no Flex at all, no Ramp.

OR

On the ASV, I would suggest no Ramp on this. I know you don't want high pressures, so let's try a modified setting somewhat like you had on the ASV 7/11 that gave you an AHI of 12.57. Not great, but it beats 56.25 on 7/9. On 7/11 you had EPAP 5-10 and PS must have been around 0-5.

ASV EPAP 6-11 PS 2-10 for now to see how it goes. There's a slight increase in pressures that is required to combat centrals. No Ramp if possible.

Try one machine or the other, assuming both are available, and post an OSCAR of it tomorrow if possible. We want you to get dialed in as fast as possible. The APAP we may work with to avoid as many Centrals as possible, it cannot treat CA. The ASV is the one to treat CA if we find the right pressures. When you try either, make mental notes on how you felt better or worse. Post your answer to "how do you feel?" when you post the chart next time around in the format Pugsy stated. It'll be plenty of data to tell us how it's working.

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Respirator99
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Sun Jul 12, 2020 7:18 pm
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G'day Jill, welcome to the forum.

There's some good advice there from Pugsy and DeltaBravo. One thing to be aware of is that this therapy needs some consistency - looking at your screenshots it seems that you were trying different pressure settings every second night - that way lies madness.

The other thing to be aware of is that the Dreamstation ASV has a lot of settings besides pressure, and it is important to get these right. I don't have the clinical manual to hand, but from memory these settings include backup rate, rise time, bi-flex, trigger, cycle time and perhaps others. These all work together to optimise your therapy and (equally important) give you a more comfortable ride. These settings aren't always understood by the therapists, much less so by DIY patients like us, so there is a lot of room to get things wrong.

I don't know your financial and insurance situation, but if at all possible, consider changing to a Resmed Aircurve 10 ASV. The general consensus on the forums is that the Resmed gives improved efficacy and comfort. It has a more sophisticated algorithm and takes care of all the subsidiary settings automatically so you (and the doc) don't need to worry about them. I started with the Respironics ASV (predecessor to your machine) but couldn't ever get comfortable and couldn't get the AHI below 20. Changing to the Resmed saw the AHI drop down to around 2, and I got a much more comfortable sleep.

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optimalsleep
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Sun Jul 12, 2020 7:31 pm

Joined: Wed Jun 10, 2020 5:47 am
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definitely flex to a minimum or off, I'll bet since you are up on your minimum pressure at 12 APAP. I went to 3 and events went below 4 most of the time. OSCAR shows non-legit CA's.... and some legit ones pop up now and again. I felt better today with better PEEP because of less flex. Lets see with no flex and no ramp how I do.


Last edited by optimalsleep on Sun Jul 12, 2020 7:34 pm, edited 1 time in total.


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DeltaBravo3.8
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Sun Jul 12, 2020 7:33 pm
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Location: Greencastle, Pennsylvania, USA
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There is the case for getting near excellent therapy fast if the ResMed 10 ASV could be had. It has just 4 pressure/therapy settings.

I think the settings on the Respironics can help, but as Respirator99 points out, it's a bit more "needy" is how I'd put it. It is capable of being more flexible than it's presenting now, if you can get it to work for your particular therapy needs.

I don't know yet some of these other settings as I have yet to have a machine with these, but there may be inhale/exhale time settings, and trigger/cycle similar to a ResMed VAuto. Maybe others can comment on that aspect.

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optimalsleep
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Sun Jul 12, 2020 7:35 pm

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algorithms are better on ResMed. My second sleep study they used a Aircurve...what a difference !


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jillkam
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Sun Jul 12, 2020 7:55 pm

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Thank you everyone! I had already planned to go back to the APAP machine at least for tonight (gotta get some rest for the workday tomorrow), and I have turned off A-flex. I'm thankful enough of the settings were visible in that left column AND that you smart people noticed this! I'll post tomorrow. If I could get below 5 on the APAP, I'm fine with that, especially if there are hypopneas that I can effectively ignore.

I will also try the other suggestions, and keep my eyes out for a ResMed. More tomorrow, thanks again!!


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optimalsleep
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Sun Jul 12, 2020 8:01 pm

Joined: Wed Jun 10, 2020 5:47 am
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AHI isn't what you want to focus on completely... it's how you feel.


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jillkam
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Mon Jul 13, 2020 5:05 am

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Thanks for the voice of reason, optimal! I usually feel pretty good on my APAP.
I *thought* I turned off my AFlex before sleep last night but Oscar says I didn't. Maybe I missed the last save button? I'll check the machine after my dear husband gets up.
I do not have ramp on my APAP -- when I said I hit the ramp button during the night to reset the pressure sometimes, it's just like a start-over button but actual "ramp" feature doesn't happen.

I will for sure get that AFlex off tonight and try again on APAP.
I've found an AirCurve that fits the budget. I'll sleep on it (ha ha), and see this week if APAP can fit the bill.

I'll post tonight's APAP screenshot. Talk to you tomorrow and have a great day, everyone!!


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LSAT
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Mon Jul 13, 2020 5:43 am

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jillkam wrote:
Thank you everyone! I had already planned to go back to the APAP machine at least for tonight (gotta get some rest for the workday tomorrow), and I have turned off A-flex. I'm thankful enough of the settings were visible in that left column AND that you smart people noticed this! I'll post tomorrow. If I could get below 5 on the APAP, I'm fine with that, especially if there are hypopneas that I can effectively ignore.

I will also try the other suggestions, and keep my eyes out for a ResMed. More tomorrow, thanks again!!



You can't ignore hypopneas...they stop your breathing just like an apnea does. It's just that the airway is not completely closed


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Pugsy
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Mon Jul 13, 2020 6:30 am
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Let's see if we get lucky with turning off Flex and maybe the centrals will reduce enough just from that change. Long explanation that I don't have time to go into at the moment.

The AirCurve ASV still will need to treat the centrals with the higher PS burrsts that you don't like. It is easier to configure and more plug and play auto kind of thing but it still needs to do the high burst to treat centrals.
Lets see if we can eliminate the need for the high PS bursts first and see what happens with Flex off.

Do remember though...and occasional central apnea is normal and no big deal. Heck, even I see them reported.
We don't worry about them unless they are consistently too numerous or they cause desats or keep waking us up.

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DeltaBravo3.8
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Mon Jul 13, 2020 10:53 am
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I may be repeating myself, but of the charts presented, the APAP got you the lowest AHI. It has a very good chance of being lower by the elimination of Flex. I can't guarantee it, but it's worth a shot.

Again, how I see it with your CA therapy need is that an APAP like this, you can avoid some CA but not treat. With the ASV and decent settings, you can treat the CA and a decent to very good therapy on all the other events.

Keep us posted on progress.

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jillkam
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Mon Jul 13, 2020 11:28 am

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Hi and and thank you! Very weird -- in Oscar it says Flex was on last night, but when I look at the screen on the machine it says off. WHY? When I was awake during the night, I did notice that at the end of an exhale, it felt a little different, kind of like the machine halted (hard to describe, but felt different, not uncomfortable) -- so I was thinking that the setting had changed. Here are screenshots of last night's Oscar + farther down the left column for the settings.

Anyone else find this strange??

I'm all for not spending more money and sticking with the APAP I have, especially if the numbers can get a little better with YOUR help, for which I am so grateful.


Attachments:
File comment: APAP 7/13 settings
apap-settings-20200713.PNG
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File comment: APAP 7/13 screenshot
screenshot-20200713-apap.png
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optimalsleep
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Mon Jul 13, 2020 12:05 pm

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raise your minimum pressure to 7 and see how that goes. I gradually raised my minimum pressure .5 cmH20 a week. Minimum pressure prevented events before they happened.

Also side sleep will most likely help..... chin strap preventing pressure leaking out of your mouth, which reduces therapy. I use a tennis ball on a pocket tshirt on backwards. It nudges you to stay on your side, not gouging like some may say. Evetually you will get optimal therapy and won't have to sleep on your side.

Room conditioning, pillow, possible cervick brace for possible chin tuck, what you eat before bed, sleep aid, dealing with congestion. With congestion consult your Dr before taking sleep aids or congestions OTC meds..... that might interfere with medication you are prescribed by your Dr and be harmful.


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Pugsy
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Mon Jul 13, 2020 12:19 pm
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Sometimes OSCAR just screws up reporting the settings. Don't worry about it. It tells me all the time my humidifier isn't attached or on and it's built in and indeed on. It's a known bug. Thought it was fixed with his latest version of OSCAR...guess I was wrong.

Your Flex was off last night...I can tell by looking at the pressure line.

You have several breaks in therapy...where I can see where you turned the machine off and back on again. So I know a lot of time was spent with the mask and machine on....

Did you ever sleep between 23:30 and 00:30 where I see obvious breaks so you were awake enough to at least turn the machine off and back on again.

Are you on any medications if so...what?...

Are you in general having much trouble with either falling asleep or staying asleep with cpap?

For a central index of 3...you don't need ASV ...even more so if the bulk of those flagged centrals are awake breathing false positives.
See the videos here...especially that bottom video.
http://freecpapadvice.com/sleepyhead-free-software

Sometimes when people use Flex or really any form of exhale relief it will trigger an imbalance in the respirations that trigger centrals.
Your central numbers are significantly reduced just with turning Flex off.
It can happen in a very small percentage of people who use exhale relief,
Even if every single one of your centrals were real asleep centrals (which I highly doubt)...you aren't having enough of them to need ASV.

So...once I get answers to the above questions..and think about things just a bit I can come up with a plan and answer questions you might also have.

I am thinking of doing a little experimenting with the APAP and Flex off and maybe just a little bit more minimum pressure but I don't like to go making a lot of changes without several nights data to see if there is a trend or pattern developing.

At this point...based on this one report so far...I don't see a need for ASV and since you don't like the way it does its job (you wouldn't like ResMed's way either) dealing with centrals anyway. Let's try to make the APAP work better for you and fix what appears to be crappy sleep quality along with maybe not quite optimal OSA treatment.

So answer the questions at your convenience and tonight...keep the same settings with no other changes. Continue with Flex off and if you have any idea why you are having the wake ups...share them.

_________________
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jillkam
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Mon Jul 13, 2020 12:31 pm

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I didn't sleep between 23:30 and 00:30, when all the centrals happened.

I'm on statin for high cholesterol and that's it. In general I don't have problems falling or staying asleep on CPAP. Sometimes I'm overtired and then I can't get back to sleep, ironically.... but mostly I get up once per night and go back to sleep pretty quickly. And usually, those first couple of hours before I get up have the lowest AHI.

I mostly sleep on my stomach, and occasionally on my side. Never on my back EXCEPT one of the nights last week on ASV, I tried to sleep on my back with a full face mask to avoid leaks (which was unsuccessful)

I had both central and obstructive apneas from my first home sleep studies, before I ever started CPAP. The studies were home-based studies, one with a dental appliance and one without it (to see if it helped, which it did a little but not enough). One report had 60 central apneas, 25 obstructive, 104 hypopneas with AHI 31.5. The other report had 55 centrals, 20 obstructives, 91 hypopneas, and AHI 26.2 (with the appliance obviously)

THANKS! I'll keep the same settings including my 5-12.5 pressure for now. And I'll post in the morning


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optimalsleep
Unread post  Post subject: Re: AutoSV titration help please  |  Posted: Mon Jul 13, 2020 12:56 pm

Joined: Wed Jun 10, 2020 5:47 am
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when I went to my second sleep study an ASV wasn't warranted due to not enough legit CA's.

Her and I said you can gradually raise minimum pressure.....but not alot too soon. I did .5 cmH20 a week and after 2 and a half months I went under 5 AHI. However, If you go up to fast too soon you could create CA. You flush out CO2 too fast and fool your Chemoreceptors to tell your brain not to breathe. You basically need pressure support on your exhale and that is where lowering your flex comes in.


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